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Evidence-based medical practice: the Cochrane Collaboration and osteoarthritis.

IT is a sine qua non of good medical practice that patients be offered the best available therapy for their condition. Evidence for the efficacy of treatments derives from clinical trials of particular agents or interventions and, of these, it is the randomized, controlled trials (RCT) which hold centre stage. It is estimated that there are now over 250 000 published controlled trials of health care interventions and over 15 000 RCTs are published annually, with the number doubling about every 5 yr. With this explosion in medical information, it seems logical to try to sort out these interventions into groups according to evidence of usefulness [1,2]. This would allow for the development of guidelines for appropriate treatment using interventions which show improvement in outcome or important benefit/harm tradeoffs—and interventions where there is clear evidence of ineffectiveness or harm. Inclusion of cost-effectiveness data will also allow decisions to be made regarding equivalent treatments of differing cost to the patient and society. It will also identify interventions where there is inconclusive evidence and further work needs to be performed. As Silagy [3] has pointed out, such systemic reviews of the medical literature are slow to evolve, investigations are often repeated and clinical practice usually lags well behind. For example, as long ago as 1972 there was clear evidence for the benefits to neonates of corticosteroids administered to pregnant women entering premature labour [4] but 11 further studies were carried out before a systematic review of these RCTs was published in 1989 [5]. This confirmed the results of the early study showing the odds ratio for babies dying from complications of immaturity could be reduced by between 30 and 50% if corticosteroids were administered appropriately. In the intervening years, mothers and babies had suffered significant morbidity and mortality, with major costs accruing to the health care system [5]. Something needs to be done to make the evidence about appropriate health care interventions readily available to every practitioner.