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systematic reviews

Proof of equipoise

12 Nov, 12 | by Bob Phillips

In order to test a new treatment, in a standard randomised controlled trial, we are ethically assumed to have ‘equipoise’: an honest uncertainty at the same chance of a patient being allocated to the new or old treatment. But, I hear you scoff, how can any investigator put themselves through the hell of ethical administration forms, R&D offices and the potential of an infestation of drug safety investigators without being pretty convinced that the new way is better?

Well, in true evidence-based self-analytical fashion, a highly respected gang of investigators determined to see if equipoise had been met [1]. They undertook a systematic review of cohorts of publicly funded studies (not pharma ones) and assessed if the new treatment was better than the old one or placebo, whichever was the comparator. They found that only slightly less than half the time the new treatment was no better than the comparator, and the new therapy was only very rarely an major advantage.

How can we use this information? Well, I think we can use it every time we face a patient and family with the option to enter a large, non-pharma, RCT. We can honestly say that, looking back, we’re right with the new treatment only half the time and that trials are truly the only accurate way of testing treatments fairly.


New treatments compared to established treatments in randomized trials. Benjamin Djulbegovic et al. Cochrane Library, DOI: 10.1002/14651858.MR000024.pub3


When is it obvious?

24 Aug, 12 | by Giordano Pérez-Gaxiola


 Most of us agree that the fairest and more objective way to test if a treatment works is the randomised controlled trial (RCT). We may also agree that there are situations where a RCT is not feasible, practical or ethical, or situations where the effect is so obvious that you don’t need to test it. An example of this is the use of parachutes when jumping from an airplane.

There is a satirical systematic review published some years ago in the Christmas edition of the BMJ where authors mention that they could not find any RCTs that proved that parachutes work. Therefore, “there is no evidence” that they do. The review is a slap in the face for RCTs fanatics, but also raises a topic to discuss. It’s obvious that parachutes works, despite anecdotes of people surviving falls without them. But if we think about other interventions, when is it too obvious that we don’t need to test it? more…

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