Monday, July 17, 2017

Self-monitoring doesn't improve control of type 2 diabetes

"Have you been checking your sugars?" I routinely ask this question at office visits involving a patient with type 2 diabetes, whether the patient is recently diagnosed or has been living with the disease for many years. However, the necessity of blood glucose self-monitoring in patients with type 2 diabetes not using insulin has been in doubt for several years.

A 2012 Cochrane for Clinicians published in American Family Physician concluded that "self-monitoring of blood glucose does not improve health-related quality of life, general well-being, or patient satisfaction" (patient-oriented outcomes) and did not even result in lower hemoglobin A1C levels (a disease-oriented outcome) after 12 months. In their article "Top 20 Research Studies of 2012 for Primary Care Physicians," Drs. Mark Ebell and Roland Grad discussed a meta-analysis of individual patient data from 6 randomized trials that found self-monitoring improved A1C levels by a modest 0.25 percentage points after 6 and 12 months of use, with no differences observed in subgroups. Based on these findings, the Society of General Internal Medicine recommended against daily home glucose testing in patients not using insulin as part of the Choosing Wisely campaign.

Still, the relatively small number of participants in trials of glucose self-monitoring, and the persistent belief that it could be useful for some patients (e.g., recent type 2 diabetes diagnosis, medication nonadherence, changes in diet or exercise regimen), meant that many physicians have continued to encourage self-monitoring in clinical practice. In a 2016 consensus statement, the American College of Endocrinology stated that in patients with type 2 diabetes and low risk of hypoglycemia, "initial periodic structured glucose monitoring (e.g., at meals and bedtime) may be useful in helping patients understand effectiveness of medical nutrition therapy / lifestyle therapy."

In a recently published pragmatic trial conducted in 15 primary care practices in North Carolina, Dr. Laura Young and colleagues enrolled 450 patients with type 2 non-insulin-treated diabetes with A1C levels between 6.5% and 9.5% and randomized them to no self-monitoring, once-daily self-monitoring, or once-daily self-monitoring with automated, tailored patient feedback delivered via the glucose meter. Notably, about one-third of participants were using sulfonylureas at baseline. After 12 months, there were no significant differences in A1C levels, health-related quality of life, hypoglycemia frequency, health care utilization, or insulin initiation. This study provided further evidence that although glucose self-monitoring may make intuitive sense, it improves neither disease-oriented nor patient-oriented health outcomes in patients with type 2 diabetes not using insulin. So why are so many clinicians still encouraging patients to do it?

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This post first appeared on the AFP Community Blog.

Sunday, July 9, 2017

Does health insurance save lives? No: primary care does.

Two recent review articles in the New England Journal of Medicine and the Annals of Internal Medicine discussed the relationship between having health insurance and improving health outcomes (including mortality, i.e., "saving lives"). In my latest Medscape commentary, I analyzed these two articles in the context of the debate over the U.S. Senate's Better Care Reconciliation Act (BCRA), which the Congressional Budget Office has estimated would lead to 22 million more uninsured persons if passed, compared to current law. I concluded that arguments about the effects of gaining or losing health insurance largely miss the point, since any positive effects of insurance are most likely mediated through providing primary care:

It is plausible that the positive effect of insurance on health is real. The next question is, why? It's not because insured people receive more or better care for acute, life-threatening illnesses. Instead, people who gain insurance generally increase their use of preventive services and are more likely to report having a usual source of primary care, which other studies have found is strongly associated with lower mortality. In fact, I would argue that health insurance's positive effects on health are mediated largely through prepaid primary care services.

The American Academy of Family Physicians has joined several other major physician groups in opposing BCRA because absent modifications, it will certainly decrease access to primary care by making insurance unaffordable for low-income and other vulnerable populations who don't qualify for Medicaid or Medicare. But paying for a barely affordable bronze marketplace plan with a $6000 deductible hardly makes primary care affordable, either, outside of a limited list of preventive services. The solution? Make it possible for more people to buy inexpensive primary care without having to go through expensive health insurance.

Health reform proposals should build on the knowledge that primary care saves lives for a fraction of the cost of a health insurance premium. In the long run, Democrats and Republicans could find common ground between their "Medicare for all" and "covering everyone costs too much" positions by removing primary care from the inefficient insurance system entirely. Instead, Congress should guarantee everyone a family doctor through a community health center or direct-pay primary care, as physician and financial planner Carolyn McClanahan has proposed.

Wednesday, July 5, 2017

Strategies to limit antibiotic resistance and overuse

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more. Antibiotic resistance occurs in the community, in long-term care facilities, and in hospital settings. Another CDC report on preventing healthcare-associated infections (also discussed in this American Family Physician article) identified six high-priority antibiotic resistance threats: carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enteroccocus, multidrug-resistant Pseudomonas, and multidrug-resistant Acinetobacter.

In a 2014 editorial, "Antibiotic resistance threats in the United States: stepping back from the brink," Dr. Steven Solomon and Kristen Oliver from the CDC identified three strategies that family physicians can use to limit antibiotic resistance: 1) Preventing infections through immunizations, standard infection control practices, and patient counseling; 2) Reporting unexpected antibiotic treatment failures and suspected resistance to local or state health departments; and 3) Prescribing antibiotics more carefully. Unfortunately, inappropriate antibiotic prescribing (also known as antibiotic overuse) is common in primary care, particularly for patients with acute viral respiratory tract infections.


Antibiotic overuse is a multifaceted problem with many potential solutions. On Sunday, July 9th at 7 PM Eastern, Dr. Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will be taking a deep dive into the evidence on the most effective strategies to curb prescribing of unnecessary antibiotics. American Academy of Family Physicians members and paid AFP subscribers can earn 4 free continuing medical education credits by registering for the #afpcme Twitter Chat, reading three short AFP articles, and completing a post-activity assessment. We hope you can join us!

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This post first appeared on the AFP Community Blog.

Thursday, June 29, 2017

Innovations in primary care for underserved populations

Lately, “innovation” is the buzz word that I am hearing most often at conferences and briefings and reading in medical journals. But what counts as innovation in primary care, and how can physicians and patients quickly distinguish true practice-changers from temporary fads? At a conference I attended last year, Ray Rosin, Chief Innovation Officer at Penn Medicine, described three techniques that can be used to rapidly test promising innovations:

Vapor tests, which help innovators determine the demand for a service or program without needing to build the service or program first.

Fake front ends, which "make ideas tangible to help answer the question 'What will people do with it?'"

Fake back ends, which allow "teams to quickly answer the question 'What happens if people actually use it?'"

Even though these techniques require relatively small investments in time and effort, primary care clinicians still need to know about promising innovations in order to test them. One good source for innovations to improve quality and reduce disparities is the Agency for Healthcare Research and Quality's Health Care Innovations Exchange, a searchable database of case studies ("innovation profiles") submitted by health organizations across the nation. Over the past few months, I've also collected several primary care innovations for underserved populations from the new Annals of Family Medicine feature and various other sources.

1) Using QR codes to connect patients to health information - a rural family medicine clinic in Iowa displays QR codes in its waiting room and other areas that, when scanned by a reader on a smartphone or tablet, load general patient education resources or materials related to the specific reason for the patient's visit.

2) Engaging complex patients with drop-in group medical appointments - a stabilizing program for uninsured, low-income patients with complex mental and physical health needs in North Carolina that over the past 6 years has reduced enrollees' hospital utilization by 50% at the cost of $100 per patient per month.

3) Fresh food by prescription - Central Pennsylvania's Geisinger Health system piloted a free, healthy "food pharmacy" for low-income patients with type 2 diabetes and their families on the grounds of one of its hospitals.

4) Telemedicine screening for diabetic retinopathy - Los Angeles County successfully implemented telemedicine screening in its safety net clinics, reducing the wait time for screening from 158 to 17 days and increasing the percentage of all eligible patients screened by more than 40%.

These innovations probably won't work in every underserved setting, but one or more could be worth a try in your clinic or health system, using one of Rosin's rapid-cycle techniques.

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.