Threads and Yarns: Weaving the Tapestry of Comorbidity

Dr. Starfield appropriately decries the disease-oriented, primary care-unfriendly nature of the American health care system. Her editorial was red meat for primary care clinician/researchers like me. I especially endorse her comment “Disease-oriented specialists are in no position to take a commanding stance in what is an appropriate procedure for patients in primary care.” But how can we, as primary care researchers, constructively communicate this message to our referral specialist colleagues? I suggest that we SORT things out with them.

The editors of the other US primary care (family medicine) journals have endorsed the Strength of Recommendation Taxonomy (SORT) as a method for evaluating the “hierarchy of evidence” supporting clinical recommendations (1). SORT ranks evidence (from strongest to weakest) as follows: “An A-level recommendation is based on consistent and good quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease- oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.” SORT defines patient-oriented outcomes as “outcomes that matter to patients and help them to live longer or better lives, including reduced morbidity, mortality, or symptoms, improved quality of life, or lower cost.” SORT defines disease-oriented outcomes as “intermediate, histopathologic, physiologic, or surrogate results (eg, blood pressure, blood sugar, flow rate, coronary plaque thickness) that may or may not reflect improvements in patient outcomes.”

My integrated multi-specialty medical group practice has included SORT as part of our taxonomy by which we make evidence-based decisions regarding system-wide implementation of disease-management programs. We also use SORT while making Clinical Practice Assessments on the strength of evidence of recently published articles. This process does not always convince our disease-oriented specialists to abandon their expert opinions in favor of better evidence; however, these disagreements usually have more to do with differential weighting of evidence versus business and financing issues than on any fundamental disagreement on the nature of evidence.

More generally, it would be a good idea to introduce all disease- oriented specialists to SORT as a means of educating them on the primary care perspective. Even if some of them refuse to acknowledge that their “expert opinion” is at the bottom of the evidentiary food chain, they need to understand ideally that any evidence that is not generalizable, internally valid, and patient-oriented is not going to be valuable or useful to primary care. A more knotty problem is convincing specialists to apply the best evidence in their own practices, as Dr. Starfield points out.

1. Ebell, M. H., J. Siwek, B. D. Weiss, S. H. Woolf, J. Susman, B. Ewigman, and M. Bowman. 2004. Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. J Fam Pract 53:111-120.

Competing interests:   None declared