For months, I’ve been keenly interested in trying to explore where the field of primary care research stands. It’s daunting to pull your head up from your own research, take stock of what your colleagues (both known and unknown) are doing and try to assess where the field is advancing. Doing this every now and then is important, but also intimidating.
It’s a bit like Spring cleaning. There is some obvious humility required for both. Sorting through your closet for the clothes that are out-of-fashion often requires a sense of humor (is it still OK to have an obsession with plaid?). But that humility pales in comparison to the fear that your research work could be equally out-of-fashion, or that your research questions (long hanging in your scientific closet) have been answered…done and dusted.
This is complicated by the fact that the field of primary care research is ill-defined. Is it research into clinical breakthroughs in primary care? Is it about the ways that we deliver primary care (a more health services research bent), which is my personal area of research? Or is it any research conducted in a primary care setting? In the end, I’ve decided it could be any of those things.
A Caveat-Filled Challenge
The challenge of staying current is not unique to the broad field of primary care research. The narrow silos that we find ourselves working in, the shifting political winds that shape the research funding landscape, and the technical complexity and depth of the research endeavor as a whole make knowing where research is blossoming a major challenge. Some researchers are able to escape those silos, and there are many colleagues who are connected deeply into the funding channels (and shaping them). Most are neither the growers nor significant shakers of the money tree.
Additionally, the sheer volume of published research today makes staying aware of and interpreting the research literature considerably harder. With almost 2.2 million scholarly publications each year [pdf], even the leading algorithm-based aggregators (such as Web of Science, ResearchGate, and Google Scholar) seem limited in their ability to help separate the wheat from the chaff. The “avalanche of research” has been both critiqued and heralded, but the challenge it presents to researchers and clinicians in staying up-to-date is indisputable.
My approach to surveying the field involved looking for the most highly cited literature pertaining to primary care. While this wouldn’t meet the requirements of a formal literature review, that wasn’t my intent. I just wanted to see the breadth of what is being published and referenced by others. I was curious who was moving the needle, and finding highly cited recent work seemed the easiest way. Using Web of Science I searched for articles with the word “primary care” in the title and I wanted to see only work published in the last five years. Given those limitations, here’s what I found.
A Brief, Targeted Assessment of Recent Research in Primary Care
In the last five years, the most highly cited paper with “primary care” in the title was published in JAMA in 2016 by Daniella Meeker and colleagues (176 citations as of the time of my search). It describes an intervention in primary care to reduce inappropriate antibiotic prescribing. The need for greater selectivity in antibiotic prescribing is widely known, and developing simple, successful interventions is clearly helping move the field forward. The study–a randomized, controlled trial–found that behavioral interventions with physicians, such as comparing doctors to one another or requiring written justification for each antibiotic ordered inappropriately, could reduce prescriptions by about 15 percentage points (down to a rate below 5%).
Also among the top 5 papers was a policy perspective published in the New England Journal of Medicine in 2015 about Brazil’s health care system (123 citations so far). Authored by James Macinko and Matthew Harris, the article describes Brazil’s Family Health Program: a system of delivering universal primary care through geographically-assigned teams led by physicians and nurses supported by “community health agents”. Each agent is assigned to (and visits) 150 households in their neighborhood every month, helping to coordinate any needed medical or social care. The system involves more than 39,000 teams and 265,000 community health agents nationally. That this international example is highly cited suggests that researchers may be looking abroad for solutions to problems at home.
Interestingly, the 6th most highly cited paper during this period was an assessment of clinical workloads in primary care in the United Kingdom’s NHS (121 citations). Published in 2016 in the Lancet, Richard Hobbs and colleagues analyzed more than 100 million consultations over a 7-year period, with a goal of verifying reports of increased workloads during this time period. Overall, they found a 16% increase in workloads (a composite of mean in-person visits, visit duration, and telephone consultations) during this time period. These concerns resonate with most family medicine and other primary care physicians in the US, and questions about universal health care in the U.S. often turn into discussions about workloads and wait times in other countries.
The most highly cited recent primary care article in our journal, Medical Care, was a 2016 article by John Graves and colleagues looking at the role of nurse practitioners (NPs) and physician assistants (PAs) in expanding access to primary care in urban and rural areas (25 citations). It had a policy focus as well, comparing the primary care accessibility in states with broad vs. narrow scope of practice laws. The conclusion is that scope of practice laws help, but don’t necessarily resolve urban-rural differences in access to primary care. In the US, a lot of weight has been placed on the shoulders of NPs and PAs to expand primary care; this study answers some questions about whether that expectation is fair.
Taking Final Stock
Recent highly cited research in primary care has focused on enhancing what primary care does best–solving common problems with relatively low-tech, low-cost solutions:
- following the evidence to help evolve the practice
- serving as a point of first contact
- building relationships with patients (e.g, the community health agents in Brazil).
I’d be curious to know what you think. How would you describe the current state of primary care research? Where have we made progress and where is the field blooming? What questions are hanging in your scientific closet? Reach out to me at gstevens@usc.edu.
Gregory Stevens