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Evidence from large, well-conducted randomized controlled trials (RCTs) can clarify whether a particular treatment is superior to placebo or to a currently accepted alternative approach. Neurologists welcome such data because RCT-level evidence is often not available to guide many clinical decisions we regularly have to make. In general, clinicians do not like uncertainty and would prefer to have evidence. When evidence is lacking, there is a potential for wide variations in practices and for a variety of non-clinical factors to influence treatment decisions.1
In some circumstances, however, new RCT evidence may make clinical decision-making more complex, rather than more straightforward. This situation is illustrated by the findings of Jacoby et al.,2 who report quality-of-life outcomes from a multicenter, randomized trial of immediate vs deferred antiepileptic drug treatment in previously untreated adults presenting with a single or a few unprovoked seizures. To be eligible for the trial, both the treating clinician and the patient had to be uncertain (in equipoise) as to whether to initiate antiepileptic drug treatment. Seizure outcomes were previously reported,3 and that study’s findings …
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