Correspondence

www.thelancet.com/neurology Vol 13 July 2014 649

Evidence or clinical implementation: which should come fi rst?

The Editorial1 in the June issue of The Lancet Neurology discusses the clinical potential of the Dutch ParkinsonNet—a multidisciplinary network of professionals that specialises in treatment of patients with Parkinson’s disease. The core of the network consists of allied health and other non-medical professionals who are trained to work according to clinical practice guidelines, who continuously increase their Parkinson’s-specific expertise by treating large caseloads, and who adopt a patient-centred, collaborative approach. The Editorial points to the value of ParkinsonNet for improvement of participatory medicine in clinical practice, but emphasises the need to gather further evidence before this multidisciplinary concept can be implemented in other health-care systems. This view is understandable in most scientifi c fields, but when multidisciplinary care is assessed, a chicken or egg discussion is at play: should we obtain evidence about multidisciplinary care and then implement it within professional networks; or should we start these networks first, even when little evidence is available, and exploit those networks to obtain the obligatory evidence that either supports or refutes the eff ectiveness of multidisciplinary care?

We favour the latter strategy. It is not possible to obtain robust evidence

for non-medical interventions such as physiotherapy or nursing when only inexperienced professionals are available who cannot deliver the intervention properly. Specialised networks such as ParkinsonNet off er the necessary infrastructure for clinical trials. Trained ParkinsonNet experts can deliver experimental interventions consistently, with little variation across practices, and in accordance with guideline recommendations or research protocols.

We previously used the ParkinsonNet infrastructure to assess several allied health interventions. The first intervention was tested in a cluster-controlled trial which compared eight regions that had specialised ParkinsonNet physiotherapists with eight regions that had generically trained therapists only.1 ParkinsonNet therapists adhered better to guidelines and offered cheaper care than did generically trained therapists, but their clinical outcomes were comparable to those of usual care. The second intervention was tested in the ParkFit trial, that assessed whether personal coaches can promote a more active lifestyle in sedentary patients with Parkinson’s disease—coaches were specifically trained ParkinsonNet physiotherapists.3 A third trial tested the eff ectiveness of occupational therapy, again using specialised ParkinsonNet therapists to deliver the intervention.4 Finally, we have done several studies within ParkinsonNet to assess the merits of integrated multidisciplinary care. We recently reported the results of a controlled, non-randomised trial that compared one region that had both a specialised Parkinson’s disease centre and a regional ParkinsonNet with two control regions that had neither.5 Our analyses showed minor benefits in favour of the integrated care model, but these disappeared after controlling for baseline diff erences. All these trials would have been impossible if the

network implementation had not preceded the studies.

Importantly, the outcomes of these trials can be readily shared with all network participants, allowing for rapid implementation of new knowledge into everyday clinical practice. To disseminate fresh research fi ndings, we increasingly use online communities where ParkinsonNet professionals meet to learn about the latest evidence.6 As such, ParkinsonNet creates an interesting infrastructure for health-care innovation, for high-quality research, and for quick dissemination of new evidence to committed professionals.BRB has received honoraria from sitting on the scientifi c advisory boards for GlaxoSmithKline, UCB, and Danone, and received research support and grants from The National Parkinson Foundation, the Netherlands Organisation for Scientifi c Research (NWO), the Michael J Fox Foundation, Prinses Beatrix Spierfonds, Stichting Parkinson Fonds, and Alkemade-Keuls Fonds. For the development of the Dutch ParkinsonNet, BB and MM received grants from ZonMw, Zorgverzekeraars Nederland, Parkinson Vereniging, Stichting Parkinson Nederland, Fonds Nuts Ohra, Prinses Beatrix Fonds, Michael J Fox Foundation, National Parkinson Foundation, Centraal Ziekenfonds (CZ), Stichting Volksgezondheidszorg (VGZ), and Achmea.

*Bastiaan R Bloem, Marten Munnekebas.bloem@radboudumc.nl

Department of Neurology (935), Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands (BRB, MM)

1 Consumer choices in Parkison’s disease. Lancet Neurol 2014; 13: 525.

2 Munneke M, Nijkrake MJ, Keus SH, et al. Effi cacy of community-based physiotherapy networks for patients with Parkinson’s disease: a cluster-randomised trial. Lancet Neurol 2010; 9: 46–54.

3 v an Nimwegen M, Speelman AD, Overeem S, et al. Promotion of physical activity and fi tness in sedentary patients with Parkinson’s disease: randomised controlled trial. BMJ 2013; 346: f576.

4 Sturkenboom IH, Graff MJ, Hendriks JC, et al. Eff ectiveness of occupational therapy for patients with Parkinson’s disease: a randomised controlled trial. Lancet Neurol 2014; 13: 557–66.

5 van der Marck MA, Munneke M, Mulleners W, et al. Integrated multidisciplinary care in Parkinson’s disease: a non-randomised, controlled trial (IMPACT). Lancet Neurol 2013; 12: 947–56.

6 Bloem BR, Munneke M. Revolutionising management of chronic disease: the ParkinsonNet approach. BMJ 2014; 348: g1838.

4 Choi AL, Sun G, Zhang Y, Grandjean P. Developmental fl uoride neurotoxicity: a systematic review and meta-analysis. Environ Health Perspect 2012; 120: 1362–68.

5 US Environmental Protection Agency. EPA and HHS Announce New Scientifi c Assessments and Actions on Fluoride. http://yosemite.epa.gov/opa/admpress.nsf/6427a6b7538955c585257359003f0230/86964af577c37ab285257811005a8417!OpenDocument (accessed May 23, 2014).