Contextual evidence in clinical medicine and health promotion

Abstract

The randomized clinical trial (RCT) and systematic review underpin evidence-based medicine. They are perceived to provide the strongest evidence on interventions—when viewed as part of an evidence hierarchy, and are generally accepted as such, in clinical medicine. Yet, they are perceived to have limited currency in health promotion practice.1 Those trying to build bridges across these fields have often been challenged as to whether or not the RCT is the design for both.2 We argue that ‘real life’, including decision making and practice both in clinical medicine and health promotion, requires contextualized evidence; that integrated research on outcome and context is feasible and desirable, both in clinical medicine and health promotion; and that these fields could learn from each other's approaches towards contextualization of evidence. Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. It integrates the best external evidence with individual clinical expertise and patients’ choice.3 In generating external evidence, various research designs are applicable. The RCT and systematic review of trials are regarded as the best options for answering questions on the efficacy of interventions. Diagnostic and prognostic studies require other types of designs. Making a clinical decision in the treatment of a specific patient requires information on the clinical profile of the patient. The clinician needs to assess whether this patient resembles the ‘average’ patient who is typically being studied in RCTs and to whom guidelines typically refer. The selection criteria in RCTs frequently exclude e.g. co-morbid conditions, younger …