Strategies to Prioritize Clinical Options in Primary Care

Patrick J. O'Connor, MD, MA, MPH; JoAnn M. Sperl-Hillen, MD; Karen L. Margolis, MD, MPH; Thomas E. Kottke, MD, MSPH

Disclosures

Ann Fam Med. 2017;15(1):10-13. 

In This Article

The Case for Prioritization

Perhaps a more reasonable and less-expensive strategy would be to prioritize clinical services related to preventive care and chronic disease care. In this issue of Annals of Family Medicine, Maciosek et al present compelling evidence that childhood immunizations and efforts to prevent or stop smoking are dominant population health priorities and rank numerous other services based on potential clinical benefit and cost-effectiveness.[3–5] Once smoking cessation and immunizations are addressed, however, we are left wondering how to prioritize the other 439 evidence-based clinical services based on their potential benefit to an individual patient.

There are several fundamentally sound reasons to prioritize clinical services at the patient level. First, the value of even very strongly evidence-based clinical services varies across patients and with time. For example, the potential benefit of screening for colorectal, lung, cervical, and breast cancer varies up to tenfold based on patient-specific demographic, clinical, behavioral, and genetic factors.[6] Likewise, the risks and benefits of intensive glucose control in patients with diabetes vary by age, comorbid conditions, cardiovascular risk, distance from personalized glycated hemoglobin (HbA1c) goal, and other factors. If an older patient with major comorbidities already on intensive glucose-lowering therapy is not at their personalized HbA1c goal, the risks of further intensifying glucose therapy may well exceed the benefits.[7,8] The ranks provided by Maciosek et al, which are based on overall population health benefit, must be further personalized to assess relative benefit of these services to an individual patient.

Second, in very large clinical trials, very small clinical benefits may be statistically significant and thus be designated as being evidence based. With respect to cholesterol-lowering medications, the number of study participants who need to be treated with a statin for 5 years to prevent 1 heart attack can vary from 6 patients to more than 240 patients, depending on baseline cholesterol level and baseline coronary heart disease risk.[9,10] In general, the number of patients who need to be treated to prevent 1 heart attack or 1 cancer death varies widely across various evidence-based clinical options.

Third, most clinical trials that assess efficacy of clinical options are limited to consenting patients who meet stringent eligibility requirements. Results observed in these highly selected patients may have low generalizability to most patients. Moreover, because patient eligibility criteria and research protocols are designed to minimize the likelihood of serious adverse events in clinical trials, serious adverse events may be much more common in community care than in published research studies.[11]

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