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Medical Research: Translation to Clinical Practice

Jackson T. Wright, Jr., M.D., Ph.D.
Case Western Reserve University

The translation of new research findings into clinical practice poses a challenge at many levels. In general, the medical community is generally slow to incorporate new information into clinical practice. This delay results from the lag time in disseminating the results, delay in gaining acceptance, and subsequent delay in implementation at each patient contact. In addition, this observation fails to consider the relative value of new information and who makes that determination. Even if the first two steps are defined by the time of release of the information in consensus statements or guidelines, implementation of these new findings is often unacceptably slow. For instance, in a 1996 survey of US physicians treating hypertension (3 yrs after its release), 41% reported that they had either not heard of the JNC-V guidelines or were not familiar with its contents.

In considering the implementation of guidelines based on clinical trial data into the clinical management of hypertensive patients, they can be divided into the two broad categories of evaluation and treatment. The evaluation of hypertension can be broken down into:

For the most part, likely advancements in this area are likely to be technological advancements in measurements, many of which will be assessed by 3rd party payers and institutions rather than providers for "cost effectiveness". Examples include 24 hr ABPM, new imaging technologies for evaluation of renal arteries. Market forces will likely play a major role in the incorporation of these advances. It is likely that potential genetic advances identifying genetic forms secondary hypertension will also fall into this category.

The incorporation of new clinical trial data regarding the treatment of hypertension, can also be simplified to include 1) treatment (especially drug selection) and 2) blood pressure treatment goals. For many of the drug-specific consensus recommendations, there is also a commercial incentive to insure dissemination and implementation. For example, due to heavy marketing by industry, ACEIs or/and ARBs are now nearly always included in antihypertensive regimens for diabetic hypertensives. Issues related to blood pressure treatment goals may be the more challenging.

Although, a much greater benefit is likely to be derived from meeting the blood pressure goals, the issues related to incorporating them are more complicated. They involve prescriber-related, patient-related, and system-related behaviors. Several studies suggest that providers fail to titrate or add additional agents adequately in hypertensives not at goal. While advances in the development of more potent and better tolerated agents and delivery systems may be helpful, incorporating findings that require behavioral or system changes will be more challenging.

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