Abstract
BackgroundEffectiveness of interventions in pragmatic trials may not translate directly into population impact, because of limited uptake by clinicians and/or the public. Uptake of an intervention is influenced by a number of factors.MethodsWe propose a method for calculating population impact of clinical interventions that accounts for the intervention uptake. We suggest that population impact may be estimated by multiplying the two key components: (1) the effectiveness of the intervention in pragmatic trials (trial effect); and, (2) its uptake in clinical practice. We argue that participation rates in trials may be a valid proxy for uptake in clinical practice and, in combination with trial effectiveness estimates, be used to rank interventions by their likely population impact. We illustrate the method using the example of four interventions to decrease antibiotic prescription for acute respiratory infections in primary care: delayed prescribing, procalcitonin test, C-Reactive Protein, shared decision making.ResultsIn order to estimate uptake of interventions from trial data we need detailed reporting on the recruitment processes used for clinician participation in the trials. In the antibiotic prescribing example, between 75 and 91% of the population would still be prescribed or consume antibiotics because effective interventions were not taken up. Of the four interventions considered, we found that delayed prescribing would have the highest population impact and shared decision making the lowest.ConclusionEstimates of uptake and population impact of an intervention may be possible from pragmatic RCTs, provided the recruitment processes for these trials are adequately reported (which currently few of them are). Further validation of this method using empirical data on intervention uptake in the real world would support use of this method to decide on public funding of interventions.
Highlights
Effectiveness of interventions in pragmatic trials may not translate directly into population impact, because of limited uptake by clinicians and/or the public
We propose a method for calculating population impact of clinical interventions that accounts for the intervention uptake
We suggest that population impact may be estimated by multiplying the two key components: (1) the effectiveness of the intervention in pragmatic trials; and, (2) its uptake in clinical practice
Summary
Effectiveness of interventions in pragmatic trials may not translate directly into population impact, because of limited uptake by clinicians and/or the public. The effectiveness of an intervention in real clinical practice may be estimated in pragmatic trials conducted on patients who represent the full spectrum of the population to which the intervention might be applied, and where the comparator group receives usual care [1, 2]. Pragmatic trials are designed to determine the effects of an intervention under the usual conditions in which it will be applied, [3] and focus on the choice between options for care rather than biological understanding [4]. Uptake of an intervention is influenced by a number of factors; for example for clinician uptake, these range from knowledge of the intervention and the skills to implement it, through to emotion regulation and beliefs about the intervention itself [12]
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