Evaluating treatments in health care: The instability of a one-legged stool

Kaplan, Bonnie; Giesbrecht, Gerald; Shannon, Scott; McLeod, Kevin

Evaluating treatments in health care: The instability of a one-legged stool

dc.contributor.author	Kaplan, Bonnie
dc.contributor.author	Giesbrecht, Gerald
dc.contributor.author	Shannon, Scott
dc.contributor.author	McLeod, Kevin
dc.date.accessioned	2015-11-07T04:26:27Z
dc.date.available	2015-11-07T04:26:27Z
dc.date.issued	2011
dc.description	This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.	en_US
dc.description.abstract	Background: Both scientists and the public routinely refer to randomized controlled trials (RCTs) as being the 'gold standard' of scientific evidence. Although there is no question that placebo-controlled RCTs play a significant role in the evaluation of new pharmaceutical treatments, especially when it is important to rule out placebo effects, they have many inherent limitations which constrain their ability to inform medical decision making. The purpose of this paper is to raise questions about over-reliance on RCTs and to point out an additional perspective for evaluating healthcare evidence, as embodied in the Hill criteria. The arguments presented here are generally relevant to all areas of health care, though mental health applications provide the primary context for this essay. Discussion: This article first traces the history of RCTs, and then evaluates five of their major limitations: they often lack external validity, they have the potential for increasing health risk in the general population, they are no less likely to overestimate treatment effects than many other methods, they make a relatively weak contribution to clinical practice, and they are excessively expensive (leading to several additional vulnerabilities in the quality of evidence produced). Next, the nine Hill criteria are presented and discussed as a richer approach to the evaluation of health care treatments. Reliance on these multi-faceted criteria requires more analytical thinking than simply examining RCT data, but will also enhance confidence in the evaluation of novel treatments. Summary: Excessive reliance on RCTs tends to stifle funding of other types of research, and publication of other forms of evidence. We call upon our research and clinical colleagues to consider additional methods of evaluating data, such as the Hill criteria. Over-reliance on RCTs is similar to resting all of health care evidence on a one-legged stool.	en_US
dc.description.refereed	Yes	en_US
dc.description.sponsorship	The authors thank the Alberta Children's Hospital Foundation and the Alberta Children's Hospital Research Institute for ongoing support.	en_US
dc.identifier.citation	Kaplan, B., Giesbrecht, G.F., Shannon, S., & McLeod, K. (2011). Evaluating treatments in health care: The instability of a one-legged stool. BMC Medical Research Methodology, 11:65	en_US
dc.identifier.doi	10.1186/1471-2288-11-65
dc.identifier.doi	http://dx.doi.org/10.11575/PRISM/33631
dc.identifier.uri	http://hdl.handle.net/1880/51014
dc.language.iso	en	en_US
dc.publisher	BMC Medical Research Methodology	en_US
dc.publisher.corporate	University of Calgary
dc.publisher.department	Department of Paediatrics	en_US
dc.publisher.faculty	Medicine	en_US
dc.publisher.institution	University of Calgary	en_US
dc.publisher.url	http://www.biomedcentral.com/	en_US
dc.rights	Attribution 4.0 International	*
dc.rights.uri	http://creativecommons.org/licenses/by/4.0/	*
dc.title	Evaluating treatments in health care: The instability of a one-legged stool	en_US
dc.type	journal article
thesis.degree.discipline	Paediatrics