DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY
EDITORIAL
Levels of evidence and traffic light alerts I still vividly remember as a medical student being struck by the way two different experts treated patients with breast cancer, one by a simple lumpectomy and the other by very radical and deforming surgery. It was clear that both could not always be right and was a forceful introduction to the need for evidence-based management. One responsibility of journals such as DMCN is to help to improve current practice by publishing peer-reviewed and statistically validated evidence for, and against, different interventions in our field. The recent systematic review by Novak et al. is an example of an attempt to do this for cerebral palsy. It included an innovative traffic light system to present the results of the GRADE scores in an easily accessible format, intended to help in knowledge translation.1 Similar traffic lights have been used in other areas of medicine, usually in the context of management guidelines, such as the UK National Institute for Clinical Evidence (NICE) advice on assessment of a febrile child.2 This is the first attempt to create traffic lights for interventions in as complex and varied a group of conditions as the cerebral palsies. It is even more challenging when individual interventions can be either aimed at the primary problems, motor control and sensory neglect, or at secondary effects, such as hypertonia and musculoskeletal problems, or a mixture of these. As pointed out in the ensuing correspondence, published in this issue, the systematic review highlights several other issues. One is to demonstrate the influence of the pharmaceutical industry, which is widely recognized to fund the vast majority of medical research worldwide. Partly this is due to the cost of meeting international drug licensing requirements, but inevitably it leads to a heavy emphasis on allopathic medicine. Anyone who has attempted research in other fields is aware of the far more limited funding available, especially as many studies will be even more expensive than a drug trial as the interventions are so much more complex than simply giving a drug or placebo. Another less expected consequence has been the interpretation that only green light interventions should be offered. This is clearly incorrect and the results must not be used in this way. As pointed out by orthopaedic and other colleagues, the fact that there is lower
level evidence for a specific procedure does not mean that it is ineffective in appropriately selected patients. However, it is a curious situation that, for example, there are at least three schools of thought in terms of habilitation: Bobath neurodevelopmental therapy, Peto conductive education, and Vojta therapy, whose use seems more based on geographical considerations than comparative studies of efficacy. A further concern has been over possible effects on funding. Publicly funded health systems are already examining the value they receive for the money they spend. For example in Denmark provision of physiotherapy and occupational therapy for people with cerebral palsy costs approximately €12 million annually. Last year the national funding bodies commissioned a Cochrane review of these interventions which also used the GRADE system and reported that the resulting levels of evidence were all low or very low. Colleagues in Denmark are understandably concerned that over-rigid interpretation of these criteria may lead to an unjustified reduction in service provision (P Uldall, personal communication 2014). In the last few decades the management of breast cancer has moved forward impressively, with multidisciplinary teamwork and targeted therapy using one or a combination of approaches based on a validated classification of the disease and large-scale trials. Management of cerebral palsy has also improved in the same way, except for the vital factor of large-scale trial evidence. Using a traffic light system to code the evidence for or against current interventions based on data published in systematic reviews, where much detail has to be omitted, has led to understandable criticism and concern about oversimplification, as the authors acknowledge. In addition, it may not have the anticipated benefits in knowledge translation.3 Nonetheless, it has been an enormously effective way of alerting us to the interventions that urgently require adequately funded research.
PETER BAXTER Editor in Chief doi: 10.1111/dmcn.12422
REFERENCES 1. Novak I, McIntyre S, Morgan C et al. A systematic review
guideline 160. 22 May 2013. http://www.nice.org.uk/
improve clinician’s evidence-based practice behavior-a
of interventions for children with cerebral palsy: state of
nicemedia/live/14171/63905/63905.pdf (accessed 16 Jan-
cluster randomized controlled trial. Implement Sci 2013;
the evidence. Dev Med Child Neurol 2013; 55: 885–910.
uary 2014).
8: 132.
2. National Institute for Health and Clinical Excellence.
3. Campbell L, Novak I, McIntyre S, Lord S. A KT
Feverish illness in children: full guideline. Clinical
intervention including the evidence alert system to
296
© 2014 Mac Keith Press
EDITORIAL
Levels of evidence and traffic light alerts I still vividly remember as a medical student being struck by the way two different experts treated patients with breast cancer, one by a simple lumpectomy and the other by very radical and deforming surgery. It was clear that both could not always be right and was a forceful introduction to the need for evidence-based management. One responsibility of journals such as DMCN is to help to improve current practice by publishing peer-reviewed and statistically validated evidence for, and against, different interventions in our field. The recent systematic review by Novak et al. is an example of an attempt to do this for cerebral palsy. It included an innovative traffic light system to present the results of the GRADE scores in an easily accessible format, intended to help in knowledge translation.1 Similar traffic lights have been used in other areas of medicine, usually in the context of management guidelines, such as the UK National Institute for Clinical Evidence (NICE) advice on assessment of a febrile child.2 This is the first attempt to create traffic lights for interventions in as complex and varied a group of conditions as the cerebral palsies. It is even more challenging when individual interventions can be either aimed at the primary problems, motor control and sensory neglect, or at secondary effects, such as hypertonia and musculoskeletal problems, or a mixture of these. As pointed out in the ensuing correspondence, published in this issue, the systematic review highlights several other issues. One is to demonstrate the influence of the pharmaceutical industry, which is widely recognized to fund the vast majority of medical research worldwide. Partly this is due to the cost of meeting international drug licensing requirements, but inevitably it leads to a heavy emphasis on allopathic medicine. Anyone who has attempted research in other fields is aware of the far more limited funding available, especially as many studies will be even more expensive than a drug trial as the interventions are so much more complex than simply giving a drug or placebo. Another less expected consequence has been the interpretation that only green light interventions should be offered. This is clearly incorrect and the results must not be used in this way. As pointed out by orthopaedic and other colleagues, the fact that there is lower
level evidence for a specific procedure does not mean that it is ineffective in appropriately selected patients. However, it is a curious situation that, for example, there are at least three schools of thought in terms of habilitation: Bobath neurodevelopmental therapy, Peto conductive education, and Vojta therapy, whose use seems more based on geographical considerations than comparative studies of efficacy. A further concern has been over possible effects on funding. Publicly funded health systems are already examining the value they receive for the money they spend. For example in Denmark provision of physiotherapy and occupational therapy for people with cerebral palsy costs approximately €12 million annually. Last year the national funding bodies commissioned a Cochrane review of these interventions which also used the GRADE system and reported that the resulting levels of evidence were all low or very low. Colleagues in Denmark are understandably concerned that over-rigid interpretation of these criteria may lead to an unjustified reduction in service provision (P Uldall, personal communication 2014). In the last few decades the management of breast cancer has moved forward impressively, with multidisciplinary teamwork and targeted therapy using one or a combination of approaches based on a validated classification of the disease and large-scale trials. Management of cerebral palsy has also improved in the same way, except for the vital factor of large-scale trial evidence. Using a traffic light system to code the evidence for or against current interventions based on data published in systematic reviews, where much detail has to be omitted, has led to understandable criticism and concern about oversimplification, as the authors acknowledge. In addition, it may not have the anticipated benefits in knowledge translation.3 Nonetheless, it has been an enormously effective way of alerting us to the interventions that urgently require adequately funded research.
PETER BAXTER Editor in Chief doi: 10.1111/dmcn.12422
REFERENCES 1. Novak I, McIntyre S, Morgan C et al. A systematic review
guideline 160. 22 May 2013. http://www.nice.org.uk/
improve clinician’s evidence-based practice behavior-a
of interventions for children with cerebral palsy: state of
nicemedia/live/14171/63905/63905.pdf (accessed 16 Jan-
cluster randomized controlled trial. Implement Sci 2013;
the evidence. Dev Med Child Neurol 2013; 55: 885–910.
uary 2014).
8: 132.
2. National Institute for Health and Clinical Excellence.
3. Campbell L, Novak I, McIntyre S, Lord S. A KT
Feverish illness in children: full guideline. Clinical
intervention including the evidence alert system to
296
© 2014 Mac Keith Press
