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Clinical trials that are designed to help inform practice in the real world are known as pragmatic trials. They are often characterized as focusing on practical aspects of study design, including recruitment and consent, adherence and the use of standard equipment.

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A practical trial that employs different investigators and participants from different geographical areas is the Home Blood Pressure Management study (HBPM). This type of heterogeneity, that is crucial for a pragmatic trial to be reliable and reduce bias in results is also essential. Too much heterogeneity, however can result in problems with the design of the trial.

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Pragmatic trials are designed to replicate real-life settings and achieve maximum external validity. They are typically commissioned by policymakers and practitioners to help inform their decisions. They can also be a great way to identify the causality between an intervention and its outcomes. However, they should not, be used to replace explanatory studies.

The pragmatism idea is controversial, and there are questions regarding whether pragmatic trials could replace explanatory tests or if they should serve as an alternative to them. Schwartz and Lellouch1 made an distinction between explanation-based studies, which confirm the validity of a physiological or clinical hypothesis, as well as pragmatic trials, which inform the decision-making process for policy and practice. They also proposed the framework for pragmatic trials, called PRECIS.2 This tool was designed to define the characteristics of a pragmatic trial that include the recruitment process, the design and delivery of the intervention, and monitoring.

The number of pragmatic trials is increasing. A recent Medline query using the keywords naturalistic and pragmatic, restricted to randomised controlled trials (RCTs), returned 34 articles. These are shown in red on Figure 2. This is a sign that the health science community is becoming more sensitive to the subject of pragmatics. It is important to note that the majority of these trials were conducted in primary care settings.