Wednesday, July 1, 2015

Book Review: "Epic Measures" and evidence-driven health workforce policy

Last month, I attended a talk by Jeremy N. Smith, whose book Epic Measures follows Dr. Christopher Murray's lifelong quest to improve measurement of global health problems, which culminated in the Global Burden of Disease study. Thanks to Tracy Kidder, whose 2003 bestseller Mountains Beyond Mountains made Murray's medical school and residency classmate Paul Farmer a minor celebrity, most people's idea of global health work is setting up clinics in impoverished countries such as Haiti and Rwanda. In contrast, after Epic Measures opens with a young Murray traveling with his family across the Sahara Desert, it mostly describes more prosaic activities: meetings with statisticians, navigating entrenched national and global health bureaucracies, and appealing to philanthropists for research support. What I loved about this book, I told Smith as he was signing my copy, is that it made sitting in an office cubicle performing complex statistical analyses seem almost as cool as practicing front-line medicine in remote areas of the world.


In his talk, Smith focused on three questions that drove Murray's research and the narrative arc of Epic Measures, beginning with: "What is the scientific evidence base for health policy?" Before Murray arrived on the scene, there was literally no one systematically measuring the overall global burden of death and disability. The World Health Organization was divided into mini-fiefdoms, each possessing its own set of disease-specific estimates and intent on defending its turf and budget share. Murray recognized the scope of this problem when he added up all of the disease-specific mortality estimates produced by various divisions of the WHO and found that the sum (30 million) was 10 million higher the United Nation's estimate of total child deaths in the same year! Non-governmental organizations were similarly haphazard in their approaches to global health problems, which received funding commensurate to the strength of political advocacy rather than an impartial assessment of their effects on specific populations. (Even today, as Murray's team recently illustrated in JAMA, the proportional match between relative disease burden and financial assistance to developing countries is imperfect, but at least the shortfalls are more transparent.)

Smith's second question: "Are we measuring the right thing?" Many chronic diseases cause enormous suffering, but may not result in death. Accounting for the amount of disability it causes over a lifetime to millions of adults, the burden of neck pain is twice as high as breast cancer in the U.S. This isn't to say that breast cancer is an unimportant health issue, but the countless walkathons, pink ribbons, and calls to raise money for breast cancer research and treatment far outpace the attention and dollars public and private sources devote to relieving neck pain.

Finally: "If we use new evidence and new measures, how far and how fast can we improve?" Quite dramatically, Epic Measures illustrated. Mexico prioritized coverage decisions for its national health insurance plan, Seguro Popular, on its national burden of disease data and saw its child mortality rate fall by almost half within a decade. Based on its burden of disease, Australia started paying for short-term depression therapy and dropped routine prostate cancer screening (a no-brainer in retrospect, given that screening has little to no effect on prostate cancer morbidity or mortality, but a hard call to make before 2011).

Smith's talk got me thinking along the same lines about the state of the health care workforce in the U.S., and how far we are from what is needed based on our national burden of disease. There isn't an easy fix when so much of our health care "system" is driven by disease-specific advocacy and perverse financial incentives to do more rather than less, and we spend more than $1 trillion each year on health professional salaries alone. But rather than simply projecting future workforce needs based on past experience or best guesses about evolving models of care in the post-ACA era, we should be asking some more basic questions. What is the scientific evidence base for U.S. health workforce policy? Are we measuring the right thing? And if we use new evidence and new measures, how far and how fast can we improve?

Tuesday, June 23, 2015

Antibiotics for acute appendicitis

Until recently, the most well-studied clinical questions about acute appendicitis have been how to efficiently diagnose it using the history and physical examination and laboratory and imaging tests. Once appendicitis was identified, the next step was to perform an appendectomy, using a laparoscopic or open surgical approach. However, a recent NEJM review discussed evidence that some cases of acute appendicitis resolve spontaneously rather than leading to perforation. A 2011 Cochrane review of five randomized, controlled trials found that three-quarters of patients with acute appendicitis who were initially treated with antibiotics rather than surgery recovered completely within two weeks and did not experience a recurrence within one year. Due to the small sizes and other limitations of these trials, the American College of Surgeons has continued to recommend surgery as the "standard" treatment for acute appendicitis.

A study published last week in JAMA may change a few minds about the utility of antibiotics for this condition. Dr. Paulina Salminen and colleagues randomized 530 Finnish adults aged 18 to 60 years with CT-confirmed uncomplicated acute appendicitis to a 10-day course of intravenous followed by oral antibiotics versus open appendectomy. 73 percent of patients in the antibiotic group did not need an appendectomy within 1 year; the rest, who underwent delayed appendectomies for signs of progressive or recurrent infections, did not develop intra-abdominal abscesses or other major complications as a result of waiting. Although the antibiotic "failure rate" of 27 percent exceeded the authors' pre-specified non-inferiority margin of 24 percent (compared to a 0.4 percent failure rate for initial surgery), the results confirm the viability of a medical approach to acute appendicitis.

A few issues would need to be addressed before antibiotics for acute appendicitis could be routinely implemented in American clinical practice. Unlike in Europe, most appendectomies in the U.S. are laparoscopic, which may make surgery more appealing to some patients. Children and adults older than age 60, who were not included in the JAMA study, may be at higher risk for complications from delayed surgery. Since acute appendicitis is common, we don't know if treatment with broad-spectrum antibiotics could worsen the problems of antibiotic resistance and Clostridium difficile infection. Finally, the lack of consensus on the "clinically important" difference needed to choose antibiotics over surgery may favor a shared decision making approach, which could be a challenge to carry out in the acute care setting.

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This post first appeared on the AFP Community Blog.

Friday, June 19, 2015

The good news, at last, in prostate cancer screening

As I previously documented in a series of posts on this blog, the road to the U.S. Preventive Service Task Force's 2012 "don't do it" recommendation on PSA-based screening for prostate cancer was long, arduous, and full of political pitfalls. It led to me leaving my position at the Agency for Healthcare Research and Quality. Later, the USPSTF took heat from screening advocates in the mainstream media and in social media. The American Urological Association labeled their recommendation statement "a disservice to men" and threw its weight behind a Congressional bill (reintroduced in 2015) that would require the USPSTF to consult with "external subject matter experts" (i.e., urologists) to, in the words of one of its sponsors, "ensure that preventive care recommendations are not made in a vacuum."

In the meantime, no doubt, many primary care physicians ignored the controversy and went on doing what they had always done: ordering annual PSA tests on every male patient from age 50 until natural death, without any semblance of shared decision-making or even a discussion.

But not all. For some with the courage to embrace a medical reversal that was based on convincing evidence of harm, the Task Force's message started getting through. Some doctors began taking the extra time to tell patients about why the PSA test was a bad idea. And some of their patients listened and chose not to get the test.

The past two weeks have offered the first definitive evidence that the USPSTF's controversial stand has spared thousands of men the harmful interventional cascade that results from prostate cancer screening.

A study published on June 8th in the Journal of Clinical Oncology used information from the National Health Interview Survey to document statistically significant declines in PSA screening rates from 2010 to 2013 in men age 50 years and older. Three days later, the American Urological Association released its second Choosing Wisely list, which called on physicians to "offer PSA testing for detecting prostate cancer only after engaging in shared decision making." Not a complete about-face, but I give them credit for not dodging the issue this time around.

And a few days ago, another study in the Journal of Urology found that prostate cancer diagnoses in the National Cancer Database declined by 28 percent in the year after the release of the USPSTF draft recommendations (in October 2011). Diagnoses of "low-risk" cancers (which are almost entirely PSA-detected) fell by 38 percent, and diagnoses of prostate cancer in men over age 70 or with other life-limiting diagnoses fell by more than a quarter.

During this year's Men's Health Month, there is at last good news to report. In a rare victory for evidence-based screening, we are finally starting to roll back the burden of prostate cancer overdiagnosis and overtreatment.

Thursday, June 11, 2015

For medical schools, mission statements matter

Over the years, applicants whom I've interviewed for positions in the first-year medical student class at Georgetown have often asked how our school's mission statement influences the educational experiences and clinical services we provide:

Guided by the Jesuit tradition of Cura Personalis, care of the whole person, Georgetown University School of Medicine will educate a diverse student body, in an integrated way, to become knowledgeable, ethical, skillful, and compassionate physicians and biomedical scientists who are dedicated to the care of others and health needs of our society.

I never quite know how to answer this question. Like the aspirational mission statement of my previous employer, the Agency for Healthcare Research and Quality, which was "to improve the health of all Americans," Georgetown's statement doesn't offer an obvious path for how to produce physicians dedicated to the "health needs of our society." Although our nascent Population Health Scholars Track will give select students perspectives and tools to address societal health needs on the population level, Georgetown consistently graduates a majority of medical subspecialists and produces few who will relieve growing national shortages of family physicians and psychiatrists. As for meeting the needs of rural and urban underserved populations, a 2010 study ranked us 102nd out of 141 U.S. medical schools in the percentage of physicians who were practicing in federally designated Health Professional Shortage Areas.

So are medical school mission statements just academic boilerplate, or do they really guide graduate specialty choice and practice location? This was the question that Dr. Christopher Morley and colleagues investigated in a fascinating study published in Family Medicine. A diverse panel of 37 medical students, educators, and administrators reviewed the mission statements of U.S. medical schools and rated them on a 5-point scale for social mission content, defined as "any language that reflects a goal of medical education to train practitioners capable of matching the needs of society and vulnerable populations or for the institution itself to serve vulnerable populations or regions."  The mean of panelist ratings for each school's mission statement turned out to be a statistically significant predictor of the percentage of graduates who entered family medicine and the percentage who worked in Medically Underserved Areas/Populations.

As the study authors noted, these interesting associations could be interpreted a number of different ways:

It is not clear from these results if graduate career choice is influenced by the orientation of the institution, or if students who go on to work in these areas of medicine self-select into institutions because of a personal predilection to work in primary care or in underserved communities; however, it appears that medical schools with a proclaimed orientation toward producing physicians in primary care and/or physicians who provide care to underserved populations are achieving these missions.

Incidentally, I don't know how Georgetown's mission statement rated on the scale of social mission content, although I imagine that it would have fallen somewhere in the middle. Also unanswered is the philosophical question of what percentage of schools should be orienting their graduates toward Morley and colleagues' definition of social mission, rather than producing excellent physician-scientists, health executives, or some other standard of accomplishment.

For medical schools, mission statements matter. Perhaps we need a national mission statement for medical education in the United States, one that embraces and expands on the American Association of Medical Colleges' "improve the health of all." This national mission statement would recognize the shortcomings of our current physician workforce and explicitly aim to produce a mix of future medical school graduates who are dedicated and prepared to build the Culture of Health that America so desperately needs.

Monday, June 8, 2015

Choosing Wisely: Learning to leave asymptomatic bacteriuria alone

Outside of pregnancy, antibiotics for patients with asymptomatic bacteriuria - that is, a positive urine culture in a patient with no signs or symptoms of a urinary tract infection - do more harm than good. Consequently, comprehensive guidelines and a Choosing Wisely recommendation from the Infectious Diseases Society of America strongly discourage this practice. But just as it is difficult for an interventional cardiologist to not stent a narrowed coronary artery in a patient with stable angina, many physicians have a hard time not treating bacteria that grow in a urine culture, no matter what the science says. To avoid this situation, the U.S. Preventive Services Task Force recommends not screening for asymptomatic bacteriuria in men and nonpregnant women.

Unfortunately, these guidelines are frequently ignored in clinical practice. Perhaps a patient's urine smells funny, or it looks darker or cloudier than usual. Someone (who may not have actually evaluated the patient) obtains a urine culture. The culture grows bacteria, the incorrect diagnosis of "urinary tract infection" makes its way into the patient's chart, and the patient subsequently receives antibiotics that at best do not help, but possibly lead to individual adverse effects and increased antibiotic resistance. Performing urine cultures on patients with urinary catheters is especially problematic, since virtually all of them develop asymptomatic bacteriuria.

A recent study by Dr. Barbara Trautner and colleagues in JAMA Internal Medicine reported on the results of an intervention to reduce treatment of asymptomatic bacteriuria in catheterized inpatients at a Veterans Affairs hospital in Texas. The intervention, part of the aptly named "No Knee-Jerk Antibiotics Campaign," focused on reducing inappropriate urine culture ordering through case audits and feedback and distribution of a guideline-based diagnostic algorithm on a pocket card. When unnecessary screening and/or overtreatment of asymptomatic bacteriuria was judged to have occurred, researchers used a script to provide feedback to teams of internal medicine residents. During the 3-year intervention and maintenance period, the rate of treatment of asymptomatic bacteriuria fell by 75 percent.

"Changing the behavior of clinicians is fraught with challenges, but change is possible," wrote Dr. Manisha Juthani-Mehta in an accompanying editorial. "Some of the components that have been successfully shown to facilitate a change in behavior include education, feedback, participation by clinicians in the change effort, and administrative interventions." The study by Trautner and colleagues demonstrated that for this common and unnecessary care problem, it is possible to motivate physicians to Choose Wisely.

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This post first appeared on the AFP Community Blog.

Sunday, May 31, 2015

The best recent posts you may have missed

Every few months, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from January through April:
If you have a personal favorite that isn't on this list, please let me know. Thank you for reading!