Elsevier

The Lancet

Volume 353, Issue 9156, 13 March 1999, Pages 916-918
The Lancet

Series
Evidence-based interventions and comprehensive treatment

https://doi.org/10.1016/S0140-6736(98)08024-6Get rights and content

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The case

To underline the perspective of clinical practice, the case we consider is a patient with asthma, for which generalpractice-based research is available. Mike Jones, a clinical epidemiologist employed by the department of health to promote evidence-based medicine, has asthma and turns to his general practitioner for treatment. With reference to a recent Medline search, the general practitioner prescribes inhaled corticosteroids to prevent the development of signs or symptoms related to

The target of evidence

A basic requirement for evidence-based treatment is the availability of effectiveness studies with external validity for clinical practice. Furthermore, it is important to translate these results to clinically useful and feasible treatment procedures. Such translation is fairly easy for interventions that can be directly implemented into daily practice,2 but is commonly much more complicated, especially in primary care.

The previous papers in this series by David Mant3 and Larry Culpepper and

No proof of effect versus proof of no effect

The complexity of interventions deserve further consideration, but first the question of absence of proof of effectiveness, versus proof of lack of effectiveness has to be addressed. Again, Mr Jones has the lead-in.

Mr Jones grudgingly pockets the prescription, but at the door he makes a last comment. He would be grateful to know what evidence there is for the general practitioner's advice to avoid house dust, which is not an easy task to achieve. In particular, the mattress covers she

Complexity of (general) practice

The complexity of clinical practice can be clarified by distinguishing the disease dimension from the personal dimension. In general practice, the personal dimension predominates,11 as indicated by continuity of care and family medicine. Adequate medical care always includes the combination of the disease and the personal dimension, but in general practice the personal dimension offers a particularly rich potential for intervention. With the RCT methodology of evidence-based medicine, the

Testing complex integrated treatment schemes

Given the fact that treatment of patients is inherently complex and the need to extend the evidence base of complex treatment procedures, some methodological cues may be helpful in coping with these challenges. First, since an assessment of each element in composite interventions is generally impossible, it is important to identify the most essential components that have not yet been evaluated. These elements can then be used as the key contrasts to be tested in the trial, keeping the other

A theory of evidence and primary care practice to bridge the gap

Further development of evidence-based general practice requires an analysis of the full range of interventions, under prevailing clinical conditions. Any clinical study should be based on a consistent, comprehensive conceptual framework of pathophysiology and patient-centred understanding, since the goal of clinical practice is to combine both dimensions in their own right. Therefore, in assessments of effectiveness, non-specific, patient-related effects should be taken at their true value and

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