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Prevention and Primary Care Research for Children

The Need for Evidence to Precede “Evidence-Based”
  • Lawrence C Kleinman MD, MPH
    Correspondence
    Dr. Lawrence C. Kleinman, 306 Elliot Street, Newton Upper Falls, MA 02164.
    Affiliations
    Department of Pediatrics, UCLA School of Medicine, Los Angeles, California, Department of Maternal-Child Health, Harvard School of Public Health, Boston, Massachusetts 02115, USA.
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      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.

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      References

      1. Nutting P. A research agenda for primary care: summary report of a conference. Agency for Health Care Policy and Research, Rockville, Maryland. AHCPR 91-08; January 1991.

        • Franks P
        • Nutting PA
        • Clancy CM
        Health care reform, primary care and the need for research.
        JAMA. 1993; 270: 1449-1453
        • Gemson DH
        • Ashford AR
        • Dickey LL
        • et al.
        Putting prevention into practice.
        Arch Int Med. 1995; 155: 210-216
      2. Put Prevention into Practice. Health Education Lifetime Plan. American Academy of Family Physicians; Spring 1995.

        • Fries JF
        • Koop CE
        • Beadle CE
        • et al.
        Reducing health care costs by reducing the need and demand for medical services.
        N Engl J Med. 1993; 329: 321-352
        • Kleinman LC
        • Kosecoff J
        • Dubois RW
        • Brook RH
        The medical appropriateness of tympanostomy tubes for children under 16 years in the United States.
        JAMA. 1994; 271: 1250-1255
        • Brook RH
        Quality of care.
        Ann Intern Med. 1991; 6: 480-490
        • Russel LB
        The role of prevention in health care reform.
        N Engl J Med. 1993; 329: 352-354
      3. Kleinman LC. A vision for disease management. Surgical Services Management 1995;1(4):22–26.

      4. Kaplan S. Measuring functional status of patients in the AHCPR’s patient outcomes research team for diabetes. Talk given at Conference, Outcomes and Disease Management of Diabetes. The Zitter Group. San Francisco, California; July 19, 1995.

        • Rothman KJ
        Causal inference. Epidemiology Resources Inc, Chestnut Hill, Massachusetts1988
        • The U.S. Preventive Services Task Force
        Guide to clinical preventive services. Williams & Wilkins, Baltimore, Maryland1989
      5. The periodic health examination. Task Force on the Periodic Health Examination, Health Services and Health Promotions Branch, Canadian Department of National Health and Welfare. Ottawa, Ontario, 1979.

      6. Healthy children: investing in the future. Office of Technology Assessment. Washington, DC; 1988.

      7. Homer CJ. Evaluation of the evidence on the effectiveness of well child care for children. Background paper prepared for the Office of Technology Assessment, Health Program under Contract H3-2755.0.

        • Eddy D
        Benefit language.
        JAMA. 1996; 275: 650-657
        • Downs SA
        • Klein JD
        Clinical preventive services efficiency and adolescent risk behavior.
        Arch Pediatr Adolesc Med. 1995; 149: 374-379
        • Starfield BH
        • Simborg DW
        • Horn SD
        • Yourtee SA
        Continuity and coordination in primary care.
        Med Care. 1976; 14: 625-636