Leadership Β· 4 min read
Research Equity: Whose Evidence Are We Building Our Practice On?
Evidence-based medicine is only as equitable as the evidence on which it is based. When the studies that populate our clinical guidelines exclude the populations most affected by the conditions they address, we are not practising evidence-based medicine for those patients. We are extrapolating β and the consequences of that extrapolation fall on those who are already most underserved.
The demographic composition of clinical trial populations in orthopaedic surgery has been examined in multiple systematic analyses β and the findings are consistent. Trial populations skew younger than real clinical populations, have fewer comorbidities, are more likely to be recruited from academic medical centres in high-income countries, and β depending on the condition studied β may significantly under-represent women, older patients, and patients from ethnic minority backgrounds. Each of these demographic gaps represents a group of patients for whom the evidence we apply may not have been generated.
The elderly patient problem
Fragility fracture patients β the majority of proximal humerus and distal radius fracture presentations in NHS practice β are systematically excluded from clinical trials through age cutoffs, comorbidity exclusion criteria, and the practical difficulty of long-term follow-up in populations with higher attrition rates. The result is a trauma management evidence base whose most robust trials involve patients who are healthier, younger, and have fewer comorbidities than the patients to whom their findings are most commonly applied.
The clinician who applies PROFHER trial findings to a frail 85-year-old with dementia, significant cardiac disease, and minimal physiotherapy access is extrapolating beyond the trial's population in ways that may or may not be appropriate. Honest acknowledgement of this extrapolation β and the clinical judgment it requires β is the foundation of applying evidence responsibly rather than mechanically.
Building equity into research design
Research equity is not achieved by adding a diversity statement to a grant application. It requires prospective strategies that are built into the study from the beginning: inclusion criteria designed to reflect the clinical population rather than research convenience; recruitment strategies that reach beyond academic medical centre patient lists; outcome measures that are validated across the demographic groups being studied; and subgroup analyses that are pre-specified and adequately powered to detect differential treatment effects across relevant demographic variables.
Every patient whose demographic group is excluded from the evidence base that guides their care deserves better from the research community. Building that better evidence base is both a scientific and an ethical imperative.
The inspiring dimension of this challenge is that the tools to address it are increasingly available: federated learning architectures that enable participation without data sharing barriers, community-based research partnerships that reach populations outside academic centre networks, and patient and public involvement practices that centre the perspectives of under-represented groups in research priority-setting. The will to use these tools, systematically and consistently, is what the field now needs.
π¬ How do you assess the applicability of trial evidence to the specific patients in your practice β and what research equity priorities do you believe deserve more attention in your specialty?