REBUTTAL FROM DRS. WRIGHT AND SHELDON

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Drs. Davies and Stradling present a well-argued case for the effectiveness of nCPAP in the treatment of obstructive sleep apnea. They describe a gradual and orderly process of evaluation and knowledge accumulation over time: first the examination of the biological effects of CPAP, followed by laboratory assessment of its impact on sleep patterns, the assessment of the attributable effect of CPAP over and above that due to medical placebos, and the potentially stronger placebo effects of a physical mask system.

In retrospect and presented this way, it appears that sleep physicians adhered closely to the scientific paradigm; that is, testing where there was uncertainty until the full picture was clear. This rational picture of the development of the service in tandem with the evidence is, however, rather misleading. Clinicians in the United States and internationally were using nCPAP and other interventions in routine practice and demanding more resources for its diffusion before the evidence about benefit had been established, and before diagnostic clarity had been achieved and agreement on treatment aims had been reached. In the United Kingdom, exaggerated claims were made that were out of line with the evidence available at the time. Health care funders, who at this time were interested in using research evidence more explicitly to inform investment decisions, were left feeling somewhat skeptical and unwilling to fund services even for severely affected patients. Clinical enthusiasts railed against "evidence-based medicine" (1).

It is to be hoped that the more sober argument presented by Drs. Davies and Stradling heralds a new period in the history of this new condition and technology. There are still large areas of uncertainty, for example, as to the comparative clinical benefit of different interventions, in which patients it is worth intervening relative to the costs, the best method of service delivery, and, most importantly, the definition of the condition and the aims of treatment. This will require careful control over the introduction, diffusion, and targeting of CPAP and competing interventions to ensure that resources are used wisely and that thresholds for treatment are not unjustifiably lowered, a phenomenon that is common in other areas of health care.

	References

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1. Stradling, J. R., and R. J. Davies. 1997. The unacceptable face of evidence-based medicine. J. Eval. Clin. Pract. 3: 99-103 .