Astronomy and Evidence: StaR Gazing for Children's Trials
On the eve of the 20th anniversary of the United Nations Convention on the Rights of the Child, which recognised the right of all children to "the enjoyment of the highest attainable standard of health", the editor of the Lancet Richard Horton was delivering a plenary address at the first summit of StaR Child Health in Amsterdam in 2009. In his address, he stated the:
“Lack of research, poor research, and poorly reported research are violations of children’s human rights.”
Individuals from various disciplines, including the World Health Organisation, the US Food and Drug Administration, and the European Medicines Agency, gathered together to discuss a topic of shared interest: the paucity and shortcomings of paediatric clinical trials.
The quality, quantity and relevance of data involving children are substantially lower than those involving adults. This problem persists despite knowledge that inadequate testing of medication in children may result in harmful or ineffective drugs being offered or beneficial drugs being withheld.
Indeed a systematic review sponsored by the World Health Organisation found that there were few guidelines relevant to the design, conduct and reporting of research in children. Most guidelines only seem to focus on what should be done, failing to address the important issue of how it should be completed.
The mission of StaR Child Health is to improve the design, conduct and reporting of "research with children through the development and dissemination of evidence-based standards."
How best to achieve this monumental task? The StaR Child Health group is using a "knowledge to action" process that involves using a systematic process to review the current knowledge base, identify gaps, develop guidance and implementation strategies. An ambitious agenda that is gaining tremendous momentum.
Based the results of a systematic review and survey of key stakeholders, they have identified 10 priority issues. Each issue will be systematically addressed by a standard development group that will produce evidence summaries, identify gaps and develop a dissemination strategy. The priority issues include recruitment and informed consent, risk of bias, sample size, age-specific dosage and administration, safety and global health.
But more guidelines and standards will not change the conduct of trials unless they are implemented. StaR Child Health is leading in knowledge translation by involving multiple stakeholders from the beginning and is working with international partners, such as the GRIP Project, a global research network in paediatrics.
For the quality of health care for children across the world to improve, trials must be conducted that address the complexity of child health and provide reliable evidence-based answers. Now we can be confident that we have a bright StaR illuminating the path forward.
The inadequate evidence base for monitoring in chronic diseases
We often undertake projects with folk who visit the department, and for this systematic review, Ivan Moschetti visiting from Italy and Daniel Brandt from Canada did a great job, undertaking the majority of the spade-work.
Our conclusion is pretty straightforward: ‘Many guidelines for cardiovascular disease do not report clearly what to monitor and what to do if a change is detected. If no evidence is available to support a specific monitoring schedule, this should be explicit in the guideline, with a description of the new research that would fill the gap’.
A lot of money is spent on monitoring in chronic diseases, and based on what we found a considerable amount of it is wasted. Read more