Specialists vs Primary Care: Whose Guidelines Matter?

Alicia Ault


June 14, 2018

In This Article

Primary and Specialty Care Schism?

Primary care societies have not shied away from establishing their own guidelines in what might be considered specialty areas, or from disagreeing—publicly—with guidelines put out by specialty societies.

The dust-up involving the ACP and the endocrine-related medical societies over A1c targets does not represent a "schism," however, said Ende. He said the organizations have been "engaged in dialogue."

But cracks have continuously emerged.

Screening for Prostate Cancer

In 2012, the AAFP and the US Preventive Services Task Force (USPSTF)—in contrast to the American Urological Association (AUA)—controversially recommended against routine prostate-specific antigen (PSA)-based screening for prostate cancer for all men.[5] The AUA, on the other hand, had urged against routine screening for men under 40 years of age, men over 70, and men between 40 and 54 at average risk. For men aged 55-69 years, the AUA recommended shared decision-making.[6] The American Cancer Society, meanwhile, recommended against routine screening in any age group.[7]

The jumble of recommendations sowed confusion among clinicians and patients.

In May 2018, the USPSTF issued a final PSA screening recommendation[8] that backed off from its previous recommendation, instead now giving tepid support to the idea of shared decision-making in men aged 55-69 years. That hewed more closely to the AUA's guidance. But USPSTF said the evidence that screening provided any benefit still only warranted a C grade.

Some primary care physicians...have questioned whether shared decision-making is realistic in their world.

The AUA said the final recommendation for 55- to 69-year-olds fell in line with "the AUA's clinical practice guideline and guidelines from most other major physician groups—including the American Cancer Society, the American College of Physicians, the American Society of Clinical Oncology and the National Comprehensive Cancer Network—all of which advocate for shared decision making."[9]

The AAFP has yet to weigh in.

Some primary care physicians, however, have questioned whether shared decision-making is realistic in their world—full of competing demands that have to be addressed within a 10- or 15-minute time slot. Other obstacles abound, including low health literacy, fear of litigation, shifting expert viewpoints, and language and cultural barriers, wrote oncologists Paul Mathew, MD, and Hilal Hachem, MD, and internist Paul Han, MD, MA, MPH, in JAMA Oncology.[10] Mathew and Hachem are affiliated with Tufts Medical Center, Boston, Massachusetts, and Han practices at the Maine Medical Center in Portland.

"It is clear that the idealized scenario of shared decision making is effectively a mirage if considered at the population level," Mathew and colleagues wrote.[10] "Yet the practical infeasibility of shared decision making routinely receives short shrift in position statements on prostate cancer screening issued by major organizations and in expert commentaries," they continued. The clinicians also noted that no financial incentives exist for shared decision-making. As a result, "it is difficult to envision a nationwide shift in this fundamental reality of primary care," they wrote.[10]

Hypertension Guidelines

Primary and specialty organizations also found themselves at odds over the latest guideline on managing hypertension[11] issued by the AHA and ACC in partnership with nine other professional societies. One of the key areas of controversy was that adults with an average systolic pressure of 130-139 mm Hg or diastolic pressure of 80-89 mm Hg are now categorized as having stage 1 hypertension. They would have previously been considered as having "prehypertension." That shifted as many as 31 million more adults into having the condition, with as many as 4.2 million being recommended for drug treatment, according to an editorial by Bell and colleagues[12] published in JAMA Internal Medicine in April.

"The ACC/AHA guideline follows a general pattern across medical specialties, whereby disease definitions are more frequently widened than narrowed," wrote the authors. People who fall into the broader definition will be labeled as unwell, giving the guideline potential to cause harm, they said. Eighty percent of those newly diagnosed with hypertension "would have no expected benefit in terms of CVD [cardiovascular disease] risk reduction with BP [blood pressure] lowering," said Bell and colleagues.

The AAFP—which pointedly noted that it wasn't involved in crafting the guideline—issued a statement[13] that it was declining an endorsement. Instead, AAFP continues to back the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults,[14] developed by the Eighth Joint National Committee (JNC8), a supposedly independent panel of experts assembled by the National Heart, Lung, and Blood Institute that was later found to have many conflicts of interest among its members.

O'Gara said the guideline was written in a way to try to achieve consensus, but that "there may be legitimate reasons for differences in opinion." The AHA and ACC "have consistently tried to enlist the ACP and the AAFP as partners in the guideline writing process with respect to prevention," he told Medscape.

Lin, the Georgetown family physician, said that a process that includes primary care "just makes for a better guideline all around." If, for instance, the hypertension guideline only relied on cardiologists, "the patients they are seeing are at the extreme end of disease," he said. Without a clinician with different experience at the table, the guidelines become lopsided, said Lin.

But at least one member of the ACC/AHA writing committee—Randy Stafford, MD, PhD—said that they had included a diversity of viewpoints, including those of patients. Stafford, professor of medicine at the Stanford School of Medicine and director of the Program on Prevention Outcomes and Practices, told Medscape that the input of patients is as important as that of professionals.

He said the hypertension guideline has been criticized as too friendly to the pharmaceutical industry because it seemed to tilt in the direction of medication over diet and exercise. But the charge isn't fair, said Stafford, who said that setting lower targets was aimed at getting people to take high blood pressure seriously. The idea was to avoid "a continuation of what we have now, which is massive undertreatment of people who have high blood pressure," he said.

The guideline is "very clear that nonpharmacologic strategies are actually preferred, in some sense," he said. But he acknowledges that behavior changes are harder to encourage and to stay with.


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