Applying Evidence to Patient Care: From Black and White to Shades of Grey
Authors: Finlay A. McAlister
Journal: Annals of Internal Medicine (2003)

Editorials3 June 2003Applying Evidence to Patient Care: From Black and White to Shades of GreyFinlay A. McAlister, MD, FRCPCFinlay A. McAlister, MD, FRCPCFrom University of Alberta; Edmonton, Alberta T6G 2R7, Canada.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-138-11-200306030-00016 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The interface between evidence and clinical care is complicated: What appears black and white in a trial report may rapidly become grey in practice (1). Even when presented with internally valid, well-conducted trials, clinicians frequently face doubts about how we can apply this evidence to our individual patients. The potential problems in extrapolating from trials that are small, are of short duration, rely on surrogate outcomes, or use active controls of uncertain efficacy are well described (2-5). However, in this editorial, I focus on the dilemma at the heart of Dr. Shlipak's paper in this issue (6): Can we extrapolate ...References1. Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet. 1995;345:840-2. [PMID: 7898234] CrossrefMedlineGoogle Scholar2. Bucher HC, Guyatt GH, Cook DJ, Holbrook A, McAlister FA. Users' guides to the medical literature: XIX. Applying clinical trial results. A. How to use an article measuring the effect of an intervention on surrogate end points. Evidence-Based Medicine Working Group. JAMA. 1999;282:771-8. [PMID: 10463714] CrossrefMedlineGoogle Scholar3. Massie BM. 15 years of heart-failure trials: what have we learned? Lancet. 1998;352 Suppl 1 SI29-33. [PMID: 9736477] CrossrefMedlineGoogle Scholar4. Califf RM, DeMets DL. Principles from clinical trials relevant to clinical practice: Part I. Circulation. 2002;106:1015-21. [PMID: 12186809] CrossrefMedlineGoogle Scholar5. McAlister FA, Sackett DL. Active-control equivalence trials and antihypertensive agents. Am J Med. 2001;111:553-8. [PMID: 11705432] CrossrefMedlineGoogle Scholar6. Shlipak MG. Pharmacotherapy for heart failure in patients with renal insufficiency. Ann Intern Med. 2003;138:917-24. LinkGoogle Scholar7. Heiat A, Gross CP, Krumholz HM. Representation of the elderly, women, and minorities in heart failure clinical trials. Arch Intern Med. 2002;162:1682-8. [PMID: 12153370] CrossrefMedlineGoogle Scholar8. Assmann SF, Pocock SJ, Enos LE, Kasten LE. Subgroup analysis and other (mis)uses of baseline data in clinical trials. Lancet. 2000;355:1064-9. [PMID: 10744093] CrossrefMedlineGoogle Scholar9. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988;2:349-60. [PMID: 2899772] MedlineGoogle Scholar10. Chandra NC, Ziegelstein RC, Rogers WJ, Tiefenbrunn AJ, Gore JM, French WJ, . Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I. Arch Intern Med. 1998;158:981-8. [PMID: 9588431] CrossrefMedlineGoogle Scholar11. Sleight P. Debate: Subgroup analyses in clinical trials: fun to look atbut don't believe them! Curr Control Trials Cardiovasc Med. 2000;1:25-27. [PMID: 11714402] CrossrefMedlineGoogle Scholar12. Oxman AD, Guyatt GH. A consumer's guide to subgroup analyses. Ann Intern Med. 1992;116:78-84. [PMID: 1530753] LinkGoogle Scholar13. Shlipak MG, Browner WS, Noguchi H, Massie B, Frances CD, McClellan M. Comparison of the effects of angiotensin converting-enzyme inhibitors and blockers on survival in elderly patients with reduced left ventricular function after myocardial infarction. Am J Med. 2001;110:425-33. [PMID: 11331052] CrossrefMedlineGoogle Scholar14. McAlister FA. Commentary: relative treatment effects are consistent across the spectrum of underlying risks usually. Int J Epidemiol. 2002;31:76-7. [PMID: 11914298] CrossrefMedlineGoogle Scholar15. Flather MD, Yusuf S, Kober L, Pfeffer M, Hall A, Murray G, . Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet. 2000;355:1575-81. [PMID: 10821360] CrossrefMedlineGoogle Scholar16. Sin DD, McAlister FA. The effects of -blockers on morbidity and mortality in a population-based cohort of 11,942 elderly patients with heart failure. Am J Med. 2002;113:650-6. [PMID: 12505115] CrossrefMedlineGoogle Scholar17. Mortality risk and patterns of practice in 4606 acute care patients with congestive heart failure. The relative importance of age, sex, and medical therapy. Clinical Quality Improvement Network Investigators. Arch Intern Med. 1996;156:1669-73. [PMID: 8694665] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From University of Alberta; Edmonton, Alberta T6G 2R7, Canada.Grant Support: Dr. McAlister is a Population Health Investigator of the Alberta Heritage Foundation for Medical Research.Disclosures: None disclosed.Corresponding Author: Finlay A. McAlister, MD, FRCPC, Department of Medicine, 2E3.24 WMC, University of Alberta Hospital, 8440 112 Street, Edmonton, Alberta T6G 2R7 Canada; e-mail, Finlay.[email protected]ca. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoPharmacotherapy for Heart Failure in Patients with Renal Insufficiency Michael G. Shlipak Metrics Cited byLipid Testing, Lipid-Modifying Therapy, and PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9) Inhibitor Eligibility in 27 979 Patients With Incident Acute Coronary SyndromeThe hospital frailty risk score in patients with heart failure is strongly associated with outcomes but less so with pharmacotherapyCardiac resynchronization therapy (CRT): Clinical trials, guidelines, and target populationsICDs, Guidelines, and National Registries: Opportunities to Enhance Quality of Patient CareChanges in Myocardial Infarction Guideline Adherence as a Function of Patient RiskTreatment of Type 2 Diabetes and Outcomes in Patients With Heart Failure: A Nested Case-Control Study From the U.K. General Practice Research DatabaseCardiac Resynchronization Therapy for Heart FailureAssociation of Metabolic Syndrome in Nondiabetic Patients with Increased Risk for Chronic Kidney Disease: The Fat Lady SingsChallenges in Systematic Reviews of Therapeutic Devices and ProceduresLisa Hartling, MSc, Finlay A. McAlister, MD, MSc, Brian H. Rowe, MD, MSc, Justin Ezekowitz, MB, BCh, MSc, Carol Friesen, MA, MLIS, and Terry P. Klassen, MD, MScEvidence-based medicine in long-term careImproving Patient Care: Learning More from Bad OutcomesUsefulness of spironolactone in a specialized heart failure clinicFrom knowledge to practice in chronic cardiovascular disease: a long and winding roadALLHAT, or the Soft Science of the Secondary End PointFranz H. Messerli, MD 3 June 2003Volume 138, Issue 11Page: 938-939KeywordsACE inhibitorsAspirinClinical trial reportingClinical trialsHeartHeart failureHospital medicineRenal analysisSaltsSurvival analysis ePublished: 3 June 2003 Issue Published: 3 June 2003 Copyright & PermissionsCopyright © 2003 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...