Three years of experience with prospective randomized effectiveness studies

In defense of the randomized controlled trial for health promotion research

The overwhelming evidence about the role lifestyle plays in mortality, morbidity, and quality of life has pushed the young field of modern health promotion to center stage. The field is beset with intense debate about appropriate evaluation methodologies. Increasingly, randomized designs are considered inappropriate for health promotion research. We have reviewed criticisms against randomized trials that raise philosophical and practical issues, and we will show how most of these criticisms can be overcome with minor design modifications. By providing rebuttal to arguments against randomized trials, our work contributes to building a sound methodological base for health promotion research.

Dolasetron Versus Ondansetron for the Treatment of Postoperative Nausea and Vomiting

The management of postoperative nausea and vomiting (PONV) remains a persistent problem. Despite the use of prophylactic antiemetics, breakthrough nausea and vomiting still frequently occur. There have been no published studies comparing dolasetron and ondansetron for the treatment of PONV. This was a prospective, randomized, double-blind, active-controlled study in adult outpatient surgery patients. We screened 559 consecutive adult surgery patients, with 92 patients randomized to either ondansetron or dolasetron. The objectives of the study were 1) to determine whether treatment of PONV with ondansetron 4 mg IV or dolasetron 12.5 mg IV would result in better outcomes in patients undergoing day surgery and 2) to compare the cost of drugs used for treating PONV. Thirty-three (70%) of 47 patients given ondansetron required rescue medication, compared with 18 (40%) of 45 patients given dolasetron (P < 0.004). Dolasetron was approximately 40% less expensive than ondansetron, and the costs of the study drug plus rescue antiemetics were 30% less in the dolasetron group than in the ondansetron group. Dolasetron provided greater efficacy for antiemetic treatment because of the need for less rescue therapy. Because of the decreased use of rescue antiemetics and acquisition cost at our hospital, costs in the dolasetron group were less than costs in the ondansetron group.

Clinical trials in psychiatry: do results apply to practice?

OBJECTIVE

The purpose of this communication is to alert psychiatrists to the difficulties of translating results of group difference obtained from large, randomized clinical trials to the treatment of individual patients.

METHOD

Reported discrepancies between a) clinical trial participants and general psychiatric patients, b) clinical trial investigators and general clinicians, and c) study trial and usual clinic conditions were assessed.

RESULTS

The results confirm that important differences exist in all 3 areas.

CONCLUSIONS

Recommendations for researchers include more complete assessments of factors that account for individual difference, an appraisal of outcomes more important to patients than symptom scores, and the use of statistical methods that permit the evaluation of individual difference. Recommendations for clinicians include a careful differentiation of results obtained in different phases of clinical trials and a clear appreciation of the different purposes of those trials. Clinicians should also appreciate that short-term effectiveness is not the same as long-term outcome and that aggregate scores may not apply to individual patients.