Limits...
Real-world research and its importance in respiratory medicine.

Price D, Brusselle G, Roche N, Freeman D, Chisholm A - Breathe (Sheff) (2015)

Bottom Line: The result is that respiratory cRCTs often enrol a small, non-representative subset of patients and overlook the important interplay and interactions between patients and the real world, which can effect treatment outcomes.The Respiratory Effectiveness Group (REG), in collaboration with the European Academy of Allergy and Clinical Immunology (EAACI) and the European Respiratory Society (ERS), is developing quality appraisal tools and methods for integrating different sources of evidence.A REG/EAACI taskforce aims to help support future guideline developers to avoid a one-size-fits-all approach to recommendations and to tailor the conclusions of their meta-analyses to the populations under consideration.

View Article: PubMed Central - PubMed

Affiliation: Respiratory Effectiveness Group, Cambridge, UK ; University of Aberdeen, Aberdeen, UK.

ABSTRACT

Educational aims: To improve understanding of: The relative benefits and limitations of evidence derived from different study designs and the role that real-life asthma studies can play in addressing limitations in the classical randomised controlled trial (cRCT) evidence base.The importance of guideline recommendations being modified to fit the populations studied and the model of care provided in their reference studies.

Key points: Classical randomised controlled trials (cRCTs) show results from a narrow patient group with a constrained ecology of care.Patients with "real-life" co-morbidities and lifestyle factors receiving usual care often have different responses to medication which will not be captured by cRCTs if they are excluded by strict selection criteria.Meta-analyses, used to direct guidelines, contain an inherent meta-bias based on patient selection and artificial patient care.Guideline recommendations should clarify where they related to cRCT ideals (in terms of patient populations, medical resources and care received) and could be enhanced through inclusion of evidence from studies designed to better model the populations and care approaches present in routine care.

Summary: Clinical practice requires a complex interplay between experience and training, research, guidelines and judgement, and must not only draw on data from traditional or classical randomised controlled trials (cRCTs), but also from pragmatically designed studies that better reflect real-life clinical practice. To minimise extraneous variables and to optimise their internal validity, cRCTs exclude patients, clinical characteristics and variations in care that could potentially confound outcomes. The result is that respiratory cRCTs often enrol a small, non-representative subset of patients and overlook the important interplay and interactions between patients and the real world, which can effect treatment outcomes. Evidence from real-life studies (e.g. naturalistic or pragmatic clinical trials and observational studies encompassing healthcare database studies and cohort studies) can be combined with cRCT evidence to provide a fuller picture of intervention effectiveness and realistic treatment outcomes, and can provide useful insights into alternative management approaches in more challenging asthma patients. The Respiratory Effectiveness Group (REG), in collaboration with the European Academy of Allergy and Clinical Immunology (EAACI) and the European Respiratory Society (ERS), is developing quality appraisal tools and methods for integrating different sources of evidence. A REG/EAACI taskforce aims to help support future guideline developers to avoid a one-size-fits-all approach to recommendations and to tailor the conclusions of their meta-analyses to the populations under consideration.

No MeSH data available.


Related in: MedlinePlus

The COMPACT study demonstrated the difference in outcomes associated with management of only lower airways inflammation (budesonide) compared with systemic (upper and lower airways) inflammation management (montelukast) in asthmatic patients without (a) and with (b) rhinitis. Reproduced from [31, 32] with permission from the publishers.
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Figure 4: The COMPACT study demonstrated the difference in outcomes associated with management of only lower airways inflammation (budesonide) compared with systemic (upper and lower airways) inflammation management (montelukast) in asthmatic patients without (a) and with (b) rhinitis. Reproduced from [31, 32] with permission from the publishers.

Mentions: Yet despite the likely association and high incidence of comorbid asthma and rhinitis, patients with rhinitis are often excluded from cRCTs of asthma therapies [29, 30]. The Clinical Outcomes with Montelukast as a Partner Agent to Corticosteroid Therapy (COMPACT) trial, however, included a broader asthma population, and examined whether asthma patients with comorbid allergic rhinitis responded differently to budesonide plus montelukast than patients without comorbid allergic rhinitis in terms of asthma control (lung function) [31]. In the subgroup of asthma patients with allergic rhinitis, a combined treatment approach that included montelukast and budesonide was found to provide significantly greater reductions in airflow obstruction than were achieved by doubling the dose of budesonide (fig. 4) [32]. The results suggest a treatment approach that targets the airway inflammation common to both diseases may be beneficial for the large proportion of asthma patients who also suffer from allergic rhinitis. They also illustrate the difference in treatment outcomes that real-life features of asthma management (i.e. presence of comorbid conditions) may affect, and the potential limitations in assuming cRCT results hold true across all patients and patient subgroups managed in routine care.Figure 4


Real-world research and its importance in respiratory medicine.

Price D, Brusselle G, Roche N, Freeman D, Chisholm A - Breathe (Sheff) (2015)

The COMPACT study demonstrated the difference in outcomes associated with management of only lower airways inflammation (budesonide) compared with systemic (upper and lower airways) inflammation management (montelukast) in asthmatic patients without (a) and with (b) rhinitis. Reproduced from [31, 32] with permission from the publishers.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4487388&req=5

Figure 4: The COMPACT study demonstrated the difference in outcomes associated with management of only lower airways inflammation (budesonide) compared with systemic (upper and lower airways) inflammation management (montelukast) in asthmatic patients without (a) and with (b) rhinitis. Reproduced from [31, 32] with permission from the publishers.
Mentions: Yet despite the likely association and high incidence of comorbid asthma and rhinitis, patients with rhinitis are often excluded from cRCTs of asthma therapies [29, 30]. The Clinical Outcomes with Montelukast as a Partner Agent to Corticosteroid Therapy (COMPACT) trial, however, included a broader asthma population, and examined whether asthma patients with comorbid allergic rhinitis responded differently to budesonide plus montelukast than patients without comorbid allergic rhinitis in terms of asthma control (lung function) [31]. In the subgroup of asthma patients with allergic rhinitis, a combined treatment approach that included montelukast and budesonide was found to provide significantly greater reductions in airflow obstruction than were achieved by doubling the dose of budesonide (fig. 4) [32]. The results suggest a treatment approach that targets the airway inflammation common to both diseases may be beneficial for the large proportion of asthma patients who also suffer from allergic rhinitis. They also illustrate the difference in treatment outcomes that real-life features of asthma management (i.e. presence of comorbid conditions) may affect, and the potential limitations in assuming cRCT results hold true across all patients and patient subgroups managed in routine care.Figure 4

Bottom Line: The result is that respiratory cRCTs often enrol a small, non-representative subset of patients and overlook the important interplay and interactions between patients and the real world, which can effect treatment outcomes.The Respiratory Effectiveness Group (REG), in collaboration with the European Academy of Allergy and Clinical Immunology (EAACI) and the European Respiratory Society (ERS), is developing quality appraisal tools and methods for integrating different sources of evidence.A REG/EAACI taskforce aims to help support future guideline developers to avoid a one-size-fits-all approach to recommendations and to tailor the conclusions of their meta-analyses to the populations under consideration.

View Article: PubMed Central - PubMed

Affiliation: Respiratory Effectiveness Group, Cambridge, UK ; University of Aberdeen, Aberdeen, UK.

ABSTRACT

Educational aims: To improve understanding of: The relative benefits and limitations of evidence derived from different study designs and the role that real-life asthma studies can play in addressing limitations in the classical randomised controlled trial (cRCT) evidence base.The importance of guideline recommendations being modified to fit the populations studied and the model of care provided in their reference studies.

Key points: Classical randomised controlled trials (cRCTs) show results from a narrow patient group with a constrained ecology of care.Patients with "real-life" co-morbidities and lifestyle factors receiving usual care often have different responses to medication which will not be captured by cRCTs if they are excluded by strict selection criteria.Meta-analyses, used to direct guidelines, contain an inherent meta-bias based on patient selection and artificial patient care.Guideline recommendations should clarify where they related to cRCT ideals (in terms of patient populations, medical resources and care received) and could be enhanced through inclusion of evidence from studies designed to better model the populations and care approaches present in routine care.

Summary: Clinical practice requires a complex interplay between experience and training, research, guidelines and judgement, and must not only draw on data from traditional or classical randomised controlled trials (cRCTs), but also from pragmatically designed studies that better reflect real-life clinical practice. To minimise extraneous variables and to optimise their internal validity, cRCTs exclude patients, clinical characteristics and variations in care that could potentially confound outcomes. The result is that respiratory cRCTs often enrol a small, non-representative subset of patients and overlook the important interplay and interactions between patients and the real world, which can effect treatment outcomes. Evidence from real-life studies (e.g. naturalistic or pragmatic clinical trials and observational studies encompassing healthcare database studies and cohort studies) can be combined with cRCT evidence to provide a fuller picture of intervention effectiveness and realistic treatment outcomes, and can provide useful insights into alternative management approaches in more challenging asthma patients. The Respiratory Effectiveness Group (REG), in collaboration with the European Academy of Allergy and Clinical Immunology (EAACI) and the European Respiratory Society (ERS), is developing quality appraisal tools and methods for integrating different sources of evidence. A REG/EAACI taskforce aims to help support future guideline developers to avoid a one-size-fits-all approach to recommendations and to tailor the conclusions of their meta-analyses to the populations under consideration.

No MeSH data available.


Related in: MedlinePlus