Sunday, June 18, 2017

Start collecting community vital signs in your practice

Primary care physicians and educators are increasingly recognizing the usefulness of assessing social determinants of health (defined by the Centers for Disease Control and Prevention as conditions in the places where people live, learn, work, and play) during health care encounters. A recent National Academy of Medicine discussion paper described the Accountable Health Communities Screening Tool, developed by the Center for Medicare and Medicaid Innovation to identify and address five domains of health-related social needs: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. Since 2011, students at Morehouse School of Medicine and Georgia State University College of Law have participated in an interprofessional medical-legal curriculum; surveys suggested that medical students who completed the curriculum were more likely to screen for social determinants of health and refer patients to legal resources. In March, the American Academy of Family Physicians (AAFP) launched its Center for Diversity and Health Equity, whose planned activities will include

- evaluating current research on the social determinants of health and health equity;
- promoting evidence-based community and policy changes that address the social determinants of health and health equity; and
- developing practical tools and resources to equip family physicians and their teams to help patients, families, and communities.

In an editorial in the June 1 issue of American Family Physician, Drs. Lauren Hughes and Sonja Likumahuwa-Ackman add another potential dimension for action on social determinants of health by introducing the concept of "community vital signs." In contrast to data collected directly from patients, the authors write,

Community-level data are acquired from public data sources such as census reports, disease surveillance, and vital statistics records. When geocoded and linked to individual data, community-level data are called community vital signs. Community vital signs convey patients' neighborhood health risks, such as crime rates, lack of walkability, and presence of environmental toxins. ... This enhanced knowledge about where patients live, learn, work, and play can help physicians tailor recommendations and target clinical services to maximize their impact. Rather than simply recommending that a patient eat better and exercise more, care teams can connect patients to a local community garden, low-cost exercise resources (e.g., YMCA), or neighborhood walking groups.

To get started using community-level data to improve patient care and population health, family physicians can consult The Practical Playbook and the AAFP's Community Health Resource Navigator. The editorial also provides a suggested five-step process for incorporating community vital signs into clinical practice.

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This post first appeared on the AFP Community Blog.

Wednesday, June 14, 2017

We shouldn't expect anyone to die in childbirth

Comparing the performance of health systems around the world is difficult to do in a straightforward way. Should one look at differences in life expectancy? Disability-adjusted life years? The percentage of the population that perceives themselves to be in "good health"? We know that poverty, low education, segregation, and other social disadvantages do more to determine health outcomes than does health care. Since newborns presumably haven't had time to become unhealthy from these social factors, the infant mortality rate is commonly cited to illustrate the failure of the U.S. health care system, which has the highest spending per person in the world, but outcomes worse than those in 27 other high income nations.

But it's not only in infant deaths that the U.S. lags behind the rest of the developed world. Last year, the Institute for Health Metrics and Evaluation reported that the maternal mortality rate (the number of deaths per 100,000 births due to complications from pregnancy or childbirth) was higher in 2013 than in 2005, and more than 50 percent higher than the rate in 1990. Even though maternal deaths remain rare (occurring about once every 3600 births in the U.S., 3 or 4 times as often as in Canada and Western European countries), they should be treated like catheter-related bloodstream infections, where the goal is zero. My wife has had four children, at at no point during any of her pregnancies, labors or deliveries did I have the slightest concern that her life was in danger. That's how it should be for moms in the twenty-first century.

And that's also why I, and doubtless many others, found the recent NPR / ProPublica article "The Last Person You'd Expect to Die in Childbirth" so heartbreaking and disturbing. The article recounts the tragic story of Lauren Bloomstein, a 33 year-old neonatal nurse in good health who died of a hemorrhagic stroke in her own New Jersey hospital, 20 hours after delivering her first child. According to the authors, Bloomstein developed preeclampsia with HELLP syndrome, and her physician did not recognize the early symptoms (high blood pressure and abdominal pain) for what they were until it was too late to stop the catastrophe.

It's possible that her death may have been prevented if the hospital had implemented standardized birth safety practices described in an Atlantic article about Dr. Steve Clark, an obstetrician who previously led obstetric safety for 115 programs in the Hospital Corporation of America. But it would be a mistake to conclude from Bloomstein's tragedy that the rising U.S. maternal mortality rate is due primarily to medical errors, when it is in fact a complex public health problem. Dr. Aaron Carroll reviewed some possible causes in a JAMA Forum, including unplanned pregnancies; poor access to preventive care; the opioid epidemic; and the increased prevalence in pregnant women of obesity, hypertension, and diabetes.

Also, the rising overall rate masks persistent disparities. According to a 2010 report on maternal mortality from the Health Resources and Services Administration, non-Hispanic Black women have 3 times the risk of maternal death than White and Hispanic women; counties where 15% or more of the population lives in poverty have twice the risk as counties with a poverty rate of less than 5%; and women in New England have one-half to one-third the risk of women in the Mid- and South Atlantic states. Maternal mortality in the U.S. is largely a problem of social, economic, and geographic inequality rather than differences in health care, and we must look beyond hospitals for solutions. In the short term, it is important to prevent the U.S. Senate from passing its version of the American Health Care Act, which takes $800 billion from Medicaid, the program that pays for 31 to 72 percent of all births depending on the state, like a thief in the night. The last person you'd expect to die in childbirth? We shouldn't expect anyone to die in childbirth, and we certainly shouldn't be hastening their deaths.

Monday, June 5, 2017

The places in America where doctors won't go

This spring, I attended the annual Teaching Prevention conference in Savannah, Georgia sponsored by the Association for Prevention Teaching and Research. Since I haven't spent much time in Georgia outside of Savannah and Atlanta, the welcoming plenary on improving health outcomes for the state's rural and underserved populations was eye-opening. According to Dr. Keisha Callins, Chair of the Department of Community Medicine at Mercer University, Georgia ranked 39th out of 50 states in primary care physician supply in 2013 and is projected to be last by 2020. 90% of Georgia's counties are medically underserved. Mercer supports several pipeline programs that actively recruit students from rural areas, expose all students early to rural practice and community health, and provide financial incentives for graduates who choose to work in underserved areas of the state. But it's an uphill battle. Even replicated in many medical schools across the country, these kinds of programs likely won't attract enough doctors to rural areas where they are most needed.

When people talk about places where doctors won't go, they tend to focus on international destinations, such as war zones in Syria or sparsely populated areas of sub-Saharan Africa. It's hard to believe that many places in America are essentially devoid of doctors, and access to medical care is as limited as in countries where average income is a tiny fraction of that in the U.S. Providing health care coverage for everyone, while important, won't automatically ensure the availability of health professionals and resources in rural communities. In a recent JAMA Forum piece, Diana Mason discussed the financial struggles of rural hospitals that support community health alongside primary care clinicians, which may become more acute if budget cuts to rural health programs and grants occur as proposed in President Trump's budget.

Georgia is hardly the only state struggling to attract doctors to rural communities. In the Harper's Magazine story "Where Health Care Won't Go," Dr. Helen Ouyang chronicles the evolving tuberculosis (!) crisis in the Black Belt, a swath of 17 historically impoverished, predominantly African American counties in rural Alabama and Mississippi. In Marion, Alabama, a single family doctor in his mid-fifties and an overwhelmed county health department grapple daily with the lack of resources to contain the spread of the disease:

There is no hospital in town. The nearest one, twenty minutes away in Greensboro, has minimal resources. The road to get there is narrow, unlit at night, and littered with roadkill. Perry County has only two ambulances, one of which is on standby for the local nursing home. Life expectancy here is seven years lower than the U.S. average, and the percentage of obese adults is almost a third higher; by the latest count, more than a quarter of births take place without adequate prenatal care. [Dr. Shane] Lee’s clinic is Marion’s only place for X-rays.

Ouyang goes on to describe the University of Alabama's Rural Health Leaders Pipeline, a program that recruits and trains medical students from rural communities to eventually become primary care physicians for those communities. Although the program has been modestly successful (since 2004, "more than half have gone on to work in rural areas, compared with only 7 percent of their classmates"), many Black Belt counties have yet to benefit from it. Many medical schools use a minimum score cutoff on the Medical College Admission Test (MCAT) that tends to penalize applicants from rural and minority communities, even though those students are more likely to become primary care physicians for underserved populations:

The purpose of doctors, after all, is to tend to patients’ ultimate needs. Increasing the supply of primary care physicians is linked to lower mortality rates; after compiling data from studies across different parts of the country, a group of public health researchers found that by adding one more doctor for every 10,000 people, as many as 160,000 deaths per year could be averted. When the same researchers considered race as a factor, this benefit was found to be four times greater in the African-American population than among white people. Studies have also observed that the availability of primary care significantly reduces health disparities that result from income inequality.


The problem of too few primary care clinicians is not limited to rural America, but those communities are where the need is greatest, since a town without a family doctor is unlikely to have any other types of physicians. Medical schools can't easily change social determinants of health on their own, but they can rewrite their mission statements to emphasize providing health care to everyone regardless of geography, and implement recruitment and admissions policies that actually support that goal.

Thursday, June 1, 2017

Selected publications list, updated June 2017

I periodically write guidelines, research articles, editorials, and letters in the medical literature about some of the topics that I write about on this blog. Below is an updated list of selected publications, with links to abstracts or full articles if available:

1. Frost JL, Campos-Outcalt D, Hoelting D, LeFevre M, Lin KW, Vaughan W, Bird MD. Pharmacologic management of newly detected atrial fibrillation: updated American Academy of Family Physicians clinical practice guideline, June 2017.

2. Bird MD, Gersch D, Hoelting D, Lin KW, Mishori R. Incarceration and health: a family medicine perspective. American Academy of Family Physicians position paper, May 2017.

3. Lin KW, Frost JL. Should screening tests for colorectal cancer all have an “A” recommendation? No: when it comes to colorectal cancer screening, test choice matters. Am Fam Physician 2017;95:618-620.

4. Lin KW. Is genetic testing sophisticated enough to make PSA screening viable for mainstream use? No. HemeOnc Today, March 25, 2017.

5. Llano J, Lin KW. Management of binge-eating disorder in adults. Am Fam Physician 2017;95:324-326.

6. Petersen J, Lin KW. Radioiodine therapy versus antithyroid medications for Graves disease. Am Fam Physician 2017;95:292-293.

7. Barreto T, Lin KW. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory tract infections in primary care. Am Fam Physician 2017;95:11-12.

8. Schwartz SR, Magit AE, Rosenfeld RM, Ballachanda BB, Hackell JM, Krouse HJ, Lawlor CM, Lin K, et al. Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg 2017;156(1S):S1-S29.

9. Lin KW, Ebell MH. How to counsel men about PSA screening. Am Fam Physician 2016;94:782-784.

10. Lin KW. Increased alignment in preventive services recommendations for children. Am Fam Physician 2016;94:272-274.

11. Lin KW, Yancey JR. Evaluating the evidence for Choosing Wisely in primary care using the Strength of Recommendation Taxonomy (SORT). J Am Board Fam Med 2016;29:512-515.

12. Ebell M, Lin KW. Counseling women about breast cancer screening. Am Fam Physician 2016;93:652-653.

13. Lin KW, Gostin LO. A public health framework for screening mammography: evidence-based vs politically mandated care. JAMA 2016; 315:977-978.

14. Lin KW. Should family physicians routinely screen patients for hepatitis C? No: one-time screening still has too many unanswered questions. Am Fam Physician 2016;93:17-18.

15. Lin K, O'Gurek D, Rich R, Savoy M. How to help your patients Choose Wisely. Fam Pract Manag 2015;22:28-34.

16. Raffoul M, Lin KW. Cultural competence education for health care professionals. Am Fam Physician 2015;91:523-524.

17. Koretz RL, Lin KW, Ioannidis JP, Lenzer J. Is widespread screening for hepatitis C justified? BMJ 2015;350;g7809.

18. Lin KW. What to do at well-child visits: the AAFP’s perspective. Am Fam Physician 2015;91:362-364.

19. Siwek J, Lin KW. Choosing Wisely: more good clinical recommendations to improve health care quality and reduce harm. Am Fam Physician 2013;88:164-168.

20. Lin KW, Sieber PR, Oyer RA. The controversial prostate-specific antigen (PSA) test: a roundtable discussion of its indications and uses. J Lancaster Gen Hosp 2012;7(4):101-110.

21. Lin KW. Practice guidelines produced by subspecialists must meet higher standards. [Letter] Ann Fam Med published online November 15, 2012.

22. Lin KW. Do electronic health records improve processes and outcomes of preventive care? Am Fam Physician 2012;85:956-957.

23. Lin K, Croswell JM, Koenig H, Lam C, Maltz A. Prostate-specific antigen-based screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 90. AHRQ Publication No. 12-05160-EF-1. Rockville, MD: Agency for Healthcare Research and Quality, October 2011.

24. Lin KW. Challenging the conventional wisdom on colorectal and prostate cancer screening. J Lanc Gen Hosp 2010;5(3):74-77.

25. Lin K, Sharangpani R. Screening for testicular cancer: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2010;153:396-99.

26. Lin K. Adverse effects. Pulse: voices from the heart of medicine. May 21, 2010.

27. Lin KW, Slawson DC. Identifying and using good practice guidelines. Am Fam Physician 2009;80:67-69

28. Lin K, Lipsitz R, Miller T, Janakiraman S. Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149:192-99.

29. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2008;148:535-43.

Monday, May 29, 2017

Should we look for pulmonary emboli in patients with syncope?

The standard evaluation of patients with syncope has changed little over the years, with considerable continuity between American Family Physician reviews published in 2005, 2011, and this March. But the field received an unexpected jolt last October, when Dr. Paolo Prandoni and colleagues published a cross-sectional study in the New England Journal of Medicine that calculated a surprisingly high prevalence of pulmonary embolism (PE) of 17.3% in patients hospitalized for a first episode of syncope. In this study, 230 of 560 patients at 11 Italian hospitals who did not have a low pretest probability of PE by the Wells rule and negative D-dimer assay underwent computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion lung scans. 97 of these patients had evidence of PE. Overall, the investigators identified PE in 25% of patients with no alternative explanation for syncope and 13% of patients with an alternative explanation.

Algorithms for syncope evaluation focus on identifying cardiac and neurally mediated causes and do not include routine testing for PE. The question raised by the Italian study is if all inpatients with syncope need evaluation, since nearly 1 in 6 patients may have PE. There are good reasons not to jump to this conclusion. First, we don't know if the prevalence of PE in this study was representative of the general population of adults hospitalized for syncope, as it only included patients admitted from emergency departments (and not patients initially evaluated in primary care settings). Second, the study did not determine if PE was the etiology of syncope, as opposed to an incidental finding. This is important because evidence suggests that the enhanced sensitivity of CTPA for detecting small, subsegmental PE is increasing overdiagnosis and overtreatment of clinically insignificant clots. Finally, the absence of a comparison group means that it is not known if the systematic workup for PE improved the patients' prognoses or just added additional cost and risk to the evaluation.

A retrospective cross-sectional study in JAMA Internal Medicine recently used clinical and administrative data from 4 hospitals in Toronto to estimate the prevalence of PE in 1305 patients with a first episode of syncope who were not receiving anticoagulation at the time of admission. 120 of these patients received CTPA, ventilation-perfusion scan, and/or compression ultrasonography, leading to the diagnosis of PE in 18 patients. As opposed to the Italian study, where all persons received at least a D-dimer test, the decision to evaluate for PE was driven by clinical judgment. Nonetheless, of 146 patients in the Toronto study who received any test for PE (presumably those who were most likely to have one), only 12% were positive, and the overall prevalence of PE was a mere 1.4%. The authors concluded that "there is little, if any, justification for routine testing for [venous thromboembolism] in all patients hospitalized for a first episode of syncope."

Based on both studies, I agree that evidence does not support routinely looking for PEs in patients with syncope. In patients with possible signs or symptoms, another clinical decision rule may be used to confidently rule out the diagnosis without resorting to the less sensitive Wells rule or less specific D-dimer test, where a positive result often leads to unnecessary CTPA.

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A slightly different version of this post first appeared on the AFP Community Blog.