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Megatrials for Clinical Decision Making
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
TO THE EDITOR:
Borzak and Ridker [1] highlight some established strengths and weaknesses of meta-analyses. In contrast to Chalmers [2] and Charlton [3], however, they provide a much less balanced view of large-scale randomized, controlled trials.
Is it helpful to use examples of megatrials with sample sizes of 60 000 to 70 000 patients to advocate megatrials, when respective meta-analyses include scarcely 2000 patients? In fact, the two examples with comparable patient numbers (although several times larger than 2000) showed no substantial differences between the two approaches. If anything, one could conclude that evidence from more cases is more reliable.
It is also common wisdom that the existing evidence should be considered when designing a clinical trial. I disagree, however, that a meta-analysis should exclusively be viewed as “hypothesis-generating” [1]. This proposal denies the fact that, however biased, a high-quality meta-analyses (“systematic review” [4]) quantitatively summarizes the existing evidence. What could be a better basis for a clinician's treatment decision at the time it must be made?
We will never have enough expertise, resources, or patients to conduct large-scale randomized, controlled trials on every topic (trials that, one could argue, would then have to be confirmed by at least one other independent trial of similar size).
The strength of individual large-scale randomized, controlled trials should not be overestimated. For practical purposes (that is, the clinical treatment decision), clinicians should practice evidence-based medicine, for which meta-analyses can be an extremely helpful tool. This approach is both more reliable than a clinician's personal experience alone [5] and more beneficial for a given patient than a clinician's disregard for the evidence from meta-analyses while awaiting the results of larger randomized, controlled trials.
Karl-Ludwig Resch, MD, PhD
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
