Primary care decisions often made without the best evidence

As medicine continues to shift toward evidence-based practice, some primary care providers may have a difficult time finding quality evidence to support their clinical decisions, according to a new study from the University of Georgia.

An analysis of 721 topics from an online medical reference for generalists showed that only 18 percent of the clinical recommendations were based on high-quality, patient-oriented evidence.

This finding highlights the need for more research in primary care and family medicine, said Mark Ebell, epidemiology professor at UGA's College of Public Health and lead author of the study.

"The research done in the primary care setting, which is where most outpatients are seen, is woefully underfunded," he said, "and that's part of the reason why there's such a large number of recommendations that are not based on the highest level of evidence."

The lack of funding stands in contrast to the use of primary care across the health care system. According to the Centers for Disease Control, primary care visits account for over half of physician's office visits in the U.S. And while primary care physicians treat the occasional cough or fever, they also bear the brunt of chronic disease management.

High blood pressure, diabetes, heart disease and high cholesterol often fall on a primary care provider's plate, and there are many different approaches to treatment. Therefore, it's essential, Ebell said, to understand which approach "has the greatest chance of providing benefit and minimizing harm, and the only way to truly know that is from well-designed studies."

Ebell and his co-authors identified areas of care supported by high-quality studies and others that are not. Topics related to pregnancy and childbirth, cardiovascular health, and psychiatry had the highest percentage of recommendations backed by research-based evidence. Hematological, musculoskeletal and rheumatological, and poisoning and toxicity topics had the lowest percentage.

About half of the recommendations overall were based on studies measuring patient-oriented health outcomes, such as quality of life, improved symptoms and lower death rates, rather than laboratory markers like blood sugar or cholesterol levels.

Because the latter may or may not translate into how long or how well people live, Ebell said, "practice should wherever possible be guided by studies reporting patient-oriented health outcomes."

Filling in the gaps for evidence-based, patient-oriented primary care research should matter to patients as well as their health care providers, said Ebell. "You would want your care to be guided by studies that have demonstrated that what the physician recommends will help you live better or longer. We should all want that kind of information to guide care."