By Tricia Pendergrast

Editors: Nikita Joshi MD, Nick Gabinet, Makini Chisholm-Baker

Evidence-Based Medicine

The practice of evidence-based medicine (EBM) is defined as the integration of clinical expertise, patient values, and best available scientific evidence during medical decision-making. With roots in both ancient Greece and China, and a mention in Avicenna’s 11th Century Canon of Medicine, EBM is almost as old as the practice of medicine itself (1-2). It was not until the late 20th century that EBM began to affect healthcare and policy in a meaningful manner, following Scottish epidemiologist Archie Cochrane’s publication of the landmark treatise, Effectiveness and Efficiency: Random Reflections on Health Services (1).

The tenants of EBM are applicable to a myriad of healthcare contexts, from choosing a cancer treatment to addressing the gun violence epidemic. In both contexts, healthcare providers and epidemiologists define a problem, search for data, critically evaluate the data for soundness, relevance, and potential biases, and apply knowledge gained to the problem. EBM is especially effective in addressing questions to which there appear to be no clear answers. At its core, data-driven methodology aims to be free from individual biases. The foundation of modern medicine and public health strives for unbiased scientific evidence. Scientific inquiry and research is needed if one intends to create real change in patterns of disease or injury.

The History of Firearm Research Funding

Twenty-five years ago, Dr. Arthur Kellerman and his colleagues at the University of Tennessee published a paper in the New England Journal of Medicine (3). The manuscript, entitled “Gun ownership as a risk factor for homicide in the home,” reported that ownership of a gun was independently and significantly associated with an increased risk of homicide. The findings refuted the party line of the National Rifle Association (NRA), that guns in the home confer safety. In fact, guns increased the risk of injury at the hands of an intimate partner or acquaintance.

The NRA responded to the media attention to Kellerman’s paper by launching a campaign to eliminate the government agency that provided the funding for the study, the Centers for Disease Control and Prevention (CDC). While it did not succeed in this regard, the NRA’s campaign achieved its desired impact in other ways.

Congress passed the Omnibus Consolidated Appropriations Act on September 30th, 1996. The bill was amended by Representative Jay Dickey, a lifetime NRA member who received nearly $50,000 from the NRA in his final congressional campaign. Dickey’s amendment added the following provision: “none of the funds made available for injury prevention and control at the CDC may be used to advocate or promote gun control” (4).

The law stripped the CDC’s budget of $2.6 million, the exact amount the agency had allotted to the study of gun violence in the previous year. The firearms research program was shut down, and the CDC has not funded any significant studies on gun violence since that time (3-4). At the time of this writing, the CDC’s website lacks any information about prevention of firearm-related injuries or death.

Representative Todd Tiahrt introduced the Tiahrt Amendment February of 2003. This served to prevent the National Tracing Center of the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) from releasing its data to any entity outside of law enforcement. The Amendment rendered impossible research on the origin of firearms used and seized in crimes. Before the Amendment, this information was readily available to the public through a Freedom of Information request. The law also removed from public record a government database that traced the origins of guns recovered in crimes, back to dealers (5). The NRA has contributed almost $80,000 to Representative Tiahrt over the course of his career (6).

Why Funding Matters

Academic research, similar to that of Dr. Kellerman and colleagues, is conducted at institutions all around the world. The purpose of academic research is supposed to be discovery and dissemination to facilitate evidence-based action.

However, research is expensive. The costs include funding for researchers, time, effort, preparation, and necessary equipment. Research is also an “all or nothing” enterprise. When designing a study, the investigators must initially identify the outcomes of interest (for example: reduced deaths by suicide in the country). They plan their statistical analysis before collecting data. They choose whether they are interested in seeing if variable A will predict B, if group X is different than group Y, and so on. Once an outcome and analysis plan are chosen, calculations are performed to determine the minimum number of participants to enroll to obtain sufficient data to draw meaningful conclusions. Fall short of this number, and the results are not valid. Invalid results will be called into question by peers, publications, or officials.

High-quality and complex research takes funding, which is often provided by governmental organizations. It follows that federal research funding cuts and allocations wield significant control over research questions that are scientifically studied. The allocation of these funds directly represents the priorities of the government. Instead of maintaining a gross sum of dollars, the government earmarks funds for areas of research that leadership deems essential. Previous focuses included motor vehicle, fire, and drowning injury prevention research, which were followed by a 31, 38, and 52 percent reduction of deaths in these areas, respectively (7).

This goes to show, research is expensive, but is important to do in order to achieve the goal of rigorous scientific results, data, and knowledge. There is no way to cut corners and still maintain this high standard. And without prioritizing or funding, we will not be able to gain knowledge about the issues surrounding gun violence and related deaths. We need this knowledge to solve this public health crisis.

References

1. Masic, I., Miokovic, M., & Muhamedagic, B. (2008). Evidence based medicine–new approaches and challenges. Acta Informatica Medica, 16(4), 219.

2. Sackett DL, Richardson WS, Rosenberg W, Haynes RB.Evidence-based medicine: how to practice and teach. 2. ed. Edinburgh: Churchill-Livingstone, 2000

3. Kellerman, A. L., Rivera, F. P., & Rushforth, N. B. (1994). Gun ownership as a risk factor for homicide in the home. Journal of Clinical Forensic Medicine, 1(1), 52.

4. H.R. 3610 (104th): Omnibus Consolidated Appropriations Act, 1997.

5. Grimaldi, J., & Horowit, S. (2010). Industry pressure hides gun traces, protects dealers from public scrutiny. Accessed from: http://www.washingtonpost.com/wp-dyn/content/article/ 2010/10/23/AR2010102302996.html

6. Representative Todd Tiahrt. Opensecrets.org

7. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting Systems: Fatal Injury Data. http://www.cdc.gov/injury/wisqars/fatal.html. Accessed December 14, 2012