Series: Pragmatic trials and real world evidence: Paper 5. Usual care and real life comparators.

Mira G Zuidgeest, Paco Welsing, Ghislaine van Thiel, Antonio Ciaglia, Rafael Alfonso-Cristancho, Laurent Eckert, Marinus J C Eijkemans, Matthias Egger,

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Pragmatic trials may deliver real-world evidence on the added value of new medications compared with usual care and inform decision making earlier in development. This fifth paper in a series on pragmatic trials in the Journal discusses usual care as a comparator and the allocation of treatment strategies. The allocation and implementation of treatment strategies should resemble clinical practice as closely as possible. Randomization at the level of the site, as opposed to at the individual level, may be preferred. Data analysis according to the intention-to-treat principle is recommended, and crossover between treatment arms and strong treatment preferences may be accounted for in the study design in specific situations. Although usual care is the comparator of choice, this may differ substantially between centers and countries complicating comparator choice. Using clinical guidelines to define usual care can be helpful in standardizing comparator treatments; however, this may decrease the applicability of the results to real-life settings. Conversely, using multiple usual-care treatment arms will increase the complexity of the study. The specific objectives of the trial and design choices should be discussed with all stakeholders to realize the full potential of the pragmatic trial.

Original languageEnglish
Pages (from-to)92-98
Number of pages7
JournalJournal of Clinical Epidemiology
Early online date7 Jul 2017
Publication statusPublished - Oct 2017


  • Comparator choice
  • Pragmatic trial
  • Real-world evidence
  • Routine clinical practice
  • Treatment strategy
  • Usual care


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