But you’re stating the obvious? It’s not like physicians don’t know trials are designed this way, and for good reasons.

Frail patients confound results. A drug may work great, but you’d never know because your frail patients die for reasons unrelated to the drug.

Second is obvious as well. Doctors know there are treatment alternatives (with the same drawback to trial design).

And I already touched on your third point. The alternative to excluding frail patients is not being able to tell if the drug does anything. In many cases that means the drug isn’t approved.

Excluding frail patients has its drawbacks, but it has benefits as well. This paper acts like the benefits don’t exist.