Downloaded from http://adc.bmj.com/ on October 23, 2014 - Published by group.bmj.com
Archimedes
Towards evidence based medicine for paediatricians Edited by Bob Phillips Compared with standard care There’s a decent argument in the analysis of quantitative studies of therapies, particularly using randomised controlled trial designs, that says that we should be looking at the totality of unbiased evidence (systematic reviews) rather than looking at individual, cherry-picked, studies. The best estimate from this comes from a pooling of all the results: meta-analysis. There’s a challenge to this, though, when the comparisons are not quite the same. In the case of trials of drug A versus drugs B, C, D and E, it can be quite easy to spot (and then perhaps undertake a network meta-analysis to address the issue). When the trials are ‘A’ versus ‘standard care’, it’s a greater challenge to see if and how ‘standard care’ varies in the different studies, and if it may have better been described as standard care ‘B’, standard care ‘C’, standard care ‘D’ etc. Take a recent systematic review of the use of procalcitonin to guide antibiotic decisions in children1 with lower respiratory tract infections. This looked at 14 trials in 4000 episodes of infection, in different clinical settings (including intensive care unit, emergency department and primary care) and used the setting as a proxy for ‘standard care’—did the location of guided treatment alter if the management mechanism was effective or not? Where the standard care is extremely variable—for example, this review of non-surgical therapies for upper limb cerebral palsy2—the challenge is massive. If there’s a well-founded belief that the variation is, functionally, minimal, then pumping is entirely reasonable. If it’s not, then while you can still pool the results, the answer becomes very very difficult to translate into clinical practice. If ‘new treatment’ is, on average, 50% better than ‘the average sort of standard treatment that gets provided,’ then how do you take this into a ward, clinic or home and know it will be effective? As usual, the skill in applying research to clinical practice is to integrate a clear analysis of what the science says, with a thorough grounding in what is being done on the ground, and sharing this with patients to make a considered decision that steps forward together. Bob Phillips Correspondence to Dr Bob Phillips, Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK; [email protected] Competing interests None. Provenance and peer review Commissioned; internally peer reviewed. Accepted 8 July 2014
▸ http://dx.doi.org/10.1136/archdischild-2014-306511 ▸ http://dx.doi.org/10.1136/archdischild-2014-306617 Arch Dis Child 2014;99:878. doi:10.1136/archdischild-2014-307136
REFERENCES 1 2
878
Schuetz P, Muller B, Christ Crain M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Evid Based Child Health 2013;8:1297–371. Sakzewski L, Ziviani J, Boyd RN. Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis. Pediatrics 2014;133:e175–204.
Arch Dis Child September 2014 Vol 99 No 9
Downloaded from http://adc.bmj.com/ on October 23, 2014 - Published by group.bmj.com
Towards evidence based medicine for paediatricians Bob Phillips Arch Dis Child 2014 99: 878
doi: 10.1136/archdischild-2014-307136 Updated information and services can be found at: http://adc.bmj.com/content/99/9/878.2
These include:
References Email alerting service
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This article cites 2 articles, 1 of which you can access for free at: http://adc.bmj.com/content/99/9/878.2#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections ADC Archimedes (200) Clinical trials (epidemiology) (423) Child health (3300) Competing interests (ethics) (128) Cerebral palsy (126) Drugs: infectious diseases (804) Journalology (178) TB and other respiratory infections (563)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Archimedes
Towards evidence based medicine for paediatricians Edited by Bob Phillips Compared with standard care There’s a decent argument in the analysis of quantitative studies of therapies, particularly using randomised controlled trial designs, that says that we should be looking at the totality of unbiased evidence (systematic reviews) rather than looking at individual, cherry-picked, studies. The best estimate from this comes from a pooling of all the results: meta-analysis. There’s a challenge to this, though, when the comparisons are not quite the same. In the case of trials of drug A versus drugs B, C, D and E, it can be quite easy to spot (and then perhaps undertake a network meta-analysis to address the issue). When the trials are ‘A’ versus ‘standard care’, it’s a greater challenge to see if and how ‘standard care’ varies in the different studies, and if it may have better been described as standard care ‘B’, standard care ‘C’, standard care ‘D’ etc. Take a recent systematic review of the use of procalcitonin to guide antibiotic decisions in children1 with lower respiratory tract infections. This looked at 14 trials in 4000 episodes of infection, in different clinical settings (including intensive care unit, emergency department and primary care) and used the setting as a proxy for ‘standard care’—did the location of guided treatment alter if the management mechanism was effective or not? Where the standard care is extremely variable—for example, this review of non-surgical therapies for upper limb cerebral palsy2—the challenge is massive. If there’s a well-founded belief that the variation is, functionally, minimal, then pumping is entirely reasonable. If it’s not, then while you can still pool the results, the answer becomes very very difficult to translate into clinical practice. If ‘new treatment’ is, on average, 50% better than ‘the average sort of standard treatment that gets provided,’ then how do you take this into a ward, clinic or home and know it will be effective? As usual, the skill in applying research to clinical practice is to integrate a clear analysis of what the science says, with a thorough grounding in what is being done on the ground, and sharing this with patients to make a considered decision that steps forward together. Bob Phillips Correspondence to Dr Bob Phillips, Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK; [email protected] Competing interests None. Provenance and peer review Commissioned; internally peer reviewed. Accepted 8 July 2014
▸ http://dx.doi.org/10.1136/archdischild-2014-306511 ▸ http://dx.doi.org/10.1136/archdischild-2014-306617 Arch Dis Child 2014;99:878. doi:10.1136/archdischild-2014-307136
REFERENCES 1 2
878
Schuetz P, Muller B, Christ Crain M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Evid Based Child Health 2013;8:1297–371. Sakzewski L, Ziviani J, Boyd RN. Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis. Pediatrics 2014;133:e175–204.
Arch Dis Child September 2014 Vol 99 No 9
Downloaded from http://adc.bmj.com/ on October 23, 2014 - Published by group.bmj.com
Towards evidence based medicine for paediatricians Bob Phillips Arch Dis Child 2014 99: 878
doi: 10.1136/archdischild-2014-307136 Updated information and services can be found at: http://adc.bmj.com/content/99/9/878.2
These include:
References Email alerting service
Topic Collections
This article cites 2 articles, 1 of which you can access for free at: http://adc.bmj.com/content/99/9/878.2#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections ADC Archimedes (200) Clinical trials (epidemiology) (423) Child health (3300) Competing interests (ethics) (128) Cerebral palsy (126) Drugs: infectious diseases (804) Journalology (178) TB and other respiratory infections (563)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
