Abstract
For decades, the evidence hierarchy - which places randomized controlled trials (RCTs) and systematic reviews at its apex – has contributed positively to decision-to-treat considerations. Nonetheless, RCTs have often failed to reveal efficacy and safety concerns relating to the studied treatments. Moreover, many of the questions posed in clinical practice are best answered by means other than RCTs. This discussion examines the flaws in RCT statistical methodology that contribute to their limitations. It also presents novel methodologies, that combine RCT data with observational data, and thereby enable clinicians to make personalized treatment decisions for individual patients – something RCTs alone cannot do. Finally, this discussion explores what constitutes the best evidence to answer the many questions clinicians confront on a daily basis. The upshot is a flattened evidence hierarchy wherein RCTs, observational studies and novel methodologies are placed in their proper context, so that their relevance to clinical medicine is neither exaggerated nor ignored.
Publisher
BioMed Research Publishers
Reference17 articles.
1. 1. Hill N, Frappier-Davignon L, Morrison B. The periodic health examination. Can Med Assoc J. 1979 Nov 3;121:1193-254.
2. 2. Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest. 1989 Feb 1;95(2):2S-4S.
3. 3. Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery. 2011 Jul;128(1):305.
4. 4. Centre for Evidence Based Medicine. [Accessed December 17, 2010]; Available at http://www.cebm.net.
5. 5. KNOWING WO. Clinical jazz: harmonizing clinical experience and evidence-based medicine. The Journal of family practice. 1998 Dec;47(6):425-28.