Thanks for the complimentary note to Indian Pediatrics on the initiation of the section on Evidence-Based Child Health, EURECA and the suggestions to the readership of the Journal. However, it may be pointed out that EURECA is not meant merely ‘to tailor evidence from the western world’ to the Indian setting, but has been designed to foster a culture of "promoting and practicing Evidence-Based Child Health".

The ‘evidence’ does not only answer the ‘decision question’ (What should I do?), but is oriented to answer a specific ‘clinical question’, that may or may not be synonymous with the decision question(1). Unfortunately, ‘evidence’ often does not provide answers to decision questions for two reasons. First, evidence from systematic reviews (usually) demonstrates ‘efficacy’ (or absence thereof) of interventions in specific clinical settings, but not necessarily ‘effectiveness’. Second, there may not be any evidence on a particular clinical question.

Put simply, ‘efficacy’ answers the question, "Does this intervention work?" and sometimes (though less often), "Can this intervention work?" On the other hand, "effectiveness" should answer the question, "Will this intervention work if it is used in my/our setting (based on current best evidence)", assuming of course that the intervention is available, accessible, acceptable, applicable and affordable (‘five A’ criteria). By extension, it leads towards the question (and answer to), "Should I use this intervention or not?". This requires weighing the evidence (obtained from systematic reviews or otherwise) in the context of the setting where it is applied. This necessitates an understanding of the biological aspects of the patient(s), presence of co-morbidities, patient values (such as preferences, compliance pattern, socio-economic impact etc), health-care setting and last, but not the least cost considerations. Therefore, in our country which has diverse modes of health-care delivery with variable ‘quality’, application of the same evidence in different settings, may result in different ‘effectiveness’ in terms of outcome.

Although it is often not possible to work out these considerations scientifically within and through the frame-work of a systematic review, EURECA tries to capture this complex concept informally (subjectively) through the term, "Extendibility"(1). A more formal (objective) way could be to undertake Health Technology Assessment (HTA) of a particular intervention that incorporates best evidence from systematic reviews, and also considers the other important issues. Thus HTA is more likely to be able to answer questions of ‘effectiveness’ than an appraisal of evidence alone; and thereby be able to answer decision questions.

Joseph L Mathew,
Advanced Pediatrics Center,
PGIMER, Chandigarh 160 012, India.
Email: [email protected]