Answering real-world clinical questions using large language model, retrieval-augmented generation, and agentic systems

OBJECTIVE: The practice of evidence-based medicine can be challenging when relevant data are lacking or difficult to contextualize for a specific patient. Large language models (LLMs) could potentially address both challenges by summarizing published literature or generating new studies using real-world data. MATERIALS AND METHODS: We submitted 50 clinical questions to five LLM-based systems: OpenEvidence, which uses an LLM for retrieval-augmented generation (RAG); ChatRWD, which uses an LLM as an interface to a data extraction and analysis pipeline; and three general-purpose LLMs (ChatGPT-4, Claude 3 Opus, Gemini 1.5 Pro). Nine independent physicians evaluated the answers for relevance, quality of supporting evidence, and actionability (i.e., sufficient to justify or change clinical practice). RESULTS: General-purpose LLMs rarely produced relevant, evidence-based answers (2-10% of questions). In contrast, RAG-based and agentic LLM systems, respectively, produced relevant, evidence-based answers for 24% (OpenEvidence) to 58% (ChatRWD) of questions. OpenEvidence produced actionable results for 48% of questions with existing evidence, compared to 37% for ChatRWD and <5% for the general-purpose LLMs. ChatRWD provided actionable results for 52% of questions that lacked existing literature compared to <10% for other LLMs. DISCUSSION: Special-purpose LLM systems greatly outperformed general-purpose LLMs in producing answers to clinical questions. Retrieval-augmented generation-based LLM (OpenEvidence) performed well when existing data were available, while only the agentic ChatRWD was able to provide actionable answers when preexisting studies were lacking. CONCLUSION: Synergistic systems combining RAG-based evidence summarization and agentic generation of novel evidence could improve the availability of pertinent evidence for patient care.