Monday, August 8, 2022

Preventive services mandate can be improved, but eliminating it isn't the answer

Over the past 12 years since the Affordable Care Act became law, individuals, business groups, and state officials who object to one or more of its provisions have filed a lengthy list of mostly unsuccessful lawsuits seeking to have part or all of it declared unconstitutional by the courts. The latest legal challenge involves the requirement that private health insurers cover without patient cost-sharing all evidence-based preventive services, defined as more than 100 services recommended by the Advisory Committee on Immunization Practices, the U.S. Preventive Services Task Force, Bright Futures, or the Women's Preventive Service Initiative. When I went to my family doctor last month and received screening tests for colorectal cancer, high blood pressure, and cholesterol, these tests were all covered under the ACA's preventive services mandate. When I take my kids to receive their school-required vaccinations, those shots are fully covered too. The same goes for the costs of clinicians counseling pregnant patients about healthy weight and weight gain to prevent complications such as gestational diabetes, and similar counseling for to midlife women (aged 40 to 60 years) to maintain weight or limit weight gain to prevent obesity.

Why would anyone have a problem with requiring insurers to cover preventive services? Some employers have religious or ideological objections to paying for birth control and sterilization, preexposure prophylaxis for HIV prevention, or testing for sexually transmitted diseases. Others might oppose the increased employer or government contribution to insurance premiums that may result from mandating that these services be covered, though in reality the types of health care that drive up premiums tend to be pricey procedures and medications such as the Alzheimer's drug Aduhelm, whose initial projected price of $56,000 per year drove the highest-ever increase in Medicare premiums from 2021 to 2022.

Ensuring that patients can afford preventive services is only the first step toward getting them done. Only about two-thirds of eligible adults are up-to-date on colorectal cancer screening, for example, and a much lower percentage of current or past heavy smokers over age 50 have been offered or received lung cancer screening. Behavioral health preventive services such as screening for depression, intimate partner violence, and unhealthy alcohol use can be difficult to fit into clinical practice workflows that rely on dysfunctional electronic health records (systems that are optimized for billing rather than patient care).

The narrow focus of the ACA's preventive services mandate on health care services also leaves out other private and public programs that can have large benefits on disease prevention and care. For example, the final report of the National Clinical Care Commission included population-level diabetes prevention recommendations involving the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, and the Department of Housing and Urban Development. A related analysis article in Health Affairs bemoaned the fragmented state of US health care and policy that has stalled progress in preventing and controlling type 2 diabetes:

At the population level, fragmentation and lack of shared population health goals across stakeholders mean that there is no ownership for large segments of the population who are at risk for or have diabetes. Payers carry the liability for the health service costs of their beneficiaries and can track utilization. Enrollee churn reduces payers' incentives to take on long-term responsibility or investments in higher-quality preventive services for which returns are only realized in the long term. ... Similarly, the movement of people between health systems undermines incentives for long-term, high-value care.

So you'll get no pushback from me if you observe that there are lots of flaws and loopholes in the preventive services mandate (beginning with the fact that it doesn't even apply to half of Americans who are either publicly insured or uninsured). But getting rid of it is throwing the baby out with the bathwater: an exceedingly dumb and harmful proposition that would result in more preventable illness and poorer quality of life for millions of Americans.

Thursday, July 28, 2022

Mismeasuring quality in primary care

After several years of doing family medicine commentaries for Medscape as part of a collaboration with Georgetown University Medical Center, I recently wrote my first commentary as a clinician and faculty member at the Lancaster General Hospital Family Medicine Residency Program about my mostly unsuccessful pursuit of elusive "quality" bonuses and the problems with current metrics used to judge care provided by primary care physicians. Here's an excerpt that discusses another notable perspective that inspired me to write about this topic: 

In a recent commentary, Drs. Christine Sinsky and Jeffrey Panzer distinguished "solution shop" from "production line" work in primary care and argued that though the medical training physicians receive makes us uniquely qualified to do the former, we end up spending most of our time and energy on the latter. Similarly, they observed that "most quality-improvement efforts have focused on improving production line–type measures and not on improving the conditions for sound medical decision-making and relationship building." Being able to correctly diagnose and treat patients who come in for chest or abdominal pain, for example, counts less (or not at all) toward my quality score compared with the percentage of patients who receive lead screening or diabetic eye exams.

Saturday, July 16, 2022

Peanut allergy: prevention and treatment advances

People with severe peanut allergy are at risk of life-threatening anaphylaxis from unintentional ingestion of small amounts of peanuts. A new drug review in American Family Physician discussed oral immunotherapy with peanut allergen powder, which increases tolerance for ingesting the amount of peanut protein in a single peanut by 63% but has important downsides: 1 in 10 patients need to use epinephrine after administration (compared to 1 in 20 in a placebo group); common short-term adverse effects include abdominal pain, throat irritation, and oral pruritus; and a price of approximately $3000 annually.

Although it was once believed that children should not consume peanuts early in life, a United Kingdom randomized trial in infants 4 to 11 months of age at high risk of developing peanut allergies found that early consumption of peanuts reduced the risk of developing peanut allergy by age 5 years by 80% (absolute risk reduction=14%, NNT=7). This finding led the National Institute of Allergy and Infectious Diseases to recommend in 2017 that peanut-containing foods be introduced into the diet of infants with severe eczema, egg allergy, or both at 4 to 6 months of age. In 2021, a consensus document on the primary prevention of food allergy from three North American professional allergy societies recommended introducing peanut-containing products to all infants around 6 months of age, regardless of their risk of developing peanut allergy.

A similar change to infant feeding guidelines in Australia occurred in 2016, recommending that all infants be introduced to peanuts before age 12 months. A recent study in JAMA evaluated changes in feeding practices and the prevalence of peanut allergy across two population-based cross-sectional samples recruited in 2007-2011 and 2018-2019. Although infants in the later sample were much more likely to have consumed peanuts before 12 months than infants in the earlier sample (86% vs. 22%), overall there was no statistical difference in peanut allergy prevalence. Noting that East Asian ancestry is considered a risk factor for peanut allergy, the authors hypothesized that the increased representation of infants with parents from East Asia in the later sample may have contributed to finding no effect. Another possible explanation is that early introduction of peanut-containing foods does not significantly modify peanut allergy development in infants not at high risk.

In a previous paper on identifying and using clinical practice guidelines, Dr. David Slawson and I observed: "The ultimate test of a good guideline is whether or not it has been prospectively validated; that is, has its adoption been shown to improve patient-oriented outcomes in real-world settings?" Based on the JAMA study, infant feeding recommendations to prevent peanut allergies have not yet passed this test. On the other hand, an accompanying editorial argued that "given the potential for benefit and the low risk of harm, the [study results] should not dissuade clinicians from following current consensus guidance that recommends early peanut introduction for infants." The challenge of identifying children at increased risk for peanut allergy (as noted in the consensus document, definitions have varied across studies and guidelines) and the inherently artificial nature of previous guidance restricting what an infant would otherwise naturally eat make this a reasonable course of action in the face of imperfect evidence.

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This post first appeared on the AFP Community Blog.

Friday, July 1, 2022

Race-based medicine and routine PSA screening in Black men

Five years ago on this blog, I asked whether routinely screening African American men for prostate cancer was warranted when evidence suggested that harms exceeded benefits in the general population. Even though many experts felt that it was, I disagreed:

What troubles me about this position is that race is as much a social construct as it is a biological one. Much of the disparity in prostate-cancer mortality between African-American and Caucasians can be explained by lower access to and quality of care, rather than a genetic predisposition for more aggressive and/or lethal cancers. In contrast to national data, studies of equal-access healthcare systems in the U.S. such as the Veterans Health Administration and the Department of Defense found no differences in prostate cancer mortality between Black and White men.

Since that time, the U.S. Preventive Services Task Force partially reversed itself and now states that "for men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one." Individual decision-making relies in part on assessing risk factors for potentially fatal prostate cancer, but aside from family history, the only other known risk factor is Black race.

Race-based medicine's drawbacks have become increasingly evident, however, and groups across the spectrum of medicine have been working to eliminate the inappropriate use of race from clinical decision-making. In this context, a group of urologists and oncologists recently updated a 2009 analysis of the effects of PSA screening in the U.S. and concluded that the benefit to harm ratio of screening over the past 3 decades was considerably more favorable in Black men than in the American population as a whole.

So was I wrong about not approaching Black men differently in PSA screening? Or as the title of the accompanying editorial asked, "Should recommendations for cancer screening differentiate on race?" Drs. Gil Welch (who authored the original analysis of PSA screening) and Adewole Adamson observed that assuming that the effectiveness of PSA screening or the harm of overdiagnosis are not substantially modified by race, then the higher prostate cancer death rate in Black men suggests that they would be more likely to benefit from screening than men of other races.

On the other hand, they argued, "in the context of addressing health disparities, cancer screening is a massive distraction. ... Cancer-associated health disparities not biased by early detection are related primarily to unequal treatment after diagnosis, not screening." All but a small fraction of the increased risk of lethal prostate cancer in Black men is likely to be mediated by social determinants of health and structural racism rather than genetics. Shockingly, "in Black men, the median age of prostate cancer death is 76 years, 4 years older than their average life expectancy [emphasis mine]," which is a strong argument for devoting more resources to improving the lives of the >95% of Black men who die from something other than prostate cancer (e.g., heart disease, lung cancer, chronic kidney disease).

I will continue to inform Black and multiracial patients in the age group highlighted by the USPSTF about population-level risks and the (increasingly inexcusable) paucity of empiric data on the benefits and harms of PSA screening in Black men. Some will choose to be screened, some will not. But I continue to believe that race-based screening for prostate cancer - i.e., screening a man only because of the color of his skin - is the wrong approach.

Friday, June 17, 2022

Podcasting in medical education: a review and example

A recent scoping review in Academic Medicine examined the published literature on the use of podcasts in undergraduate (medical school) and graduate medical education (GME; residency). The researchers identified a total of 62 articles; 44 studies reported descriptive outcomes and 38 reported educational outcomes. The latter group assessed learner reaction and attitudes, knowledge retention, and behavior change; no studies reported on system change or patient outcomes. Medical podcasts appeared to communicate knowledge as well as traditional teaching methods; are valued by learners for their portability, efficiency, and entertainment value; and measurably improved skills in documentation and selected clinical practices.

If you are new to medical podcasts, you can check out some of my favorites or a family medicine-specific list compiled by residents and faculty at the University of Arizona College of Medicine Phoenix Family Medicine Residency Program, which produces the American Family Physician podcast.

During the 2018-2019 academic year, I created two episodes of a podcast for a first-year medical course in health policy as my project for an interdisciplinary Technology-Enhanced Learning (TEL) Colloquium for Georgetown faculty. Below is an excerpt from my final report describing the project.

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I created an audio podcast to provide an overview of the U.S. health system in spring 2019. The podcast episodes replaced a 90-minute lecture from the previous year, enabling better integration between the background health system content and two small group sessions during the same week on the patient-centered medical home and implications of the Affordable Care Act for patients and physicians.

During the TEL colloquium, I read about using podcasts for teaching in publications identified in PubMed and utilized resources on the Gelardin New Media Center website. Then, I became familiar with the recording and editing software program Audacity by viewing a tutorial on Lynda.com, accessed through the Georgetown University library. I posted finished podcast episodes on the P3 Canvas webpage and, through the podcast hosting service Libsyn, made them available on popular podcast directories, including Apple ITunes, Google Play, and Stitcher. I wanted to give students the option of listening to the podcast on their commutes or during workouts, rather than sitting at a desk or a library carrell.

Listening to and reflecting on the podcast episodes was not a stand-alone assignment, but instead incorporated into preparation for the small group sessions. I adjusted my teaching strategies in several ways. First, in the absence of a live audience, I switched to a less lecturing, more conversational tone of voice when recording. Although I posted a few key visuals (e.g., pie charts of insurance coverage types, percentages of national spending on various health services) from the previous year’s lecture slide set on Canvas for students to view during or after the podcast, most of the slides containing text simply weren’t necessary to reproduce. It was a little humbling to realize how much “slide reading” I must have been doing the year before.

My originally stated goal in joining the 2018 TEL Colloquium was to develop a blended learning project to “help me and course faculty engage in new and deeper ways with future [GUSOM] classes to better prepare them to be well-rounded physicians who are prepared to advance and advocate for their patients’ health outside of medical settings.” My two major objectives were to reduce course didactic time and to integrate online / asynchronous and in-person learning activities. I didn’t change my overall goal or specific objectives as the Colloquium progressed, but I did change the timing of the project in response to feedback from CNDLS faculty and peers. I originally envisioned the podcast beginning during the October intensive course week, continuing through the months in between, and concluding during the March course week. I fairly quickly realized that this timing was impractical, as students would not have time or motivation to listen to P3 podcasts while they were taking other courses with tests. So I instead decided to focus on the March course week, where the U.S. health system overview lecture was most amenable to being converted into a podcast because 1) I was the assigned lecturer; 2) the content had been identified by past students as being too much to digest in a single sitting.

Were students able to better absorb and engage with this material in a podcast versus a lecture? It’s hard to say for certain. Unfortunately, I did not think to add a specific question or questions about the podcast to the student course survey, and none of the free text comments from students thus far mentioned the podcast. Anecdotally, several students in my own small group of 10 said that they found the podcast to be informative and easy to digest, and course faculty e-mailed some encouraging comments about it:

“I definitely think you should write this up as an innovative way of teaching!”
“Your podcasts are excellent!
“I think it is so nice for them to get this info via a different medium than lectures or reading.”


I came into the TEL Colloquium with the prior experience of having blended learning (specifically, team-based learning exercises) not having gone particularly well in the past – a lot of time and effort invested, but mostly negative feedback. In contrast, the podcast was fun to create and seemed to have a positive, or at least neutral, effect on the faculty and student experience. Although I don’t have any specific plans to integrate podcasts into my other teaching roles, I certainly would consider doing so if an opportunity arises.

Monday, June 13, 2022

Supervised injection sites prevent overdose deaths, improve public safety

In a fortuitous alignment, the medical journals with the three largest print circulations (JAMA, American Family Physician, and The New England Journal of Medicine) each recently published editorials or features making the case for opening supervised sites for injection drug use in the United States as a form of harm reduction for patients with substance use disorders.

A news feature in JAMA observed that these sites come in many varieties depending on agency resources and patient needs: 

Supervised consumption sites can be as modest as a social service agency restroom stall, the door shortened at the bottom to make it easier to spot an unconscious person, or as expansive as Vancouver’s trailblazing Insite, which averaged 312 injection room visits per day in 2019 and offers detox rooms with private bathrooms, transitional housing for people in recovery, and other wraparound services.

In the U.S., a legal statue forbidding the operation of establishments where illicit drugs are consumed has generally forced these sites underground. Nonetheless, a research report on the outcomes an unsanctioned site located in an undisclosed U.S. city reported that over 5 years, 33 overdoses were successfully treated with naloxone administered by trained staff, with no patients requiring transfer to an outside medical institution. Advocates of supervised consumption sites argue that they do not "enable" substance use; rather, they relocate use that otherwise occur without medical supervision, often in public places, and prevent deaths from overdoses. The JAMA article quoted Sam Rivera, executive director of a nonprofit organization that operates two sites in New York City, as saying: “Every person who walks in has tried treatment and detox. We want them to be able to try again when they're ready, and in order to do that they have to be alive.”

An editorial in AFP by Drs. Jorge Finke and Jie Chan cited abundant evidence demonstrating that supervised injection sites improve health outcomes for persons who use illicit drugs and the surrounding community:

One study found a 26% net reduction in overdose deaths in the area surrounding a supervised injection site in Vancouver, Canada, compared with the rest of the city. A supervised injection site in Barcelona, Spain, was associated with a 50% reduction in overdose mortality from 1991 to 2008. People who inject drugs are significantly less likely to share needles if they regularly use supervised injection sites. ... Supervised injection sites can also reduce the number of publicly discarded syringes, and they improve public safety. ... One study in Vancouver, Canada, observed an abrupt, persistent decrease in crime after the opening of a supervised injection site.

In addition, modeling studies predict that opening supervised injection sites could be cost-saving "by preventing HIV, hepatitis C, hospitalizations for skin and soft-tissue infections, overdose deaths, ambulance calls, and emergency department visits and by increasing uptake of addiction treatment."

NEJM Perspective article asserted that the Biden administration should take action to "[make] it clear that the federal government won't stand in the way of organizations or state or local governments that want to establish overdose-prevention centers," given that the Department of Justice under the Trump administration asked courts to block the opening of a sanctioned site in Philadelphia in 2019. Arguably, Section 856 of the Controlled Substances Act (also known as the "crack house statute") was not intended to limit the operations of public health facilities, but continued legal ambiguity makes it difficult for state health officials to gain support for supervised injection sites. In a related NEJM Perspective, two clinicians at a primary care and buprenorphine clinic in Chicago emphasized that these sites are desperately needed to save people's lives:

We hand out naloxone, distribute cookers and syringes, and counsel our patients on safer injection practices — such as not injecting alone — but this work isn’t enough to keep them safe. In the clinic, we use a low-threshold model for prescribing buprenorphine to reduce harm and increase access to lifesaving medications for opioid use disorder, offering same-day buprenorphine initiation, van-based outreach, telehealth appointments, and recovery-support services. It still isn’t enough. Our patients continue to die in the largest numbers we’ve ever seen.

The largest numbers we’ve ever seen. The Centers of Disease Control and Prevention reported that in 2021, more than 107,000 people died of a drug overdose, a 15% increase over the previous record high in 2020 and "roughly one U.S. overdose death every 5 minutes." By publishing pieces that provide compelling rationales for opening supervised injection sites, the top three journals in medicine have made a statement that these effective public health interventions should be employed widely to reverse this terrible trend.

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This post first appeared on the AFP Community Blog.