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Quality of Life and the One-Trial Reflex

Quality-of-life has become a buzz word, enough to bring tears to most clinicians' eyes. This is a shame because we really do need ways to measure the ways in which interventions can "make patients feel better".

The efficacy bandwagon - purchase the effective, discard the ineffective - is long overdue, although Bandolier likes the phrase "stop unnecessary interventions" best. The cautionary note is that if we try to measure the efficacy on one dimension alone, however well validated those measurements may be, we may miss subtleties from other dimensions - the things which make the patient feel better. An example of this may be the use of counsellors in primary care - one of the DEC reports featured in this issue.

A crude example would be functional disability measurement. This may well categorise end-of-life disability, but be useless for more minor degrees of disability such as inability to raise an arm to comb hair. The danger is that we discard interventions because of their failure to `score' on one outcome and miss the subtlety, the excuse to get better, in our haste. Physiotherapy in primary care has by and large scored poorly in many of the reviews, but few of the trials have looked for these subtleties. Those seeking relief of symptoms in a self-limited disorder may appreciate those subtleties.

The one report reflex

Clinicians on the leading edge have a problem. A new trial is published showing marvellous results in a previously intractable condition. The trial meets all the critical appraisal quality standards. Surely the next ten patients coming to the surgery with that problem should get the treatment (and the others without the condition too)?

A wise professor of medicine challenged Bandolier when confronted with the evidence that the profession was very slow to change its ways - the specific example was the use of thrombolytics after myocardial infarction - and the more than ten years it took to filter through to practice [1]. The professor's point was that this delay might serve a purpose, to make sure that the findings were right before they were applied widely. The point was well taken, as recent flawed reviews on magnesium in myocardial infarction and low dose aspirin in high-risk pregnancy have shown.

Perhaps this is even more of a problem when safety rather than efficacy is the issue. A trial reports that drug X causes problems. Everyone stops taking drug X. The spate of pregnancies after the DVT and oral contraceptive publicity is a glaring example ( Bandolier 21 ). For personal reasons Bandolier is worried that stopping selegiline in Parkinson's may extend quantity of life for 1 in 10 patients but reduce quality of life for the nine ( Bandolier 23 ).

All this shows that life isn't easy. You have to assess the evidence and act. At least doctors have an advantage over most all other areas of professional life in that they have evidence on which to base their decisions.

Reference:

1 E Antman, J Lau, J Jiminez-Silva, et al. A comparison of results of meta-analyses of randomised control trials and recommendations of experts. Treatments for myocardial infarction. Journal of the American Medical Association 1992 268:240-248.






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