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Wednesday Jun 28, 2017

Primary Care Needs -- and Deserves -- More Research Dollars

My patient wanted to discuss two things: 1) an article he read online about a miracle back surgery that could cure chronic pain and 2) golfer Tiger Woods. This conversation took place in the aftermath of Woods' fourth back surgery in three years and a related announcement about his prognosis(news.tigerwoods.com) that his fans met with optimism.

I told the patient that -- Woods' news notwithstanding -- the evidence does not show that spinal fusion surgery works better than nonsurgical interventions(ard.bmj.com) for chronic low back pain. 

Although the number of spinal fusions performed in the United States skyrocketed from 56,000 in 1994 to 465,000 in 2011, an analysis of 125,000 patients who had the procedure(www.washingtonpost.com) found that roughly half were unnecessary.  

So, I didn't waver when I encouraged my patient to stay active instead of seeking questionable treatment, and I was thankful for the many researchers who gave me that solid answer.

At its core, evidence-based medicine is transformative. Focusing on quality research and the patient's values, while avoiding unproven or anecdotal treatments, leads to better outcomes for patients, keeps them safe and minimizes unnecessary costs.

Utilizing evidence-based resources can help primary care physicians stay current on medical research without having to read 17 journal articles a day, as one journal article estimated(www.ncbi.nlm.nih.gov). But in reality, the application of evidence-based medicine is more nuanced. The dearth of true evidence-based medicine in primary care is highlighted in a new study(ebm.bmj.com), which found only 18 percent of clinical recommendations from one online medical reference were based on consistent, high-quality, patient-oriented evidence. Half were based on expert opinion or disease-oriented outcomes.

The study demonstrates the need for more primary care research, which is "woefully underfunded(news.uga.edu)," according to the study's lead author, Mark Ebell, M.D., an epidemiology professor at the University of Georgia College of Public Health in Athens.

The lack of high-quality evidence has a profound effect on physicians, who often have insufficient data to make definitive care decisions for some of the patients they see.

Under the guise of "evidence-based medicine," professional organizations and even insurers release numerous conflicting guidelines each year. Because of the paucity of high-quality systematic reviews, these groups use the best available evidence, which may be studies with nonrandomized control groups, poor statistical power and multiple confounding factors. And although these organizations attempt to rate the quality of the evidence and the strength of the recommendation, in the real world, that doesn't always mean much.

It's worth noting that the AAFP develops true evidence-based clinical practice guidelines for family physicians. The AAFP also reviews recommendations released by the U.S. Preventive Services Task Force and makes recommendations based on the evidence. The Academy uses a modified Grading of Recommendations Assessment, Development and Evaluation approach, which evaluates the quality of the evidence and provides a framework to make recommendations based on that evidence.

But what about guidelines and recommendations from other sources? Who can you trust? Even when systematic reviews are available, they are sometimes funded by pharmaceutical companies, which raises the specter of conflicts of interest. And these companies have no clear incentives to conduct postmarket trials to evaluate broader impact.

For example, Stanford University researcher John Ioannidis, M.D., found 54 of 185 systematic reviews of antidepressants had authors who were employees of the assessed drug's manufacturer and 147 had authors with some sort of tie to industry(www.milbank.org). Although 58 reviews made negative statements about antidepressants, only one of those reviews had an author with ties to a pharmaceutical company.

Additionally, pharmaceutical companies focus on medical conditions for which there is a potential pill treatment, even if it's unclear that the condition actually constitutes an unmet health need. For example, the FDA approved a pill for hypoactive sexual desire disorder in 2015 after the sponsoring company's third application, despite the fact that only 10 percent of women who have low libido experience distress(www.theguardian.com) associated with their condition and that there were numerous adverse effects associated with the drug(www.healio.com)

When evidence is piecemeal or questionable, it compromises a physician's ability to provide truly evidence-based, patient-centered, affordable, quality care. And the problem only stands to get worse.

The Trump administration's proposed 2018 budget cuts NIH grant funds by 22 percent(www.sciencenews.org), from $34.6 billion to $26.9. The proposal also would roll the Agency for Healthcare Research and Quality (AHRQ) into NIH(www.statnews.com), a move that could eliminate AHRQ.

AHRQ's mission(www.ahrq.gov) is to "produce evidence to make health care safer, higher quality, more accessible, equitable and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used."

Scientific inquiry, especially in primary care, is not a priority of the current administration. Clearly, it should be. Primary care visits account for more than half of all medical office visits in the United States. Primary care research needs increased investment and application, in addition to leadership through a nonpartisan federal agency.

The AAFP has launched a Speak Out campaign aimed at preserving AHRQ. It's a quick and easy way to contact your legislators and let them know that evidence-based research for primary care shouldn't be on the chopping block.

Natasha Bhuyan, MD, is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).

Posted at 12:14PM Jun 28, 2017 by Natasha Bhuyan, M.D.

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