Primary care research - is it important?

FD Richard Hobbs

HK Pract 2018;40:98-100

Much of healthcare internationally remains empirical and not evidence based. And, even where evidence exists, implementation into clinical practice is often slow sometimes due to uncertainties on how to apply the data. The need to better understand these implementation delays have led to more applied clinical research. This has included the science of evidence-based medicine, developing better methods of synthesising and presenting the totality of quality evidence and thereby reducing uncertainty.

But is research based within primary care important? Since most patient contacts start and end in primary care, in most developed health systems at least, the necessity to research more within primary care seems obvious. It’s where the full spectrum of disease is represented, where the trajectory of disease is discoverable, and where patients are representative of the total population and behave across the full range of behaviours. The traditional model of researching the more extreme disease states in hospital patients remains important, and efficient, for early research and estimating 'best treatment effects' because patients triaged to hospital will usually experience higher and earlier event rates. Care in specialist settings also needs to be based on research conducted in specialist settings. However, the corollary is also true – care in the community should be based on evidence from community populations, whether for diagnostic or therapeutic interventions.

Failure to provide such contextual evidence has contributed implantation delays – 'my patients aren't anything like those in that landmark trial.' These uncertainties are increasingly answered by applied research refining 'what to do' by 'how to do it.' Health science needs evidence derived from the very populations where that evidence is to be applied, so therefore more research evidence in primary care is scientifically essential. There are also additional practical benefits of this approach - it's increasingly difficult to recruit to major trials, especially with active comparators, without recruiting in primary care. Furthermore, since doctors who are involved in research are early adopters of interventions found to be positive, this itself is a cost-effective implementation strategy.

But if research based in primary care is important, are primary care academics needed for some of this research? Perhaps surprising to some, influential primary care researchers have been evident for a long term – Jenner a general practitioner (GP) in the late 1700s observed associations with smallpox, trialled a cowpox vaccine, and founded the science of immunisation, and the identification of atrial fibrillation and the invention of the electrocardiogram was by the Scottish GP James McKenzie.

More recently, there has been important research by academic GPs on the consultation,¹ and observations on the inadequacies of healthcare² that helped spawn evidence-based medicine (EBM).³ Primary care researchers are strongly represented in advancing EBM internationally and have become essential contributors to the more reliable methods of generating evidence-based guidelines.⁴

The impact of primary care academics has accelerated in the past 20 years, across many clinical areas. There is notable health services research on surrogate measures for quality of care, evidence on whether pay for performance works and what happens when incentives stop, key evidence for more evidence-based policy development.

In terms of evidence for clinical practice, primary care researchers have made major advances in better disease diagnosis, such as cost-effective methods of diagnosing and managing hypertension,^5,6 best thresholds for biomarkers, such as natriuretic peptides in symptomatic patients,⁷ and the development of validated disease risk scores.⁸ These all help to triage at-risk populations more efficiently. Primary care researchers have also provided evidence for screening or early detection of major impact disorders, such as heart failure, diabetes,¹⁰ and atrial fibrillation.¹¹

Within disease management, primary care academics have delivered definitive trials in infection research, including antibiotic conservation,¹² and in acute problems, such as Bells Palsy.¹³ In terms of health services research, we have shown what makes a better consultation,¹⁴ or how to re-configure services,¹⁵ or focus on major social issues.¹⁶ The strong tradition of primary care academics in public health research has continued - the emerging importance of multi-morbidity in our increasingly ageing populations is pioneered by primary care academics.¹⁷

In summary, it would be difficult not to conclude that more research based in primary care is important and that research led by primary care is essential, with their evidence impacting on changing international clinical guidelines, a useful surrogate for relevance and impact. The rate of such research has accelerated in the past 20 years, as has the complexity and quality. We should invest more in this key area for health systems – better evidence for clinical primary care and more researchers to deliver this.

Acknowledgement:

I only cite research that has been cited more than 200 times and been conducted in the UK to further emphasise the recent track record of primary care research since excellent examples also exist from Europe, North America, and Asia.