Fair Testing: The Science And Politics Of Effective Health Care

Abstract

This slim book is a trenchant guide to the methods, uses, and politics of “fair tests” of the effectiveness of interventions for preventing, diagnosing, and treating disease. By fair tests the authors mean research that evaluates interventions by identifying bias and taking proper account of the laws of chance. The authors avoid the ambiguous and often embattled phrase “evidence-based” in discussing this research. The methodology of fair testing, elaborated over many years, has advanced especially rapidly since the 1970s. These methods are now being used globally to evaluate drugs, diagnostic and screening tests, and surgical procedures. In the United States, national policy to prioritize, subsidize, and disseminate the results of fair tests that compare the clinical and cost-effectiveness of competing interventions has recently become politically plausible. The best-known fair-test methodologies are randomized controlled trials (RCTs) and systematic reviews. These reviews, which are currently the most rigorous fair tests, once only aggregated and evaluated data from RCTs. In recent years, however, reviewers have been taking account of data from less rigorous trials, as well as from observational and even qualitative studies. Other approaches to fair testing are evolving: for example, simulations, patient registries, and the development of evidence as a condition of coverage. Effective Care in Pregnancy and Childbirth (ECPC), two volumes published in 1989, applied the methodology of fair testing to an entire field of patient care for the first time. Iain (now Sir Iain) Chalmers, a coauthor of Testing Treatments, was a principal organizer and author of ECPC. Several years later Chalmers took the lead in organizing an international collaboration to set standards for systematic reviews, as well as to conduct and publish them. More than 14,000 reviewers in about ninety countries now participate in the Cochrane Collaboration (named after Archie Cochrane, a pioneer of fair testing). In 1987, two years before the publication of ECPC, fewer than 100 systematic reviews appeared in the international literature of the health sector; in 2006, around 2,500 did. Many other organizations also promote, conduct, and sponsor fair tests of interventions to maintain and improve health. For most of the 1990s the United States lagged behind Australia, Canada, and the United Kingdom in developing and applying the methods of fair testing. During the current decade, however, attention to fair tests in the United States has increased, especially among agencies of the federal government and the states, integrated delivery systems and insurers, nonprofit research organizations, and the pharmaceutical industry. Testing Treatments is the best available introduction to the methods, uses, and value of fair testing. The authors draw most of their examB o o k R e v i e w s