Monday, May 23, 2016

Does convenience outweigh continuity of care?

Several years ago, after leaving my scientific position at AHRQ and feeling that my patient care skills had become rusty, I took a part-time job as a staff physician at a rapidly growing chain of urgent care centers. I thought that urgent care's relatively limited scope of practice would ease my transition back into the clinic, and though the pace was often intense, I quickly became comfortable sewing up lacerations, draining abscesses, diagnosing fractures, and fishing various objects out of ears and noses. All in all, it was a rewarding experience: my physician colleagues were friendly and experienced, the support staff skilled and professional, and since we stayed open from from 7 AM to 10 PM every day of the year, our walk-in patients were generally grateful to be seen.

After about a year of this work, I decided to return to academic medicine. During my interview, I mentioned to the then-Department Chair that I had been working in urgent care. He visibly grimaced, then said something about urgent care centers "skimming the cream" of primary care and leaving full-service family practices with the more complex and less lucrative types of visits. And I couldn't really disagree. If there's one axiom at the heart of family medicine, it's the importance of continuity of care - meaning, whether you feel sick or well, seeing a doctor who knows you will make it more likely you will get the care you need. A systematic review in the Journal of Family Practice and a more recent review in the Journal of Evaluation in Clinical Practice both concluded that increased continuity was associated with higher quality care, better outcomes, and higher patient satisfaction.

The problem with prioritizing continuity of care is ensuring access. My current practice is open until 8 PM two evenings per week and, until recently, we also saw patients on Saturday mornings. But none of us really like to work on Saturdays, and we recently learned that of all the primary care practices in our health system, we are the only ones who ever even try be open on that day. Further, the nature of an academic practice is that my colleagues and I are only each at the office a day or two per week, further limiting the ability of patients to see the same doctor every time. Can continuity of care be said to have the same value if it's only with the same office, rather than the same person? It's a question that needs answering, as a study from the Robert Graham Center found that an increasing proportion of Americans identify an office or facility, rather than an individual clinician, as their usual source of health care.

Finally, retail health clinics (think CVS's Minute Clinics), like urgent care centers, have emerged and prospered as a response to deficiencies in primary care access, but handle a more limited range of acute problems and are staffed by nurse practitioners rather than physicians. On one hand, retail clinics may disrupt continuity of care, but on certain measures of quality, such as antibiotic prescribing for respiratory infections, they are more likely to adhere to national guidelines. And even a respected health policy researcher such as Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University, admits that he would rather take his child to a retail clinic for a sore throat than deal with the hassle of getting a same-day appointment with their usual physician. So much for continuity of care and the patient-centered medical home that physician groups have been advocating for the past decade as the solution to excessive health spending and mediocre outcomes! Or can these concepts coexist with the convenience of urgent and retail health care?

Tuesday, May 17, 2016

Ready for World Family Doctor Day?

On Thursday, May 19th, the World Organization of Family Doctors (WONCA) will celebrate World Family Doctor Day, a day that since 2010 has highlighted the roles and contributions of family physicians in health and health care systems worldwide. The term "global health" has evolved from being used primarily to describe volunteer medical work in developing countries to a broader concept that recognizes the easy transmission of infectious diseases across continents and international boundaries (e.g., outbreaks of Ebola and Zika virus) and the presence of international refugee and immigrant populations with specific medical needs in the "backyards" of the United States. In a 2015 American Family Physician editorial, my Georgetown and Medscape Family Medicine colleague Dr. Ranit Mishori and Dr. Jessica Evert explained why incorporating global health experiences into Family Medicine training and practice "matters now more than ever":

Global health exposure internationally and locally helps develop a broader health system perspective, greater attention to the social determinants of health, and an understanding of population health concepts. Engaging in global health can bolster cross-cultural competencies, along with the desire to work in resource-poor settings. Additionally, it can strengthen skills and passion to care for underserved populations domestically. A few studies have even suggested an association between global health experiences and an increased interest in primary care.

Dr. Kyle Hoedebecke wrote a blog post last year about why new physicians should care about global health and hosted an episode of "Family Medicine On Air" directed at family medicine interest groups (FMIGs) in the U.S. This year, one of my former Health Policy Fellows, Dr. John Parks, whose research on the global landscape of family medicine training informed the AAFP's World Health Mapper online tool, will host a live Google Hangout at 11 AM Eastern on World Family Doctor Day. Students can submit questions for Dr. Parks, who is now a faculty lecturer in the Department of Family Medicine at the University of Malawi College of Medicine, by e-mailing their FMIG Network Regional Coordinator by Wednesday, May 18th.


This post first appeared on the AFP Community Blog.

Monday, May 9, 2016

Don't delay palliative care in heart failure

For me, the words "palliative care" bring to mind a picture of a patient suffering from incurable cancer, perhaps one that has spread to the bone or brain. Avoiding death from cancer, even via screening tests or therapies that increase the risk of death from other causes (thus providing no overall health benefit) is a reason that physicians sometimes cite for continuing cancer screening long beyond what guidelines recommend. Clinicians may be less likely to view patients with non-cancer diagnoses, such as end-stage heart disease, as potentially eligible for palliative or hospice care, Dr. Marc Kaprow wrote in a 2010 editorial in American Family Physician. In a 2013 editorial, Drs. Rebecca McAteer and Caroline Wellbery encouraged readers to take a broader view of this underutilized service:

Palliative care improves the quality of life for patients with a life-threatening illness and for their families. It aims to relieve suffering by identifying, assessing, and treating pain and other physical, psychosocial, and spiritual problems. Palliative care can be provided whether an illness is potentially curable, chronic, or life-threatening; is appropriate for patients with noncancer diagnoses; and can be administered in conjunction with curative-aimed therapies at any stage of the illness.

Heart failure provides a good example of a condition that benefits from palliative care, especially in its advanced stages. Although increasing resources have been devoted to preventing heart failure readmissions, palliative care interventions remain poorly integrated despite the downward disease trajectory that nearly all patients experience. A 2009 review in Circulation concluded that palliative care improved patient and family satisfaction; facilitated communication between patients and health professionals; increased access to community support services; and was associated with a greater likelihood of patients dying at home. It also produced significant cost savings from fewer invasive end-of-life interventions and hospitalizations.

A more recent review in BMJ summarized the past 5 years of medical literature on palliative care in heart failure. Common symptoms that palliative care can address effectively include pain, breathlessness, fatigue, and depression. Older adults with heart failure have 4-5 comorbidities on average and are more likely to experience frailty than the general population. As rising numbers of these patients receive implanted cardioverter defibrillators and left ventricular assist devices, device deactivation is rarely discussed even when patients become critically ill. The American Heart Association encourages scheduling an "annual heart failure review" to provide time for shared decision-making around these topics and to assure that treatment intensity and future plans are aligned with patients' goals and preferences.


This post originally appeared on the AFP Community Blog.

Friday, April 29, 2016

Medical officers' labor is essential, but often unheralded

I recently gave a talk on diabetes screening to Preventive Medicine residents at Uniformed Services University of the Health Sciences, where I re-connected with two former residents, now faculty, whom I supervised as a medical officer at the Agency for Healthcare Research and Quality (AHRQ) from 2006 to 2010. A lot has changed in the past six years. The Center for Primary Care, Prevention, and Clinical Partnerships, which housed the U.S. Preventive Services Task Force program, is now known as the Center for Evidence and Practice Improvement, and the role of USPSTF medical officers has been considerably circumscribed. Staff no longer perform in-house systematic reviews such as this one on prostate-specific antigen screening that won me AHRQ's Article of the Year Award in 2009. Individual medical officers are no longer even acknowledged by name in USPSTF documents, which now thank generic "AHRQ staff," I suppose to preemptively distance the agency from any politically controversial recommendations.

This isn't to say that I think the job is no longer worth doing. Indeed, when I found out earlier this year that AHRQ was looking to fill USPSTF medical officer positions, I shared the job description with contacts far and wide. Yes, the role may have changed, even somewhat diminished. Yes, it may never be more trendy to be anti-government (and less trendy to work for the government) than it is today, when an ignorant, unqualified billionaire reality TV star who can't let a day go by without offending another constituency is close to clinching a Presidential nomination. But the work of the Task Force must go on, as it has since 1984. And the engine that drives the Task Force's work is - and always has been - the labor of a group of unheralded, and now unnamed, medical officers at a small federal agency whose existence is perennially imperiled. To my former colleagues and others whom I haven't met, thank you for your selfless service, and for improving the health of all Americans.

Tuesday, April 26, 2016

Obstacles to stopping cancer screening in older adults

I recognized a glitch in my electronic medical record's decision support software when it prompted me to consider prostate and colorectal cancer screening in a 93 year-old man, who, though remarkably vigorous for his age, was unlikely to live for the additional 10 years needed to benefit from either test. Although deciding not to screen this patient was easy, determining when to stop cancer screening in older patients is often more challenging. In the April 15th issue of American Family Physician, Drs. Brooke Salzman, Kathryn Beldowski, and Amanda de la Paz present a helpful framework for decision making in these clinical situations, where population-level guidance derived from studies of screening younger patients "generally do not address individual variations in life expectancy, comorbid conditions, functional status, or personal preference."

The authors recommend that clinicians take into account not only average life expectancy at a given age, but also significant variations in life expectancy linked to functional impairment and comorbid conditions, using one or more validated prognostic tools. Although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence about screening mammography in women 75 years or older, modeling studies suggest that women with projected life expectancies of greater than 10 years may still benefit from this test - with these important caveats:

Although the sensitivity and specificity of mammography increase with age, overdiagnosis also increases because of reduced life expectancy and an increased proportion of slower-growing cancers. In other words, women with breast cancer diagnosed at an older age are more likely to die of something else, compared with younger women. In addition, treatment of breast cancer in advanced age is associated with greater morbidity, including an increased risk of postoperative complications and toxicity from chemotherapy.

Similar considerations apply to screening for colorectal cancer, which the USPSTF made a "C" grade recommendation (small population-level benefit, use individual decision making) for adults 76 to 85 years of age and recommended against screening adults older than 85 years, when the harms clearly exceed the potential benefits. Nonetheless, surveys have found that 31% of adults age 85 years and older, and 41% of adults with a life expectancy of less than 10 years, received screening colonoscopies. To discourage overuse of cancer screening without alienating patients, the authors advise: "It is important to convey that a decision to stop cancer screening does not translate into decreased health care. Rather, discussions can focus on health promotion strategies that are most likely to benefit patients in the more immediate future, such as exercise and immunizations."

A recent qualitative study in JAMA Internal Medicine explored the reluctance of primary care clinicians to explicitly incorporate long-term prognosis in the care of older adults. Most study participants relied on their own clinical experience, rather than validated tools, to estimate a patient's life expectancy, and were reluctant to stop screening in relatively younger patients even with limited life expectancies. Barriers mentioned by participants included inadequate training, time constraints, concern about negative patient reactions, competing practice incentives, and fear of lawsuits. Readers, do you share these concerns? What strategies do you use to communicate with an older adult whose age or life expectancy suggests stopping cancer screenings because harms outweigh benefits?


This post first appeared on the AFP Community Blog.

Thursday, April 21, 2016

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 November through March:

2) College tuition and health care costs are unsustainable (1/25/16)

3) Book Review: "Ending Medical Reversal" is revolutionary (11/11/15)

4) Pharma industry free speech is anything but free (12/16/15)

5) Is vitamin D supplementation good for anything? (1/14/16)

If you have a personal favorite that isn't on this list, please let me know. Thank you for reading!