Journal of health services research & policy
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J Health Serv Res Policy · Apr 1999
ReviewThreats to applicability of randomised trials: exclusions and selective participation.
Although the randomised controlled trial (RCT) is regarded as the 'gold standard' in terms of evaluating the effectiveness of interventions, it is susceptible to challenges to its external validity if those participating are unrepresentative of the reference population for whom the intervention in question is intended. In the past, reporting on numbers and types of potential subjects that have been excluded by design, and centres, clinicians or patients that have elected not to participate, has generally been poor, and the threat to inference posed by possible selection bias is unclear. ⋯ Narrow inclusion criteria may offer benefits such as increased precision and reduced loss to follow-up, but there are important disadvantages, such as uncertainty about extrapolation of results, which may result in denial of effective treatment to groups who might benefit, and delay in obtaining definitive results because of reduced recruitment rate. Selective participation by teaching centres and sicker patients in treatment RCTs may exaggerate the measured treatment effect. Prevention trials, on the other hand, may underestimate effects as participants have less capacity to benefit.
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J Health Serv Res Policy · Apr 1999
Historical ArticleGovernment funding of the UK National Health Service: what does the historical record reveal?
To examine the historic funding record of the UK National Health Service (NHS) by year (1948-1997), political administration and political party. ⋯ As a guide to voting, this analysis may confirm some prejudices. However, judging the performance of political administrations in relation to the NHS is rather more complex than a macro analysis of financial inputs alone suggests. The apparently weak relationship between inputs and outputs and the possible ability of governments to increase productivity by restricting inputs (and hence partially to deflect criticism of their funding policy) perhaps confirms other prejudices about the productive slack of large organisations. Again, however, care should be taken in the interpretation of the macro analysis, since the potential costs (e.g. reduced quality) arising from parsimonious funding are not captured by the global output measure used in this analysis.