Thus, decision makers are active partners in the design of the pragmatic trials.6,7 The tree or the forest? The distinction

between an explanatory and a pragmatic trial in real life is not that easy. Most trials have both explanatory and pragmatic aspects. Gartlehner et al proposed a set of seven domains to evaluate the explanatory or pragmatic nature of a trial.8 Although they acknowledged that efficacy (explanatory) and effectiveness (pragmatic) exist in a continuum, they used a binary system (yes/no) in the evaluation of these domains. Thorpe et al, a few years later, introduced the pragmatic-explanatory continuum indicator summary (PRECIS) tool.9 PRECIS #KU-57788 manufacturer keyword# was created to enable investigators to design trials acknowledging the explanatory/pragmatic continuum in 10 domains: Eligibility criteria Flexibility of the experimental intervention Practitioner expertise (experimental) Flexibility of the comparison intervention Practitioner Inhibitors,research,lifescience,medical expertise (comparison) Follow-up intensity Outcomes Participant compliance Practitioner adherence Primary outcomes. To illustrate, a very pragmatic trial

across these 10 domains would be: There are no inclusion or exclusion criteria Practitioners are not constricted by guidelines on howapply the experimental intervention The experimental intervention Inhibitors,research,lifescience,medical is applied by all practitioners, thus covering Inhibitors,research,lifescience,medical the full spectrum of clinical settings The best alternative treatments are used for comparison with no restrictions on their application The comparative treatment is applied by all practitioners, covering the full spectrum of clinical settings No formal follow-up sections The primary outcome is a clinical meaningful one that does not require extensive training to assess There are no plans to improve or alter compliance for the experimental or the comparative treatment No special strategy to motivate

Inhibitors,research,lifescience,medical practitioner’s adherence to the trial’s protocol The analysis includes all participants in an intentionto-treat fashion. The idea of the explanatory continuum is very intriguing, although rather challenging to apply and quantify. Some modifications of the PRECIS tool have been developed. Koppenaal et al, for example, adapted the PRECIS Terminal deoxynucleotidyl transferase tool in the assessment of systematic reviews, introducing a scale from 1 to 5 for the 10 domains (1 is for explanatory and 5 for the pragmatic end).10 Using the ordinal scale system, they demonstrated how their modification (named the PR-tool) could quantify the continuum per domain and study, thus giving an overall summary for systematic reviews. The study by Tosh et al11 in this issue of Dialogues in Clinical Neuroscience adapts PRECIS into the Pragmascope tool to help the appraisal of RCTs by mental health researchers.