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Am Fam Physician. 1998;58(7):1550-1552

to the editor: I was extremely disappointed with the editorial by Dr. Stevens on the Guidelines for Adolescent Preventive Services (GAPS).1 It was shortsighted, redundant2 and sounded as if it was written by a person who works for a managed care company.

The article by Dr. Montalto3 made several significant points that were virtually ignored in the editorial. GAPS, or similar prevention guidelines, have already been implemented or approved by several significant health care organizations, including the American Medical Association, the American Academy of Pediatrics and the Maternal and Child Health Bureau. How to apply such guidelines is left completely to the discretion of the practicing physician, but it is possible to apply such guidelines, even in a busy office setting.4 Finally, the rationale for GAPS is completely and convincingly spelled out in the original publication.5

In addition, since GAPS was first published, considerable evidence now exists to justify practices such as providing contraceptive health services for teenage patients. Two new studies have found that making contraception more accessible does not increase sexual activity among adolescents, but it does increase the use of birth control.6,7 Do we really need “evidence-based studies” to justify providing confidential health care for teenage patients or counseling them about injuries, drugs or sexually transmitted diseases? If a study were published tomorrow that found no effects from such efforts, would we discontinue our efforts in office-based counseling? Medicine should involve the use of common sense instead of simply a blind allegiance to statistics and data.

Family physicians are smart enough to take what they want and can use from GAPS and apply it to their own practices (which is what Dr. Montalto wisely recommends in his article), rather than wait for the evidence-based studies that Dr. Stevens feels are necessary. How many more teenagers will succumb to sex, drugs and violence while we wait for the managed care, bureaucratic go-ahead to do what needs to be done?

in reply: I read with interest Dr. Strasburger's response to my editorial, which suggested caution in adopting the Guidelines for Adolescent Preventive Services (GAPS).1 Other readers may share his frustration so I will respond directly to the issues he raises. First, the issues of behavioral health that adolescents must face are serious and should be addressed as effectively as possible, given what we know. Second, health plans, which increasingly manage the care we provide, play a complex role in the dissemination and implementation of guidelines. In my community, the effect of the use of GAPS is quite the opposite of what was suggested by Dr. Strasburger. Finally, physician backlash against evidence-based care is counterproductive both to good medical care and to the promotion of more relevant primary care research.

The adolescent years are behaviorally risky times in the human life span. New evidence that supports community intervention is always available for our review. Dr. Strasburger cites a recent study that suggests the availability of condoms in metropolitan high schools increases condom use, but not sexual activity, in adolescents.2 These results are helpful in defending such programs against their vocal critics. The question practicing physicians should ask themselves is, would providing condoms to adolescents in my practice have the same beneficial effect? This example of evidence illustrates my point very well. Most of the behavioral interventions that are recommended in GAPS are based on community interventions such as this one. Is this evidence good enough to support the diversion of our limited clinical time and resources to this effort? I think not.

In the Seattle area, a region-wide health plan distributed GAPS to all participating physicians and included an explanation of how to bill for implementation. The next step will be to measure physicians' adherence to GAPS. If they are evaluated on their adherence, physician practices put resources into compliance. All physicians should question health plans about the quality of evidence that supports any guidelines they provide. We should expect explicit evidence before our compliance is measured by report cards. Organizational endorsements should not be mistaken for assurance of high quality evidence. Each organization brings its own biases to the endorsement of any guideline.

Many health plans seem to have adopted the position that practice uniformity, that is, less practice variation, is inherently good. When we have high-quality evidence, this is likely to be true. We know that screening mammography after the age of 50 or the use of warfarin to treat chronic atrial fibrillation prevents deaths. Encouraging more uniform adoption of these practices is good for our patients. In the case of GAPS, if the evidence supports community interventions to improve adolescent health, we should participate and encourage the health plans in which we participate to make generous contributions to local schools and community group efforts to improve the health of adolescents.

As frustrating as the lack of evidence may be for so much of medical practice, it is counterproductive to reject the pursuit of high-quality evidence. Lorne Becker, M.D., a family physician leader in the Cochran Collaboration, uses the metaphor of “clinical jazz” to describe our situation. Trying to play jazz without the basic chord patterns is cacophonous. Jazz is at its best when improvisation is based on the known structure. High-quality evidence alone seldom provides the basis for a clinical decision, but our clinical improvisations should be based on the evidence we have.

The compilation and careful examination of the quality of evidence has another powerful effect. It tells us where the holes in our knowledge are. In the case of GAPS, a randomized trial by practice, looking at adolescent health outcomes is necessary. It will be worth our efforts to implement GAPS when we have evidence that this will improve the health of adolescents. Until we have that evidence, our resources are better spent on community interventions that we know will work.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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