ArticleBMC medical research methodology2006
Circular instead of hierarchical: methodological principles for the evaluation of complex interventions.
Article in BMC medical research methodology, 2006. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 64 papers, 5 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
64 citing papers in PubMed, 5 syntheses or guidelines pooled it.
- [Cannabis and cannabinoids for the treatment of acute and chronic pain].Der Anaesthesist · 2021Pooled it
- Pooled it
- Ketogenic diets in medical oncology: a systematic review with focus on clinical outcomes.Medical oncology (Northwood, London, England) · 2020Pooled it
- 10 years of mindlines: a systematic review and commentary.Implementation science : IS · 2015Pooled it
- The evidence for Shiatsu: a systematic review of Shiatsu and acupressure.BMC complementary and alternative medicine · 2011Pooled it
- Randomised controlled trials may underestimate drug effects: balanced placebo trial design.PloS one · 2014Trial
- Trial
- Exploring integrative medicine for back and neck pain - a pragmatic randomised clinical pilot trial.BMC complementary and alternative medicine · 2009Trial
- Homeopathic and conventional treatment for acute respiratory and ear complaints: a comparative study on outcome in the primary care setting.BMC complementary and alternative medicine · 2007Trial
- Clinical research on homeopathic preparations: protocol template for a series of systematic reviews.Systematic reviews · 2026Article
- Framework for evidence synthesis of traditional, complementary and integrative medicine systems incorporating context and complexity, illustrated by the example of homeopathy.Frontiers in public health · 2026Article
- Review
- Lack of pragmatic attitude of self-labelled pragmatic trials on manual therapy: a methodological review.BMC medical research methodology · 2024Review
- Protocol for a scoping review of traditional medicine research methods, methodologies, frameworks and strategies.Frontiers in medicine · 2024Article
- Wheel Replacing Pyramid: Better Paradigm Representing Totality of Evidence-Based Medicine.Annals of global health · 2024Article
- Influence of an oral health promotion program on the evolution of dental status in New Caledonia: A focus on health inequities.PloS one · 2023Article
- Review
- Effects of an intervention program with health education and hatha yoga on the health of professionals with musculoskeletal symptoms.Revista brasileira de medicina do trabalho : publicacao oficial da Associacao Nacional de Medicina do Trabalho-ANAMT · 2020Article
- When assessing generalisability, focusing on differences in population or setting alone is insufficient.Trials · 2020Article
- Statement to an Insufficient Systematic Review onEvidence-based complementary and alternative medicine : eCAM · 2020Article
4 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe reasoning behind evaluating medical interventions is that a hierarchy of methods exists which successively produce improved and therefore more rigorous evidence based medicine upon which to make clinical decisions. At the foundation of this hierarchy are case studies, retrospective and prospective case series, followed by cohort studies with historical and concomitant non-randomized controls. Open-label randomized controlled studies (RCTs), and finally blinded, placebo-controlled RCTs, which offer most internal validity are considered the most reliable evidence. Rigorous RCTs remove bias. Evidence from RCTs forms the basis of meta-analyses and systematic reviews. This hierarchy, founded on a pharmacological model of therapy, is generalized to other interventions which may be complex and non-pharmacological (healing, acupuncture and surgery). DISCUSSION: The hierarchical model is valid for limited questions of efficacy, for instance for regulatory purposes and newly devised products and pharmacological preparations. It is inadequate for the evaluation of complex interventions such as physiotherapy, surgery and complementary and alternative medicine (CAM). This has to do with the essential tension between internal validity (rigor and the removal of bias) and external validity (generalizability). SUMMARY: Instead of an Evidence Hierarchy, we propose a Circular Model. This would imply a multiplicity of methods, using different designs, counterbalancing their individual strengths and weaknesses to arrive at pragmatic but equally rigorous evidence which would provide significant assistance in clinical and health systems innovation. Such evidence would better inform national health care technology assessment agencies and promote evidence based health reform.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.