Korttila K, Apfel C C
Department of Anaesthesia and Intensive Care, Helsinki University Hospital, Helsinki, Finland.
Acta Anaesthesiol Scand. 2005 Aug;49(7):927-9. doi: 10.1111/j.1399-6576.2005.00622.x.
Many scientific articles are written merely to get something published, neglecting the clinician who would like the medical literature to guide their practice. Evidence-based medicine is expected to help in clinical decision-making. Systematic reviews of the literature followed by a meta-analysis of randomized, controlled trials (RCT) have claimed to represent the highest strength of evidence. However, the results published in meta-analyses have not always been confirmed in subsequent large RCTs. An analysis of 12 large RCTs and 19 meta-analyses addressing the same questions found that the outcomes of these large RCTs were not predicted accurately 35% of the time by previously published meta-analyses. Therefore, meta-analyses of several small RCTs do not obviate the need for large, multicentre RCTs, which can still be considered as a gold standard for the development of clinical guidelines or practice plans. Moreover, large RCTs using a factorial design can be highly efficient because they can answer several clinical questions at the same time and offer the only systematic approach to investigate an interaction of combinations in multimodal approaches.
许多科学文章仅仅是为了发表而撰写，忽视了那些希望医学文献能指导其临床实践的临床医生。循证医学有望助力临床决策。对文献进行系统评价，随后对随机对照试验（RCT）进行荟萃分析，据称代表了最高强度的证据。然而，荟萃分析中发表的结果在后续大型RCT中并非总能得到证实。一项针对12项大型RCT和19项荟萃分析的分析发现，对于相同问题，先前发表的荟萃分析有35%的时间未能准确预测这些大型RCT的结果。因此，对多个小型RCT进行荟萃分析并不能消除开展大型多中心RCT的必要性，大型多中心RCT仍可被视为制定临床指南或实践计划的金标准。此外，采用析因设计的大型RCT可能效率极高，因为它们可以同时回答多个临床问题，并且是研究多模式方法中组合相互作用的唯一系统方法。
