Monday, March 12, 2018

Public health and advocacy resources for family physicians

Shaping local and national policies to improve patients' health outcomes is an appropriate and important role for family physicians. For the past several years, I have taught public health and advocacy skills to medical students, and last month, I attended Academy Health's National Health Policy conference in Washington, DC, for the first time. Although the majority of participants were researchers or policy analysts, family physicians were well-represented as medical directors, public health and insurance officials, and leaders of privately funded community health improvement projects.

In a previous blog post, I discussed the concept of assessing social determinants of health through "community vital signs," geocoded and individually linked data derived from public data sources. Although American Family Physician focuses on health interventions that clinicians provide in offices, emergency rooms, hospitals, and long-term care facilities, it also publishes resources to help family physicians improve social determinants outside of health care settings. For example, a 2014 editorial examined the role of the family physician in preventing and managing adverse childhood experiences, and a review article in the February 1 issue discussed implications for physicians of childhood bullying.

Previous editorials and articles have addressed environmental health hazards such as lead, radonair pollution and climate change, and a 2011 Letter to the Editor urged family physicians to take action to affect the built environment of American communities by "working to ensure that our patients have safe, convenient, and enjoyable places to walk, run, and bike." Other public health issues where physician advocacy can make a positive difference include food insecurity, homelessness, and firearm safety.

Family physicians are often first responders to natural and unnatural disasters in their communities. From influenza pandemics to bioterrorism, preparedness and early recognition is essential to protecting our patients. A 2015 editorial by my Georgetown colleague, Dr. Ranit Mishori, argued that the rapid spread of infectious diseases and migration and displacement of diverse populations have made global health knowledge essential for every family physician, regardless of location: "As the recent Ebola epidemic demonstrated, the world is not only smaller than ever, but it is also more intricately connected. Exotic diseases once confined to the third or developing world are now everyone's concern. Global has truly become local." For example, clinicians are likely to encounter victims of sex trafficking and labor trafficking in their practices.

AFP's sister publication, FPM, also provides resources for primary care clinicians with community and public health roles, from launching a community-wide flu vaccination plan, to following the Grand Junction, Colorado example of improving health system cost and quality outcomes, to working with community-based senior organizations. Finally, family medicine advocates can stay abreast of national initiatives that will shape the specialty's future, such as direct primary care, the patient-centered medical home, and the Medicare Access and CHIP Reauthorization Act (MACRA).


This post first appeared on the AFP Community Blog.

Tuesday, March 6, 2018

Once again, the Agency for Healthcare Research and Quality stands in the line of fire

For the past 30 years, a little-known U.S. health agency has supported and produced volumes of groundbreaking research on how to make health care safer, less wasteful, and more effective. Dubbed "the little federal agency that could," AHRQ has accomplished this feat with a small fraction of the budgets of its higher-profile cousins, the Centers for Disease Control and Prevention and the National Institutes of Health. Nonetheless, its work has often been politically unpopular and unheralded outside of a small community of health services researchers and patient advocates. Sadly, when all medical waste is somebody's income, there is little enthusiasm in the medical-industrial complex or on Capitol Hill in allocating the $3 trillion the U.S. spends on health care more wisely or efficiently. In fact, our legislative and executive branches have periodically proposed that AHRQ's budget be slashed or eliminated entirely.

In 1994, the agency (then known as the Agency for Health Care Policy and Research) dared to publish a back pain guideline that suggested that there was little role for surgery in most patients. As later documented in Health Affairs, this act raised the hackles of back surgeons with powerful allies in Congress who were already annoyed by the agency's association with the failed Clinton health reform plan. The agency's budget was zeroed out by the House of Representatives and narrowly restored by the Senate in 1995 after a 21 percent cut and a name change to emphasize that its mission would be to produce evidence to inform policy, rather than attempt to actively shape policy.

Despite this deliberately circumscribed mandate (I lost count of the number of times during my tenure as an AHRQ medical officer from 2006-2010 that I was told, "We don't make guidelines. We make evidence that other groups use to make guidelines"), the passage of the Affordable Care Act made AHRQ a target again in 2012, when a House appropriations subcommittee voted to zero out its budget again. AHRQ survived that episode, only to be zeroed out by the House once again in 2015, when the danger to the agency's survival seemed real enough that former Senate majority leader Bill Frist and former CMS director Gail Wilensky both penned op-eds urging their Republican colleagues to reconsider - which they eventually did.

Ironically, the need for AHRQ's work has never been greater. The proliferation of clinical practice guidelines of varying quality and conflicting recommendations has led to calls to systematically evaluate guidelines for their impact on patient outcomes. AHRQ would be a natural place for this evaluation to occur, as its National Guideline Clearinghouse already summarizes and synthesizes guidelines that meet certain evidence-based development criteria. But funding to maintain the NGC will run out a little more than 4 months from now, and there seems to be little hope of rescue.

In the meantime, the Trump Administration has proposed dissolving AHRQ as an independent agency in the next fiscal year and transferring its current functions into a new institute within the NIH, with a 21 percent budget cut from 2017. Although such an arrangement has both potential pros and cons, as a previous AHRQ director observed, it's hard to imagine that the shrunken agency would not be marginalized and lost amid NIH's biomedical research behemoth.

Why do I care? Why should you? You need not be ill enough to be hospitalized or care about practice guidelines to suffer if AHRQ is eliminated for good. Not only does it produce several important tools and resources for primary care practice, but it disseminates and implements evidence about what works to improve health, through its National Center for Excellence in Primary Care Research. AHRQ supports research that generates evidence about "effective models of care, patient- and family-centered care, shared decision making, quality improvement, and health information technology." This is research and evidence that no one, healthy or ill, can afford to lose. Academy Health maintains an advocacy toolkit for use by any person or organization who wants to help #SaveAHRQ from becoming a casualty of ignorance, indifference, and/or conflicts of interest. I hope that I have persuaded you to join the fight.

Thursday, March 1, 2018

Does a rising tide of health outcomes lift all boats?

Politicians who favor reducing taxes and other financial policies that predominantly benefit "the rich" have argued that wealthy people have an outsized influence on the general health of the economy, and that their prosperity will benefit lower earners by directly or indirectly creating new or higher-paying jobs. A more pithy expression for this sentiment that President Kennedy first made famous is: "a rising tide lifts all boats." I don't have the expertise to comment on the veracity of this statement in an economic sense, but a 2016 study in Preventing Chronic Disease by Dr. David Kindig and colleagues asked an analogous question: can states simultaneously improve health outcomes and reduce health outcome disparities?

The study authors used age-adjusted mortality data from a Centers for Disease Control and Prevention database to compare the annual percent change in combined black and non-Hispanic white mortality by state with the annual change in black-white mortality disparities in those states from 1999 through 2013. Overall, in states where sufficient mortality data was available for analysis, combined-race mortality fell by a mean of 1.1% and the black-white disparity fell by a mean of 3.6% per year. However, there was no relationship between combined mortality and racial disparity reductions across states. A few states (Georgia, Maryland, Massachusetts) experienced above average improvements on both measures, but others (Oklahoma) were below average on both, and most states experienced relatively greater improvement on one measure than on the other.

Figure courtesy of CDC.

The implications of these findings are that strategies to improve health across all populations (the "rising tide") may be different from those aimed at eliminating racial health disparities ("all boats"). They also provide a baseline for what state health departments may reasonably expect when setting health improvement and disparity reduction goals in future years.


This post first appeared on Common Sense Family Doctor on October 6, 2016.

Friday, February 23, 2018

Enthusiasm shouldn't outweigh evidence on vitamin D

In 2005, my colleague Dr. Mark Ebell, also a family physician and medical editor, authored an editorial on the rise and fall of vitamin E, subtitled "lessons in patient-oriented evidence." Observational studies had associated lower vitamin E levels with coronary artery disease, leading many physicians to recommend that patients take vitamin E supplements for cardiovascular protection. 19 randomized, controlled trials later, the verdict was in: vitamin E supplementation actually increased all-cause deaths. Dr. Ebell viewed the "vitamin E saga" as an instructive cautionary tale:

It is important to remember that biochemical theory does not equal clinical benefit. Improvements in disease-oriented outcomes, such as free-radical activity, are no substitute for patient-oriented outcomes, such as all-cause mortality. Sometimes our enthusiasm for unproven treatments may harm our patients.

Physicians and patients, it turns out, were already turning to testing and treatment with another vitamin that was a marker of chronic health conditions in observational studies: vitamin D. Between 2000 and 2010, the volume of serum 25-hydroxyvitamin D levels in Medicare patients increased 83-fold, and by 2014, 4 out of 10 adults 70 years or older reported taking a daily vitamin D supplement of at least 1,000 IU, and nearly 7 percent of adults over 60 were taking more than 4,000 IUs daily, a level that the National Academy of Medicine considers to be potentially toxic.

Unfortunately, the vitamin D saga has much in common with the vitamin E saga. According to a review article in the February 15th issue of American Family Physician by Drs. Michael LeFevre and Nicholas LeFevre, vitamin D supplementation in community-dwelling adults has not demonstrated any benefits for ischemic heart disease, cerebrovascular disease, or cancer in clinical trials. The U.S. Preventive Services Task Force and the American Academy of Family Physicians concluded that there is inadequate evidence that supplements improve psychosocial or physical functioning in persons with lower vitamin D levels.

In an accompanying editorial, I argued that the harms of routine screening and supplementation with vitamin D outweigh the benefits, especially when the costs of testing (more than $300 million annually in Medicare alone) are considered:

It is time for clinicians and patients to curb our enthusiasm for vitamin D screening and supplementation. Strategies to decrease unnecessary testing could include distributing the patient handout on vitamin D tests created by Consumer Reports for the Choosing Wisely campaign and implementing clinical decision support for ordering laboratory tests. ... Family physicians should also counsel patients on the recommended dietary allowance for vitamin D (600 IU per day in adults 70 years and younger, and 800 IU per day in adults older than 70 years), and discourage most patients from using supplements, especially in dosages near or above the tolerable upper limit of 4,000 IU per day.


This post first appeared on the AFP Community Blog.

Tuesday, February 13, 2018

Why I teach health policy and advocacy in medical school

From 2009 to 2012, I directed the graduate course "Fundamentals of Clinical Preventive Medicine" at Johns Hopkins University's Bloomberg School of Public Health. It was a required course for Hopkins preventive medicine residents, and also usually attracted other Master's level public health students and undergraduates with a strong interest in medicine. The class size was 15 to 25 students. In that setting, with a small group who generally believed that the material was important, if my teaching was inspired and the presentation compelling, I could reasonably hope for positive feedback from nearly every student.

In every academic year since (after returning to the family medicine faculty at Georgetown), my primary teaching responsibility has been co-directing a mandatory course in population health, health policy and advocacy for about 200 first-year medical students. I am proud that student ratings for the course overall and the course directors in particular have improved every year, though I suspect that at least some of this improvement is the result of more students being already aware of the health impacts of national, state, and local policy decisions, even those that ostensibly have nothing to do with medical practice.

A case in point is the U.S. Department of Agriculture's recent proposal to save money by replacing food stamps with food boxes containing nonperishable food items for poor families that qualify for financial assistance. Historically, Native American tribes who were forced to live on reservations, cut off from natural water and food sources, were supplied with boxes of dry and canned foods high in sodium and calories and low in nutritional value. The result was a catastrophic rise in obesity, hypertension and type 2 diabetes in this population. The USDA eventually modified the program to incorporate fresh produce, which begs the question of why anyone should take seriously this new proposal whose end result would be making the national obesity epidemic many times worse than it already is.

But back to my course. Every year, a few students complain in their evaluations that what we teach just isn't relevant to their future careers, or more commonly, that the content is "too political." This is a tough criticism for me to stomach, as we go to great lengths to present a broad spectrum of perspectives on health and the health care - what the "system" does well and where it fails by every conceivable standard. To me, that U.S. life expectancy has declined for two years in row means that business as usual just isn't cutting it. Yes, solutions to these problems invariably involve advocacy and political choices. And it's perfectly fine for my students to debate the relative contributions of various determinants of health, and in particular rising economic inequality, in this unfolding disaster. It is not okay for a student to turn a blind eye to health policy and think that everything will turn out fine as long as he or she is accepted into a residency program in a reliably high-paying subspecialty of choice.

So kudos to Faiz Kidwai, a second-year medical student who wrote a thoughtful editorial for STAT about why medical schools shouldn't divorce education from politics. One particularly eloquent point hit home for me:

A class on health policy cannot replace classes on pathology or pharmacology, nor should it. But without making policy and public health a major component of medical education instead of a side interest to be pursued on students’ own time, medical schools will continue to churn out exceptionally talented physicians who are exceptionally ill-prepared to deal with the medical bureaucracy and byzantine health care policies that hit them the moment they begin to care for patients.

Another piece that recently hit home, by pediatrician and former CMS Administrator Don Berwick (whose selected previous writings have long had a place in my course), was "Moral choices for today's physician," in JAMA. Berwick argued that for physicians "to try and avoid the political fray through silence is impossible, because silence is now political." Berwick obviously has no love for the Trump Administration, but what he wrote could apply to any clinician - conservative, libertarian or liberal, Republican or Democrat, or none of the above:

Healers cannot deny that leaving refugees at our gates unwanted, or children unfed, or families unhoused, or basic medical care uncovered, or relying on conflict, rather than compassion, are health problems. ... The work of a physician as healer cannot stop at the door of an office, the threshold of an operating room, or the front gate of a hospital. The rescue of a society and the restoration of a political ethos that remembers to heal have become the physician's jobs, too. Professional silence in the face of social injustice is wrong.

These quotes from Kidwai and Berwick explain why I continue to be energized year after year to teach students who are at times excited, and at times indifferent to health policy and advocacy. I know that most didn't come to medical school to learn about politics or public health. But it's my job to make sure that my students don't graduate ill-prepared or professionally silent in the face of human suffering.

Wednesday, February 7, 2018

The changing of the guard at American Family Physician

The February 1 issue of AFP marked the first time since 1988 that a family physician other than Dr. Jay Siwek was serving as the journal's editor-in-chief. Dr. Siwek, who bade farewell to readers in a poignant, memory-filled editorial in the January 15 issue, will stay on as editor emeritus. This month, Dr. Siwek introduced his successor, longtime associate editor Dr. Sumi Makkar Sexton. You can read about Dr. Sexton's extensive qualifications and experience in Dr. Siwek's latest piece, and learn about her plans for the future of AFP, which include making journal content more usable at the point of care, in her introductory editorial.

It has been my good fortune to know Jay and Sumi for the past 14 years, since I arrived at Georgetown University School of Medicine as AFP's medical editing fellow in the summer of 2004. Both played critical roles in my development as a family physician and medical editor, during and after my one-year fellowship. It was Jay, in his previous capacity as Chair of Georgetown's Department of Family Medicine, who hired me as a junior faculty member and supported each of my subsequent promotions to assistant, associate, and full professor. After I left the department for several years to work as a medical officer at the Agency for Healthcare Research and Quality and earn a master's degree in public health, it was Jay who convinced me to return and deploy my new skills to direct the department's health policy fellowship and eventually take on other leadership and teaching positions in population health.

On the other hand, it was Sumi, as the editor of Tips from Other Journals (an AFP department that ended in 2013) who continued to hone my writing and evidence-based medicine skills for years after my fellowship ended. Under her supervision, from 2005 to 2010 I wrote more than 60 summaries of primary care-relevant research studies for AFP. And after my first post-fellowship clinical position unexpectedly fell through, it was Sumi who hired me to see patients at her thriving practice, Premier Primary Care Physicians, which was an early adopter of innovations such as electronic medical records and advanced-access scheduling.

As AFP's new deputy editor, I have worked closely with Sumi and Jay for the past several months to support their changing of the guard at editor-in-chief, and I look forward to many more years of collaborating with them both. Moving on from Dr. Siwek to Dr. Sexton is an important transition, but the best-read journal in primary care won't miss a beat.


This post first appeared on the AFP Community Blog.