Inspired by a hugely successful series entitled Treating Individuals, originally published in The Lancet, this volume will become essential reading for any professional involved with performance and evaluation of trials and systematic reviews or clinical patient care. There are many books explaining the importance of evidence-based medicine and how randomised clinical trials (RCTs) and systematic reviews should be performed. However, this is the first book to tackle the apparent conflict between the importance of evidence-based decision making and the widely-held view that it is often very difficult to apply the overall results of RCTs and systematic reviews to decisions about individual patients in routine clinical practice. The book brings together experienced clinicians, statisticians and trialists to focus on the two key questions that are most frequently asked by clinicians. Is the evidence relevant to my clinical practice? How can I judge whether the probability of benefit from treatment in my current patient is likely to differ substantially from the average probability of benefit reported in the relevant trial or systematic review? These questions are addressed from methodological and clinical perspectives, and potential approaches to improving the targeting of treatment are considered, with detailed reviews of several areas of medicine and surgery where useful progress has been made.
Section 1: Reliable determination of the overall effects of treatments
1) Reliable assessment of the effects of treatment on mortality and major morbidity 2) The lethal consequences of failing to make full use of all relevant evidence about the effects of medical treatments: the importance of systematic reviews
Section 2: Is the trial relevant to this patient?
3) Assessment of the external validity of randomised trials 4) Applying results to treatment decisions in primary care 5) The older patient 6) Applying results to treatment decisions in complex clinical situations 7) External validity of pharmaceutical trials in neuropathic pain 8) External validity of pharmaceutical trials in asthma and chronic obstructive pulmonary disease
Section 3: Is the overall trial result sufficiently relevant this patient?
9) When should we expect clinically important differences in response to treatment? 10) Genes and the individual response to treatment 11) Reliable estimation and interpretation of the effects of treatment in subgroups 12) Can meta-analysis help target interventions at individuals most likely to benefit? 13) Use of risk models to predict the likely effects of treatment in individuals 14) Evaluating the performance of prognostic models 15) Are "n-of-1" trials of any practical value to clinicians or researchers?
Section 4: Targeting of treatment in routine practice
16) Primary prevention of cardiovascular disease: the absolute risk-based approach 17) Antithrombotic therapy to prevent stroke in patients with atrial fibrillation 18) Reperfusion therapies in acute cardiovascular and cerebrovascular syndromes 19) Choice of agent in treatment of epilepsy 20) Pharmacogenomic targeting of treatment for cancer
Edited by Peter M. Rothwell, MBChB, MD, PhD, FRCP(London), Professor, Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK