SeriesEvidence-based interventions and comprehensive treatment
Section snippets
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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Cited by (63)
Addressing complexity in health research, a big issue
2017, Journal of Clinical EpidemiologyMedical acupuncture
2011, Pain Procedures in Clinical Practice: Expert ConsultMedical Acupuncture
2011, Pain Procedures in Clinical PracticeGroup analysis versus individual response: The inferential limits of randomized controlled trials
2010, Contemporary Clinical TrialsCitation Excerpt :Rosser [2] decries the fact that public health agencies and insurance companies rely on population level data to justify monetary incentives encouraging physicians to provide preventive treatment to all patients, regardless of “the patient's personal context and values” (p. 663) [2]. Van Weel and Knottnerus [3] discuss the problem of complex treatment packages that are not typically tested in standard RCTs. And Mant [4] describes a number of limitations in generalizing from RCTs to individual patients (e.g., participants in RCTs typically have less serious disease and lower co-morbidity than many patients seen in clinical practice).
Homeopathic Research
2009, Classical HomeopathyFamily practices registration networks contributed to primary care research
2006, Journal of Clinical EpidemiologyCitation Excerpt :But a problem in interpreting these data is, that in contrast to the academic database [23] it is uncertain if all patients with diabetes in the practices were included, or only the ones who contacted their FP for follow-up. Analysis of this mismatch between expected and realized health gains—the gap between efficacy and effectiveness—will identify ways to translate state-of-the-art approaches into routine care [26]. The contribution of family practice databases to this primary care research mission depends to a large extent on two factors: the organization and structuring of data and the organization of access to general practice care, the research infrastructure.