182 CHAPTER 9 also receive an invitation to participate in this study. Her GP is sceptical because frail older patients like Mrs. de Jong are often excluded from study participation. Nevertheless, the GP visits the website clinicaltrials.gov with details of the study in question and to the GP’s positive surprise Mrs. de Jong is eligible to participate. Mrs. de Jong is very pleased and she hopes to be randomised to the intervention arm. THE ‘INVERSE RESEARCH LAW’ The positively surprised reaction of the general practitioner (GP) about a frail old lady not being excluded from research does not emerge out of the blue. So far, almost no randomised controlled trials (RCT) have been conducted in populations with a sufficient number of frail older people, let alone RCTs exclusively focused on this patient group, while in this large and growing population there is a major need for evidence-based and personalised management. Therefore, the management of this population is mainly based on trial and error, generalising evidence from RCTs conducted in younger, non-frail patients or relying on observational data that are affected by confounding that is often difficult and sometimes even impossible to prevent or adjust for. The phenomenon that the availability of evidence is inversely related to the actual need for evidence in society is analogous to the observation that, in clinical practice, people with the greatest needs in healthcare often have the least access to healthcare services. This latter was first put into words by the British GP Julian Tudor Hart in 1971 using the term ‘inverse care law’.30 In this landmark publication he argues that vulnerable people (e.g. frail older people, but also those with a low socioeconomic status) have more health problems and need more medical care, but at the same time face more barriers in obtaining high-quality healthcare. In the areas where they live, there is less access to healthcare and both physicians and nurses have more work with a heavier patient caseload, less staff and equipment, more outdated practice buildings and less hospital support as compared to areas where more vital and younger people with a higher socioeconomic status live. This unequal distribution can further reinforce health and socioeconomic inequalities within society. Thereby, the introduction of the term ‘inverse care law’ underlines the need to address these health inequalities to ensure that those who need the most care have access to high-quality healthcare. Investing in high-quality healthcare for these vulnerable populations will certainly pay off and is more useful than trying to improve the already good healthcare for the non-vulnerable in society. This maldistribution of care is also observed in research where participants in an RCT (one of the highest quality studies according to the evidence-based medicine pyramid) and study populations in similar RCTs are in the vast majority considerably less diverse than society and therefore do not properly reflect day-to-day practice. Therefore, key questions for daily clinical practice and from a societal perspective are regularly not
RkJQdWJsaXNoZXIy MTk4NDMw