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Educating, with evidence
EDITORIAL
THE LANCET Volume 363, Number 9420
Educating, with evidence Most practitioners probably agree that evidencebased practice guidelines are a good thing, at least in theory. But, as someone once, surely apocryphally, said, “in theory, there’s no difference between theory and practice, but in practice there is”. Moving research findings into clinical practice continues to pose formidable challenges. A Research letter in this week’s issue of The Lancet (see p 1525) highlights the difficulty. James Ryan and colleagues show that guidance issued by the UK’s National Institute for Clinical Excellence (NICE) on two procedures, wisdom tooth extraction and primary total hip replacement, has had little effect on clinicians’ behaviour. NICE is not alone in its efforts to change practice. Having witnessed the techniques used by drug companies to promote their products, funding agencies, including the US National Institutes of Health (NIH), are appropriating the remarkably successful marketing tactics of industry. “Academic detailing” sends clinical experts, not drug-industry equivalents, into doctors’ offices to inform them about the best evidence for treatment, based on the published findings of large clinical trials. The NIH is now asking investigators seeking funding for large trials to develop plans for disseminating their findings. And the National Heart, Lung, and Blood Institute (NHLBI) will soon begin an initiative aimed at educating doctors about the results of its Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, which showed that most patients with hypertension should be started on or switched to a cheap thiazide diuretic, not newer and more expensive agents. Some professional societies are working on other projects. The American Society of Hypertension (ASH), for example, has developed a programme deployed through its network of local chapters. Doctors who become certified as clinical hypertension specialists act as community resources for primary-care providers, including physician assistants and nurse practitioners, educating them about clinical guidelines and facilitating treatment recommendations.
But these efforts are under-resourced compared with those backed by the deep pockets of the private sector. Novartis recently announced Take Action for Healthy BP, a consumer awareness campaign that includes a 30-day free trial of medication (the drugs include, some in combination, an angiotensin II antagonist, an angiotensin-converting-enzyme inhibitor, and a calcium-channel blocker), complete with a money-back guarantee. The company acknowledges in a note that its combination drugs are not indicated for the initial treatment of hypertension. That detail, which effectively excludes the first level of evidence-based treatment, is likely to be obscured by the short-term economic lure of the guarantee. Although neither NHLBI nor ASH recommends any particular drug or treatment regimen, both organisations are supporting the Novartis campaign. Such partnership might be interpreted as privatesector appropriation of what ought to be a publichealth programme. While the unaffordability of drugs is a big problem in hypertension control, incentives such as Novartis’ are only temporary fixes. They deflect attention away from evidencebased recommendations and can undermine the promotion of cost-effective care. Some 60 million Americans have hypertension. Many patients do not even know whether they are affected, and far more have uncontrolled hypertension, often the result of inadequate compliance (they do not have symptoms or the drugs cost too much) or inappropriate prescribing. Educating patients about the disease is a laudable undertaking. But a national health plan, affordable drugs, and evidence-based treatment regimens devised by knowledgeable clinicians who use their best judgment about the needs and wishes of individual patients would go much further to solve this public-health problem. What patients and doctors need are public programmes, not industrysponsored initiatives that parade as education but are in fact thinly disguised marketing tools. The Lancet
THE LANCET • Vol 363 • May 8, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
1485
THE LANCET Volume 363, Number 9420
Educating, with evidence Most practitioners probably agree that evidencebased practice guidelines are a good thing, at least in theory. But, as someone once, surely apocryphally, said, “in theory, there’s no difference between theory and practice, but in practice there is”. Moving research findings into clinical practice continues to pose formidable challenges. A Research letter in this week’s issue of The Lancet (see p 1525) highlights the difficulty. James Ryan and colleagues show that guidance issued by the UK’s National Institute for Clinical Excellence (NICE) on two procedures, wisdom tooth extraction and primary total hip replacement, has had little effect on clinicians’ behaviour. NICE is not alone in its efforts to change practice. Having witnessed the techniques used by drug companies to promote their products, funding agencies, including the US National Institutes of Health (NIH), are appropriating the remarkably successful marketing tactics of industry. “Academic detailing” sends clinical experts, not drug-industry equivalents, into doctors’ offices to inform them about the best evidence for treatment, based on the published findings of large clinical trials. The NIH is now asking investigators seeking funding for large trials to develop plans for disseminating their findings. And the National Heart, Lung, and Blood Institute (NHLBI) will soon begin an initiative aimed at educating doctors about the results of its Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, which showed that most patients with hypertension should be started on or switched to a cheap thiazide diuretic, not newer and more expensive agents. Some professional societies are working on other projects. The American Society of Hypertension (ASH), for example, has developed a programme deployed through its network of local chapters. Doctors who become certified as clinical hypertension specialists act as community resources for primary-care providers, including physician assistants and nurse practitioners, educating them about clinical guidelines and facilitating treatment recommendations.
But these efforts are under-resourced compared with those backed by the deep pockets of the private sector. Novartis recently announced Take Action for Healthy BP, a consumer awareness campaign that includes a 30-day free trial of medication (the drugs include, some in combination, an angiotensin II antagonist, an angiotensin-converting-enzyme inhibitor, and a calcium-channel blocker), complete with a money-back guarantee. The company acknowledges in a note that its combination drugs are not indicated for the initial treatment of hypertension. That detail, which effectively excludes the first level of evidence-based treatment, is likely to be obscured by the short-term economic lure of the guarantee. Although neither NHLBI nor ASH recommends any particular drug or treatment regimen, both organisations are supporting the Novartis campaign. Such partnership might be interpreted as privatesector appropriation of what ought to be a publichealth programme. While the unaffordability of drugs is a big problem in hypertension control, incentives such as Novartis’ are only temporary fixes. They deflect attention away from evidencebased recommendations and can undermine the promotion of cost-effective care. Some 60 million Americans have hypertension. Many patients do not even know whether they are affected, and far more have uncontrolled hypertension, often the result of inadequate compliance (they do not have symptoms or the drugs cost too much) or inappropriate prescribing. Educating patients about the disease is a laudable undertaking. But a national health plan, affordable drugs, and evidence-based treatment regimens devised by knowledgeable clinicians who use their best judgment about the needs and wishes of individual patients would go much further to solve this public-health problem. What patients and doctors need are public programmes, not industrysponsored initiatives that parade as education but are in fact thinly disguised marketing tools. The Lancet
THE LANCET • Vol 363 • May 8, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
1485