Why Does Musculoskeletal Research Stall Before Reaching the Clinic?

Research in rheumatoid arthritis and other musculoskeletal disorders frequently stalls between laboratory and clinic, leaving patients without the benefit of the most up-to-date treatments.  A new review finds barriers along every step of the translational research pathway, from limited funding for rheumatoid arthritis, osteoarthritis, gout and back pain to systemic factors that keep doctors from instituting the latest findings in their practices. More must be done to smooth the way from the bench to the bedside, Australian researchers wrote in June in the journal Nature Reviews Rheumatology. "At the moment, just publishing the research and presenting it at meetings and writing guidelines doesn't seem to be enough," said review co-author Rachelle Buchbinder, a rheumatologist and the director of the Department of Epidemiology and Preventative Medicine at Monash University in Australia.[[{"type":"media","view_mode":"media_crop","fid":"43961","attributes":{"alt":"©R.Badowski/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_3904729338828","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4888","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©R.Badowski/Shutterstock.com","typeof":"foaf:Image"}}]] Buchbinder and her colleagues reviewed the barriers to establishing evidence-based treatments for musculoskeletal disorders and found deep-seated problems. Though rheumatoid arthritis, osteoarthritis, back pain, neck pain and gout together account for 21 percent of all years lived with disability world-wide, they wrote, these conditions receive relatively scant research funding.  In Australia, for example, the National Health and Medical Research Council devoted $237 million Australian (approximately $170.3 million U.S.) to arthritis and osteoporosis funding between 2005 to 2014. But this paled in comparison to funding for diabetes, which received $584 million Australian ($419.6 million U.S.). What limited funding there is may not always be used wisely. Citing a 2009 study in the journal The Lancet that found that as much as 85 percent of biomedical research is wasteful, Buchbinder and her colleagues warned that a majority of musculoskeletal research dollars might go to low-priority or clinically irrelevant studies. Researchers often fail to conduct systemic reviews of earlier findings before launching their own studies, which end up answering questions that have already been answered. And industry involvement can potentially bias what studies get published and are included in any systemic reviews that exist, the researchers added.  When studies are useful, their findings may languish, caught in the nexus between academic publications and physicians' examination rooms. A bevy of factors keep research results from translating into clinical practice, including slow publication process on the academic side. In the clinic, doctors may be reluctant to adopt new guidelines that go against their established practice routines; they may not even be aware of research results, given the difficulty of sifting through new publications and papers. And patients often expect certain treatments, regardless of whether those treatments been shown to be helpful or not.  In other cases, doctors and patients rush to adopt new treatments without enough deliberation, Buchbinder and her colleagues wrote. For example, after biologic drugs were shown to help a subset of rheumatoid arthritis patients who don't respond to disease-modifying antirheumatic drugs (DMARDs), doctors began prescribing biologics to rheumatoid arthritis patients with less severe disease. Biologics are far more expensive than DMARDs, and several studies have found that for these less-affected patients, they do not outperform the older, cheaper drugs. However, there is reason for optimism, Buchbinder said. In Australia, an ongoing review of government-subsidized treatment aims to ensure that money goes preferentially to those with real benefits. Globally, the clinician-led Choosing Wisely campaign has the goal of creating recommendations based on whether a treatment is evidence-based, unique from other treatments, free from harm and truly necessary. That program focuses more on what physicians shouldn't do than what they should do, Buchbinder said. Other efforts could include making guideline recommendations more accessible at the point of care, she said.  Larger systemic factors will need to be addressed, too, Buchbinder said. One major boon to medicine, she and her colleagues argue, are implementation trials. Currently, studies on how new treatment recommendations are implemented are next-to-nonexistent, the researchers wrote. Not a single musculoskeletal research trial funded by Australia's medical and health research body between 2008 and 2013 included an implementation trial, they found. Implementation trials could be funded by money saved by slashing the cost of inappropriate care, the researchers suggested. Or, perhaps government funders of healthcare could institute a "low-value" tax that would tax lower-value treatments at higher rates than high-value treatments to discourage the use of the former. "We also need to focus on changing patient expectations to be in line with evidence so that they are not presenting for care expecting that they will get a test or treatment when the test or treatment has been shown to be of no benefit," Buchbinder said.  Some of these changes are likely to be contentious - already, Australia's attempt to review government-funded treatments for usefulness has been attacked by some as cost-cutting at the expense of patients, Buchbinder said. But as the cost of health care rises, the problem of ineffective treatment is taking center stage.  "We are just at the cusp of finding ways of making evidence more easily translatable into practice so I am optimistic that changes will occur," Buchbinder said. "Especially as we are so more aware now of the problem."  

Key points for physicians

​Information courtesy Nature Reviews Rheumatology.

References:

Buchbinder, R., Maher, C. & Harris, I. 

Setting the research agenda for improving health care in musculoskeletal disorders.

 Nature Reviews Rheumatology 11, 597–605 (2015). doi:10.1038/nrrheum.2015.81. Published online 16 June 2015. Chalmers,I.&Glasziou,P.

Avoidable waste in the production and reporting of research evidence.

Lancet 374, 86–89 (2009).  Sokka, T. et al.

Similar clinical outcomes in rheumatoid arthritis with more versus less expensive treatment strategies. Observational data from two rheumatology clinics.

Clin. Exp. Rheumatol. 31, 409–414 (2013).