Hie need for high-quality, widely applicable evidence is gaining momentum, especially amidst health care policy makers.2-4 The increased costs of interventions and health care in a resource-limited environment have fueled the demand for clinically effective and applicable evidence. What is a pragmatic trial? The concern of whether trials produce results applicable to everyday practice was raised many decades ago. Schwartz and Lellouch, back in 1967,

coined the terms “explanatory” and “pragmatic” to differentiate trials.5 The term explanatory was used to describe trials Inhibitors,research,lifescience,medical that aim to evaluate the efficacy of an intervention in a well-defined and controlled setting, whereas the term pragmatic was used for trials designed to test the effectiveness of the intervention in a broad routine clinical practice. The explanatory trial is the best design to explore if and how an intervention works, and the whole experiment is designed in order to control for all known biases and confounders, so Inhibitors,research,lifescience,medical that the intervention’s effect is maximized. Usually the intervention under examination is compared with a placebo Inhibitors,research,lifescience,medical or with another active treatment. The pragmatic trial, on the other hand, is designed to

test interventions in the full spectrum of everyday clinical settings in order to maximize applicability and generalizability. The research Inhibitors,research,lifescience,medical question under investigation is whether an intervention actually works in real life. The intervention is evaluated against other ones (established or not) of the same or different class, in routine practice settings. Pragmatic trials measure a wide spectrum of outcomes, mostly patient-centered, Inhibitors,research,lifescience,medical whereas explanatory trials focus on measurable symptoms or markers (clinical or biological). Figure 1 illustrates some main differences between pragmatic and explanatory trials.

Figure 1. Schematic of the relationship between explanatory and pragmatic trials. The wide base of the pyramid depicts the relatively higher proportion of explanatory trials. Generally, the explanatory trials focus towards homogeneity, so that the errors and biases will influence the results as little as possible, whereas pragmatic trials are a race towards maximal heterogeneity in all aspects, Carfilzomib eg, patients, treatments, clinical settings, etc. In order to overcome the inherited heterogeneity, which leads to dilution of the effect, pragmatic trials must be large enough (to increase power to detect small effects) and simple in their design. Simple trials are easier to plan, perform, and follow up. Policy makers have an active interest in pragmatic trials, since these are designed to answer the question most relevant to a decision maker’s agenda: comparative effectiveness of interventions in the routine practice.