With the management of complex chronic care shifting from the hospital to the community clinic setting, identifying and bridging important gaps in the provision of care for patients will be a central responsibility of the primary care provider. In Canada, organisations that fund healthcare delivery have already begun a formal review of current practice patterns in family medicine in order to understand more fully how patient care and healthcare costs can be optimised.1 To a large extent, this process will be driven by a mandate to assess the contribution of family physicians to persistent care gaps that threaten to overwhelm public health services and resources.

A ‘care gap’ represents a difference in health outcomes between best care and usual care.2 Recent Canadian data show that family physicians are major drivers of drug prescriptions, diagnostic testing, and the healthcare system as a whole.1 In fact, drug costs represent the second-highest spend in the Canadian healthcare system.3 Some might argue that this information provides a legitimate basis for considering the family physician (at least in part) as a leading accomplice in the development of care gaps related to pharmacotherapy utilisation. For example, despite the availability of new treatments for asthma, and evidence-based Canadian asthma guidelines that are regularly updated,4–6 asthma control in Canada remains suboptimal.7

What might be the reasons for this? A recent study suggests that a median of only 6% (range 0% – 43%) of patients treated for asthma meet the eligibility criteria for major trials cited in evidence-based treatment guidelines.8 In his excellent article published in the PCRJ in 2010,9 Halpin outlines many fundamental limitations of landmark COPD trials and how such trial data may be difficult to apply at the primary care level. For example, in relation to trials such as ISOLDE,10,11 TORCH12 and UPLIFT,13 there has been minimal, if any, discussion around the pragmatic implications of high early withdrawal rates from the active treatment arms in these studies — a reality that invariably compounds the difficulty of translating trial information into the most cost-effective care for our primary care patients. Since numbers-needed-to-treat are difficult to adjust for early terminators, it is likely that treatment effects are often overstated in these landmark trials, thus further contributing to perceived care gaps in the real world.

In the UK, most patient contact and 90% of prescribing occur in primary care — yet until recently much of the evidence to support this activity was generated in secondary or tertiary care settings.14 Similar trends are observed in Canada.1 There are also reports which suggest that most primary care clinically-relevant research uses less rigorous study designs — such as the cross-sectional survey — and that the majority of papers do not meet established criteria for relevance and validity.15 This potential disconnect between family medicine's limited involvement in pharmacotherapeutic research and its role in driving drug costs represents a leadership void that could leave our discipline incapable of effectively identifying and bridging care gaps in a timely manner. This scenario likely also applies to other areas of healthcare delivery that are driven by family physician activities.

Outside the pharmacotherapeutic domain, it is sobering to consider that some clinical guideline recommendations cannot be translated into clinical practice in their current form yet continue to be widely promoted in primary care with little effort directed at conducting formal validation studies. For example, many guidelines recommend simple (pre- and post-bronchodilator) spirometry as the first line test for asthma diagnosis in primary care. In the Canadian asthma management guideline4 this strategy is rated as level 4 evidence — a rating that acknowledges the lack of randomised trials on the subject. What is not outlined in guideline recommendations is the very low sensitivity of spirometry (compared to methacholine challenge testing) for confirming a diagnosis of asthma at the time of testing.16 In fact, fewer than 20% of patients with a physician diagnosis of asthma will respond to a bronchodilator challenge in accordance with guideline-defined spirometric diagnosis of asthma.16–19 Most patients with asthma managed in primary care have lung function that is well preserved and which changes little in response to a bronchodilator challenge.20 This begs the question; why utilise a first-line diagnostic test that will be helpful, at best two out of ten times, when other more sensitive tests like methacholine challenge testing can be made available to most primary care physicians in a reasonably timely fashion? Furthermore, what are physicians to do with patients who have suspected asthma and who have normal lung function on initial testing? Treating such patients on clinical grounds risks over-diagnosis and renders future spirometry testing almost irrelevant. To date, there are no data describing the cost implications of diagnosing asthma in primary care using simple spirometry compared to methacholine challenge. These comments are not meant as a slight against simple spirometry — with its well-established role in evaluating pulmonary mechanics — but a recognition that more convincing, pragmatic evidence is required before costly, widespread adoption of spirometry as the key test for diagnosing asthma is considered standard practice in primary care.

It is likely therefore, that the family physician is an unknowing accomplice in the development of primary care gaps, since guidelines developed in the tertiary setting are used to drive care in the primary care environment. Furthermore, given that family medicine is a major driver of drug costs, is it fair to suggest that family physicians have a professional obligation to participate in pharmaceutical-sponsored clinical trials in order to create opportunities to participate directly in guideline development?21 Is it also fair to suggest that if family physicians are not developing clinical guidelines and messages firsthand they simply become messengers for those who are?

The great challenge faced by family medicine is the translation of knowledge, often acquired in a very controlled setting, into a clinical practice environment (i.e. primary care) that is as much diverse as it is complex. Simply attempting to implement published guidelines relating to common chronic conditions like asthma and COPD may fall well short of delivering the best care. Simply being critical of the available scientific literature may not allow for more appropriate generalisations that might serve to bridge care gaps. For example, while many study designs may appear appropriate, the questions being addressed may not deal with issues that have meaningful primary care relevance.

Nevertheless, we must not forget the rapid progress that our discipline has made in recent years. The publication of the International Primary Care Respiratory Group guidelines in this journal in 200622 represented a pivotal leadership milestone that will provide us with much needed direction for years to come. Outstanding primary care research such as that by Price et al.,23 which examined the benefits of leukotriene modifying agents in asthma care, brilliantly clarifies the disconnect between real world research studies and findings reported in traditional trials that are more rigidly controlled. The PCRJ itself is a fundamental part of this progress, with the publication of top quality primary care-relevant research — as epitomised by the excellent research papers in this issue — and recent initiatives such as the education@pcrj section which enhance our ability to translate knowledge into effective day-to-day patient management.

This progress must continue. Evolving fiscal realities in Canada and other parts of the world will dictate an increasing role for family physicians to be wise stewards of scarce resources. Without a paradigm shift in how evidence is acquired and adopted into the primary care setting, family physicians will invariably be forced to accept the role of accomplice in the development of primary care gaps.