Pragmatic Clinical Trials: Real-World Impact & the PRECIS-2 Framework

Introduction

In contemporary clinical research, the relevance of a study's results to real-world healthcare settings is paramount. This has spurred growing interest in pragmatic clinical trials—studies intentionally designed to mirror routine practice conditions. Distinct from their explanatory counterparts, which focus on efficacy under ideal circumstances, pragmatic trials emphasize effectiveness in everyday clinical environments. The PRECIS-2 tool further enhances this approach by guiding researchers in aligning trial design with the intended degree of pragmatism.

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The Explanatory–Pragmatic Continuum

Clinical trials can be positioned along a continuum from explanatory to pragmatic. Explanatory trials, often termed mechanistic, seek to determine whether an intervention can work under optimal conditions. These studies prioritize internal validity and use rigorous controls to isolate treatment effects. Pragmatic trials, conversely, ask whether an intervention does work in real-world clinical settings, focusing on generalizability and decision support in actual practice.

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Core Distinctions

1. Study Context and Purpose

• Explanatory trials investigate efficacy within highly controlled environments, targeting narrowly defined populations and enforcing strict treatment regimens.

• Pragmatic trials evaluate the intervention’s effectiveness across diverse, real-world settings, using broader inclusion criteria and more flexible protocols.

2. Patient Populations

• Explanatory designs typically enroll homogeneous participants to reduce variability.

• Pragmatic trials embrace heterogeneity to reflect the patient mix encountered in daily practice.

3. Treatment and Protocols

• Explanatory studies enforce uniform interventions and rigid schedules.

• Pragmatic trials permit individualized or variable treatment delivery, aligning with clinical autonomy.

4. Blinding and Use of Placebo

• Blinding and placebos are standard in explanatory trials to minimize bias.

• In pragmatic trials, these features are often relaxed, accepting certain biases as reflective of real-world conditions.

5. Outcome Measures

• Surrogate or intermediate outcomes dominate explanatory trials.

• Pragmatic trials prioritize patient-centered and clinically meaningful outcomes, such as quality of life or major health events.

6. Follow-Up

• Explanatory designs utilize intensive, protocol-driven follow-ups.

• Pragmatic trials rely on follow-up schedules that mirror usual care, accepting losses to follow-up as part of real-world data.
  

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The PRECIS and PRECIS-2 Tools: Structuring Pragmatism

The PRECIS (PRagmatic Explanatory Continuum Indicator Summary) tool was developed to help researchers consciously design trials along the explanatory–pragmatic spectrum. The revised PRECIS-2 tool provides more granular guidance through nine design domains, each scored on a 1 (very explanatory) to 5 (very pragmatic) scale.

PRECIS-2 Domains

1. Eligibility Criteria

   • Pragmatic: Includes all patients likely to receive the treatment in usual care.

   • Explanatory: Narrow inclusion, often with multiple exclusions.

2. Recruitment

   • Pragmatic: Patients recruited during routine appointments.

   • Explanatory: Extra efforts like advertisements or incentives.

3. Setting

   • Pragmatic: Matches routine care settings.

   • Explanatory: Specialized or academic centers only.

4. Organization

   • Pragmatic: Uses existing infrastructure and standard staff.

   • Explanatory: Requires added training, resources, or specialized teams.

5. Flexibility in Delivery

   • Pragmatic: Intervention delivered with usual clinician discretion.

   • Explanatory: Strict delivery protocol and monitored compliance.

6. Flexibility in Adherence

   • Pragmatic: No special efforts to improve adherence.

   • Explanatory: Adherence is enforced or optimized through additional measures.

7. Follow-Up

   • Pragmatic: Relies on routine care visits and standard data collection.

   • Explanatory: Intensified and protocol-specific follow-ups.

8. Primary Outcome

   • Pragmatic: Directly relevant and meaningful to patients.

   • Explanatory: Surrogate or biologic outcomes needing central adjudication.

9. Primary Analysis

   • Pragmatic: Intention-to-treat approach including all randomized patients.

   • Explanatory: May exclude non-compliant or ineligible participants post-randomization.
     

Visualizing the Trial Design

The PRECIS-2 tool encourages the creation of a “wheel” diagram where each domain is plotted to visualize the overall trial orientation. A trial with points near the center (score of 1) is more explanatory, while a trial with scores near the perimeter (score of 5) is more pragmatic.

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Practical Implications

Why This Matters Clinically: Pragmatic trials enhance the translational value of clinical research by ensuring that results are applicable to routine care. For instance, a trial on antihypertensive therapy that includes patients with comorbidities, varied adherence, and flexible follow-up more accurately predicts population-level impact than a tightly controlled explanatory study.

Use Case Imagine evaluating a new inhaler for asthma. An explanatory trial might test the device in specialized centers with expert training and ensure perfect technique. A pragmatic trial, in contrast, would distribute the inhaler to general practitioners and assess real-world usage and outcomes such as exacerbation rates and patient-reported satisfaction.

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Conclusion

Designing trials with pragmatism in mind is not merely an academic exercise; it is a strategic alignment with the realities of patient care. The PRECIS-2 framework equips researchers to purposefully shape their studies for real-world relevance, supporting more meaningful clinical decisions and policy-making. Understanding and applying this approach ensures that research truly serves the people it intends to help.