Original Articles
Prevention and Primary Care Research for Children: The Need for Evidence to Precede “Evidence-Based”

https://doi.org/10.1016/S0749-3797(98)00012-9Get rights and content

Abstract

Medical care in the United States continues to face tremendous financial pressures. Public and private health policy claim to encourage primary care and preventive services, but also discourage services that have not been demonstrated to be effective and/or cost-effective. This article suggests a model to illustrate the conceptual relationship between traditional American medical care and “evidenced-based” medicine. It further examines how the lack of an adequate research base makes a move to purely evidence-based care premature for primary care and prevention services. The paper defines a new conceptual statistic, the uncertainty index, as the proportion of non-refuted current practice that is also not corroborated by research evidence. The greater the uncertainty index, the less appropriate is a clinical model restricted to evidence-based care.

Specific theoretical barriers to outcomes research in prevention are discussed and simple criteria to determine the desirable components of care are suggested. The need for theoretical and empirical research into primary care and prevention, especially for children, is emphasized. Care that is of low risk, not of extremely high cost, and that is generally believed useful by the community of practitioners is particularly desirable in the absence of data refuting its value.

Section snippets

Background: A Revolution in American Medicine

Cost pressures are changing medicine in revolutionary ways. The mantra of these changes has included emphasis on the provision of services in primary care versus specialty care, an increased emphasis on the use of preventive services, and an increased awareness of limiting clinical services to those that have medically appropriate indications.1, 2, 3, 4, 5, 6While these trends have the potential to improve the quality of care, the implementation of policies to bring about these trends has

A Simple Model Linking Research and Evidence-Based Care

Research that focuses on primary care and preventive services is fundamental to a rational approach to the practice of medicine as we head to the twenty-first century. The need for evidence precedes the ability to move to evidence-based primary care.

This thesis follows from the model shown in Fig. 1, Fig. 2. Fig. 1 illustrates how traditional medical practice results from physicians following through on their beliefs regarding best clinical practice. As research evidence accumulates, belief

Thesis: Increase the Research Base of Preventive Services for Children

The literature regarding adult preventive services has been driven largely by a perceived need to understand the number of lives saved or improved by a given clinical preventive service at some unit cost. This literature has often focused on evaluating expensive interventions, particularly those related to leading causes of death. It has contributed to our understanding, for example, of the impact of various intervals and methods for screening for diseases such as breast cancer and colorectal

Conclusion: Prematurity of a Purely Evidence- Based Paradigm for Primary Care and Prevention

Financial pressures are radically changing the nature of the U.S. health care system. Attempts to limit costs have led to the seemingly attractive idea of limiting clinical services (or the third party payment of such services) to care that has been demonstrated to be effective. This paper has introduced a schematic model that relates the “traditional,” autonomous practice of medicine to the practice of evidence-based medicine. The model suggests a statistic, the uncertainty index or UNI, that

Acknowledgements

The author wishes to thank Drs. Charles J. Homer, Maureen Mangotich, Bruce Davidson, Kevin Knight, David Rabin, and Hurdis Griffith for various contributions leading to the writing of this manuscript.

References (18)

  • Nutting P. A research agenda for primary care: summary report of a conference. Agency for Health Care Policy and...
  • P Franks et al.

    Health care reform, primary care and the need for research

    JAMA

    (1993)
  • DH Gemson et al.

    Putting prevention into practiceimpact of a multifaceted physician education program on preventive services in the inner city

    Arch Int Med

    (1995)
  • Put Prevention into Practice. Health Education Lifetime Plan. American Academy of Family Physicians; Spring...
  • JF Fries et al.

    Reducing health care costs by reducing the need and demand for medical services

    N Engl J Med

    (1993)
  • LC Kleinman et al.

    The medical appropriateness of tympanostomy tubes for children under 16 years in the United States

    JAMA

    (1994)
  • RH Brook

    Quality of caredo we care?

    Ann Intern Med

    (1991)
  • LB Russel

    The role of prevention in health care reform

    N Engl J Med

    (1993)
  • Kleinman LC. A vision for disease management. Surgical Services Management...
There are more references available in the full text version of this article.

Cited by (7)

  • Towards a learning system for pediatric outcomes: Harvesting meaning from evidence

    2018, Progress in Pediatric Cardiology
    Citation Excerpt :

    For rare diseases, such as pediatric cardiomyopathy, the challenge may include that there are insufficient subjects to study to produce statistically robust findings or that there is insufficient investment to fund the sorts of multicenter studies that could potentially answer even key questions in the field [58]. Lack of evidence is not evidence of lack [59]. Mindless dependence upon P-values furthers the contrary myth and should be avoided.

  • Assessment of quality of care in vascular surgery and the emergence of quality improvement programs

    2016, Reviews in Vascular Medicine
    Citation Excerpt :

    Although it is axiomatic that the quality of structures and processes which drive healthcare, impact the eventual outcome, due to the resilience of patients, weak or deficient structures and processes do not always lead to adverse outcomes, even when there is a direct causal relationship between the two [44]. For this reason assessment of processes in delivery of healthcare (such as adherence to best practice guidelines) is inherently more sensitive as a quality measure than assessment of outcomes [43,44]. There is gradual acceptance that failure to deliver planned or necessary clinical activity or follow up represents a poor outcome and may lead to medical errors [45].

View all citing articles on Scopus
View full text