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Reference: Progress in clinical research in surgery and IDEAL. Peter McCulloch et al (2018) Lancet 2018; 392: 88–94

This weeks paper of the week is brought to you by Professor Sir Muir Gray, 3V Executive Director.

Bottom line

“The Idea, Development, Exploration, Assessment, and Long-term Follow-up (IDEAL) Framework and Recommendations specify desirable qualities for surgical studies, and outline an integrated evaluation pathway for surgery, and similar complex interventions. We used the IDEAL Recommendations to assess methodological progress in surgical research over time, assessed the uptake and influence of IDEAL, and identified the challenges to further methodological progress. Comparing studies from the periods 2000–04 and 2010–14, we noted apparent improvement in the use of standard outcome measures, adoption of Consolidated Standards of Reporting Trials (CONSORT) standards, and assessment of the quality of surgery and of learning curves, but no progress in the use of qualitative research or reporting of modifications during procedure development.”

Implications for value improvement 

I have sympathy for the people and companies developing drugs. They produce evidence and we criticise the papers they produce but we don’t criticise many of the developments that have taken place over the last 20 years in lab testing, imaging and surgery because there has been so little evidence produced. It’s like the famous joke about the policeman who asks the drunk looking for his keys under the lamp, although he dropped them in the dark, because that is where the light is.

Of course, it is more difficult to do randomized controlled trials in surgery principally because of the need for surgeons to develop the skills to do the operation, as distinct from the ease of prescribing a new drug but there are solutions and the IDEAL method has been increasingly influential in encouraging surgeons to think and evaluate.

The key issue is to ensure that no innovation is introduced without either very strong evidence or a commitment to evaluate that innovation from the first time it is used.