No 70: Primary Care is at the start of a research evolution
Welcome Back to No 70!
It has been quite a while since I wrote anything medical. I am going to restart my regular posts with a big bang prediction.
Everything you read in the news about healthcare is either awful or is suggesting that AI is going to replace us all.
My prediction is that primary care in the UK is now at a point where we can use “simple” software platforms like AccuRx and RedCap to revolutionise how we do real world medical research.
As with most ideas in life, someone else got here before me. Dr Ben Goldacre started working on and writing about large scale trials within primary care about a decade ago. If you haven’t read his brilliant books - then you should!
Evidence Based Medicine (EBM) has been a truly glorious revolution in the history of civilisation. EBM also has lots of faults.
One of the main issues we come across in primary care is that almost all of the RCTs were done by specialists, in secondary care, in very select groups of patients, with lots of additional monitoring and resources.
Then guidelines are written based on these studies.
However, our real world population that we treat in GP is often very different to the study populations and the guidelines often gloss over polypharmacy, interactions, rare diseases or anyone who was slightly different to the study population.
And a further issue with EBM is that it is time consuming and expensive. So once a drug has been found approved and put into the guidelines, there is often very little incentive to study it further unless its obvious it has other good properties (unintentionally) or there are lots of bad outcomes.
However, I would argue that means that there is huge scope for GPs to design large-scale, open-label RCTs within our day to day practice.
I am sure AccuRx could be used to send out study information and consent forms. AccuRx could be used for at home monitoring and collecting survey data or observations. RedCap is an easy to use piece of software that creates surveys and databases. Creating the research survey on RedCap and sending it to the patient or clinician via AccuRx would be a very simple way to run a research study.
I am sure someone could easily develop software that works with EMIS or System1 to produce a pop up that covers consent, patient registration, trial number generation and drug randomisation within a few clicks.
Then this pop up could be automatically programmed to pop up whenever a “study decision” is being made. And a prescription generated. Then an AccuRx is sent a few weeks later with a follow up survey.
I am sure that there are loads of flaws in what I have just said and lots of issues that would need to be resolved. But I believe the principle is sound and will become the norm in the next few years.
There is no reason why every single patient consultation should not be part of a research study.
Below are some simple suggestions of where this type of approach could get started…
RCT questions for GP / Primary care
Hypertension
Which ACEi is better tolerated over a year?
Are ARB better tolerated than ACEi?
Which ACEi or ARB has the best effect on BP lowering?
Which of the A+C+D BP drugs is most effective as the initial solo treatment over 12 months?
Should we be aiming for BP control to 140/90 or 120/80?
Should we be repeating U/E after each dose titration of an ACEi or only after the initiation?
Mental health
Which of the SSRI is better tolerated for anxiety?
Which of the SSRI is better tolerated for depression?
Which of the SSRI is more effective at improving mood and QOL?
Is Mirtazapine more effective than an SSRI for anxiety and depression?
Pain
Which NSAID or Colchicine is better for acute gout pain relief? Which is better tolerated?
Which NSAID is better for LBP?
Is LBP better relief by NSAID alone, NSAID with Amitriptyline, NSAID with gabapentin or NSAID with diazepam short term?
Post-surgical pain - is there any difference in any of the weak/moderate opioids in tolerability and pain relief?
Does taking NSAIDS slow recovery from fractures?
Other Subjects
Should Asthma patients be started on SABA or MART?
Should all patients have their vitamin D checked and given replacement therapy to above 50 to improve natural immunity to common infections and reduce osteoporosis?
Which of the PPI produces better outcomes?
Which COCP is the best tolerated?
Does Gabapentin really help with chronic pain?
Which anti-histamine is most effective?
I am sure it would be easy for most clinicians to spend a minute and come up with multiple simple suggestions to add to this list.
Will these research questions win a Noble prize? - no.
Might they help patients with a slightly more effective and better tolerated treatment? Maybe.
Might they save some money by showing that the cheaper and older alternatives actually worked better? - Quite possibly.
As always, I look forward to reading your thoughts.