An Approach to Assess Generalizability in Comparative Effectiveness Research: A Case Study of the Whole Systems Demonstrator Cluster Randomized Trial Comparing Telehealth with Usual Care for Patients with Chronic Health Conditions

Med Decis Making. 2015 Nov;35(8):1023-36. doi: 10.1177/0272989X15585131. Epub 2015 May 18.


Background: Policy makers require estimates of comparative effectiveness that apply to the population of interest, but there has been little research on quantitative approaches to assess and extend the generalizability of randomized controlled trial (RCT)-based evaluations. We illustrate an approach using observational data.

Methods: Our example is the Whole Systems Demonstrator (WSD) trial, in which 3230 adults with chronic conditions were assigned to receive telehealth or usual care. First, we used novel placebo tests to assess whether outcomes were similar between the RCT control group and a matched subset of nonparticipants who received usual care. We matched on 65 baseline variables obtained from the electronic medical record. Second, we conducted sensitivity analysis to consider whether the estimates of treatment effectiveness were robust to alternative assumptions about whether "usual care" is defined by the RCT control group or nonparticipants. Thus, we provided alternative estimates of comparative effectiveness by contrasting the outcomes of the RCT telehealth group and matched nonparticipants.

Results: For some endpoints, such as the number of outpatient attendances, the placebo tests passed, and the effectiveness estimates were robust to the choice of comparison group. However, for other endpoints, such as emergency admissions, the placebo tests failed and the estimates of treatment effect differed markedly according to whether telehealth patients were compared with RCT controls or matched nonparticipants.

Conclusions: The proposed placebo tests indicate those cases when estimates from RCTs do not generalize to routine clinical practice and motivate complementary estimates of comparative effectiveness that use observational data. Future RCTs are recommended to incorporate these placebo tests and the accompanying sensitivity analyses to enhance their relevance to policy making.

Keywords: causal inference; chronic health conditions; external validity; generalizability; randomized trials; telehealth.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Chronic Disease / mortality
  • Chronic Disease / therapy*
  • Cluster Analysis
  • Comparative Effectiveness Research
  • Electronic Health Records
  • Emergency Service, Hospital / statistics & numerical data
  • England / epidemiology
  • Humans
  • Placebos
  • Primary Health Care* / methods
  • Primary Health Care* / statistics & numerical data
  • Telemedicine* / statistics & numerical data
  • Treatment Outcome


  • Placebos