Wednesday, April 22, 2015

Should women start having mammograms before age 50?

The best answer to this question, I tell both my patients and loved ones, is: it depends on you.

As the U.S. Preventive Services Task Force affirmed this week in its updated draft recommendations on breast cancer screening, "The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years." The Task Force went on to suggest that women with first-degree relatives who had breast cancer might be more motivated to start screening in their 40s.

What this decision shouldn't depend on is being bullied by one's doctor into getting a mammogram "just to be safe." Screening mammography's benefits and harms are closely balanced, and as two of my mentors in preventive medicine observedsome women might reasonably decide to say no:

Over the years we have learned more about the limited benefits of screening mammography, and also more about the potential harms, including anxiety over false-positive results and overdiagnosis and overtreatment of disease that would not have caused health problems. More and more, the goal for breast cancer screening is not to maximize the number of women who have mammography, but to help women make informed decisions about screening, even if that means that some women decide not to be screened.

Two women at "average risk" for breast cancer might make different decisions after they turn 40, depending on how concerned they are about dying from cancer, being diagnosed with cancer, and their tolerance for harms of screening. One well-informed female science journalist might choose to start being screened. Another female reporter, equally well-informed, might choose to opt out. Neither of these decisions is right or wrong on an individual or population level, regardless of the apocalyptic protests of self-interested radiology groups.

What concerns me is how current quality measurement and pay-for-performance approaches could end up pressuring more doctors to behave like bullies and drive up health care costs. Fee-for-service Medicare already spends about $1 billion each year on mammography; across all payers, about 70% of U.S. women age 40 to 85 years are screened annually at a cost of just under $8 billion. Doctor A is not necessarily a better doctor who deserves higher pay than Doctor B because more of Doctor A's patients get mammograms. In fact, the opposite might easily be true.

A recent study estimated that patients and insurers in the U.S. spend an additional $4 billion annually on working up false-positive mammogram results or treating women with breast cancer overdiagnoses. That's an extraordinary amount to spend for no health benefit, and it could be substantially less if physicians had the time and resources to explain difficult concepts such as overdiagnosis. But that doesn't appear to be where we're headed.

Finally, the notion that has been written into law in nearly half of the states in the U.S. requiring that women with dense breast tissue be notified so that they can get supplemental testing for mammography-invisible cancers is particularly misguided. The USPSTF's review found no proof that breast ultrasound, MRI, or anything else improves screening outcomes in women with dense breasts, and a sizable percentage of women can transition between breast density categories over time.


Portions of this post first appeared on the AFP Community Blog.

Thursday, April 16, 2015

What can Rwanda teach the U.S. about primary care?

The relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world but rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although economic inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I'd argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.

Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of a 2013 Atlantic headline: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to 38% of eligible U.S. girls in 2013.

Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:

Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.
Image courtesy of BMC Health Services Research.

The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this:

At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.

The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that don't require imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.


This post first appeared on Common Sense Family Doctor on December 2, 2013.

Tuesday, April 7, 2015

Palliative care makes a difference at all ages

A troubling study published earlier this year in the Annals of Internal Medicine reported that patients and their caregivers were more likely to report pain, depression, and periodic confusion during the last year of life in 2010 than in 1998. This worsening trend occurred despite increasingly frequent calls to improve end-of-life care communication and the interim publication of practice guidelines on palliative care for adults from the National Consensus Project for Quality Palliative Care and the American College of Physicians. Although the reasons for underutilization of palliative care are not entirely clear, persistent misconceptions about these services being the equivalent of "giving up" on patients or hastening their death likely play a role.

On the other end of the age spectrum, a Close-ups in the April 1st issue of American Family Physician highlighted the benefits of providing palliative care at the beginning of life: in this case, to a baby with trisomy 13 diagnosed by prenatal genetic testing. The devastated parents testified to the importance of their family physician providing support and guidance throughout the pregnancy and after their child's birth:

She helped us understand the decisions we had to make and helped us express our goals for the care of our unborn daughter. We wanted our daughter to have a comfortable life - for however long she lived - and a natural death. At the same time, we wanted as few medical interventions as possible to avoid unnecessarily prolonging her death or suffering.

Although less well-studied than palliative care in adults, critically ill neonates and infants who received palliative care consultations spent fewer days in intensive care units, received fewer blood draws and invasive interventions, and received more referrals to chaplains and social services than comparable patients with life-limiting diagnoses. Perinatal hospice programs take perinatal palliative care one step further and provide compassionate, multidisciplinary support for parents from the time of prenatal diagnosis through the remainder of pregnancy and their child's birth and death. Clinicians who provide maternity and/or newborn care and would like to learn more about perinatal hospice can consult the website, which lists contact information for more than 200 programs across the United States and internationally.


This post first appeared on the AFP Community Blog.

Thursday, April 2, 2015

The way we provide care near the end of life requires resuscitation

During one of the plenary sessions at the Lown Institute's Road to Right Care conference in March, a speaker recounted how overdiagnosis and overtreatment ruined her father's last year of life. Diagnosed with symptomatic multi-vessel coronary artery disease but otherwise in good health and independent at age 85, her father underwent successful coronary artery bypass surgery. His postoperative course was happily uneventful, except for a single stool sample that was positive for blood.

Why her father's stool was tested at all was unclear, since his blood counts were normal during his hospitalization. But his heart surgeon nonetheless strongly recommended that he see a gastroenterologist and undergo a colonoscopy. She tried to dissuade her father from doing this, since at his age even an advanced colorectal cancer would be unlikely to progress enough to cause symptoms before he died a natural death, most likely of heart disease. But her father was accustomed to following doctors' orders, so he dutifully underwent the colonoscopy, which showed a single precancerous lesion.

That should have been the end of the story, but since the gastroenterologist was unable to completely remove the lesion, he recommended consulting a surgeon to operate and take out the entire affected section of large intestine. Her father was barely four weeks out from heart surgery, and she again advised him to disregard this spectacularly ill-advised plan. But he wanted to get everything taken care of, to get this all behind him, so he consented to going under the knife again. This time, the postoperative course did not go well. He developed profuse and unremitting diarrhea, most likely from an antibiotic given prior to the surgery. His doctor pronounced the surgery a success - the cancer was cut out, after all - and expressed little interest in dealing with diarrhea. Her father was then transferred to a nursing home, where his diarrhea continued to resist all treatment, and where he died, miserable beyond all imagining, 6 months later.

Conference organizer and Lown Institute senior vice president Shannon Brownlee told another sad end-of-life story about her own father in a book review in the current issue of Washington Monthly. The article's subtitle about says it all: "How Medicare and other federal subsidies rope the elderly into painful, futile, and costly end-of-life care." Despite her father's expressed wish to never go to "the big hospital in Portland" again, he not only ended up there anyway, but underwent a totally unnecessary nuclear stress test and was hooked up to intravenous nutrition before his hospitalist could be persuaded to call in the palliative care team. Brownlee minces no words in describing the deficiences of what passes for end-of-life care in America:

When a frail, elderly person gets sick, takes a fall, or has trouble breathing, it’s as if they have stepped onto a slippery chute leading straight into the hospital, no matter how fervently they and their families might wish to avoid invasive treatment as they age and approach death. That’s because hospital services are what our medical industrial complex has been built to offer, and delivering invasive end-of-life care is the job for which we have trained our doctors and nurses. ... What we don’t do is train clinicians to talk to patients, and what we don’t have is the community-based infrastructure for delivering “high touch” care to people where they live.

I've written before about my belief that the future of medicine is low-tech and high-touch, and I agree with Brownlee that changing Medicare regulations that value ineffective "technology-rich, hospital-centric" interventions rather than house calls and social services to help elderly persons age in place are a necessary first step in resuscitating the way we provide care near the end of life. It's equally critical that we change the mindsets of physicians who see their roles as sustaining life at all costs ("doing everything," in classic medical parlance) even when they are only prolonging death. Internal medicine resident Aaron Stupple recently made a highly sensible proposal in an editorial in BMJ: pair advanced cardiovascular life support (ACLS) training with communication training about palliative care:

Coupling ACLS with communication training has several advantages. Firstly, it legitimizes the skill set as an important and valid component of today’s medical practice. ... Secondly, affixing communication training to mandatory ACLS training binds this material to an established curriculum with a good track record of reliability and measurability. ... Thirdly, all clinical disciplines receive ACLS training, so it could be used to teach a common message and an essential skill set.

Alas, Dr. Stupple's proposal makes so much sense that I fear it may be ignored. How long have we been trying to change the health care system to protect older patients from harmful interventions near the end of life? I remember reading the late surgeon Sherwin Nuland's How We Die in college and being shocked that most of us will die in hospitals, receiving "heroic" interventions that we don't want and won't do us a bit of good anyway. That was more than twenty years ago, and very little has changed. Let's spread the word about the Right Care Movement and dedicate ourselves to making sure I won't be able to write that again twenty years from now.

Thursday, March 26, 2015

Housing the chronically homeless is Right Care in action

I've been a fan of Dr. Mitchell Katz, director of the safety net health care system in Los Angeles County, California, since reading his 2013 editorial arguing we should stop offering prostate-specific antigen screening because the substantial resources devoted to testing and subsequent diagnostic workups could be better utilized to provide high-value care. I had the chance to hear Dr. Katz speak in person a few weeks ago at the Lown Institute's Road to Right Care conference on another topic that I've written about before: providing supportive housing to chronically homeless persons.

As profiled in a feature article in the March/April issue of Mother Jones, the "Housing First" approach recognizes that many, if not most people who are chronically homeless struggle with mental illness or addiction. Both of these health problems, if inadequately treated, are likely to land patients in two of the most expensive temporary housing situations imaginable: hospital emergency rooms or prisons. Provided with a place to live and convenient access to counseling and health services, however, these individuals often thrive, at a fraction of the costs they would have incurred otherwise.

Housing First has been as successful in Salt Lake City as in New York City, and is now improving population health in Los Angeles. As Dr. Katz put it simply in his presentation, "There are a lot of chronic health problems that we can't cure. Chronic homelessness isn't one of them. Provide supportive housing. Problem cured."

An obstacle to implementing this strategy is resistance from local residents to the prospect of living next door to an apartment complex full of previously homeless people. And sometimes a suitable building is either too expensive to rent or just unavailable. One alternative approach is scattered-site housing, where clients are dispersed into housing units in multiple locations across a city. Until recently, though, we didn't know how well this would work. Earlier this month, JAMA published a randomized trial of scattered-site housing and case management services in four Canadian cities that found improved housing stability compared to usual care 24 months into the program. As the evidence accumulates, it is time to advocate for taking down bureaucratic barriers, Dr. Katz wrote in an accompanying editorial:

An important step toward substantially reducing chronic homelessness would be reimbursement for housing as a medical service for persons who are chronically ill and covered by Medicaid, Medicare, and private insurance. ... Clinicians who provide care for homeless persons are aware that they can order a variety of reimbursable tests and treatments for them, except the one intervention that most likely would make all the difference - supportive housing.

Created by the Affordable Care Act and chaired by the Surgeon General, the National Prevention Council is intended to coordinate federal prevention, health promotion, and public health activities across 20 different federal agencies, including several that are not traditionally thought of as being health-related but have significant influences on health. A strong recommendation from the Prevention Council to Congress supporting the addition of housing as a preventive service that saves money and improves health outcomes might actually be something both political parties could get behind.

Friday, March 20, 2015

Patients: steer clear of these six orthopedic procedures

After the American Academy of Orthopaedic Surgeons (AAOS) released its Choosing Wisely list, it was criticized for selecting items that are uncommonly used or have little effect on the income of its members. In an editorial in the New England Journal of Medicine, Dr. Nancy Morden and colleagues pointed out that the five services listed by this specialty group were particularly "low impact":

The American Academy of Orthopaedic Surgeons named use of an over-the-counter supplement [glucosamine and chondroitin] as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.

At the Lown Institute's recent "Road to Right Care" conference, a group of orthopedic surgeons identified five other procedures that, in contrast to the AAOS list, are frequently performed at great expense in the U.S. but provide little or no benefit to patients.

1) Vertebroplasty for spinal compression fractures - in two randomized controlled trials comparing vertebroplasty to a sham procedure, there were no differences in pain or quality of life between the intervention and control groups. Risks of vertebroplasty include causing compression fractures in adjacent vertebrae, dural tears, osteomyelitis, cement migration, and radiculopathies requiring subsequent surgery.

2) Rotator cuff repair for non-traumatic tears in older adults - A randomized trial comparing physical therapy, physical therapy plus acromioplasty, and physical therapy plus acromioplasty and rotator cuff repair found no differences between the control and surgery groups after one year. About 600,000 Americans undergo rotator cuff surgery every year.

3) Clavicle fracture plating in adolescents - In adolescents with clavicle fractures that were displaced and shortened, there were no differences between nonoperative management (a sling for the affected arm) and surgery in appearance, range of motion, or participation in sports activity two years after the injury. However, 1 in 4 adolescents who underwent surgery required re-operation for surgical complications.

4) Anterior cruciate ligament (ACL) reconstruction - In young, active adults with acute ACL tears, a randomized trial comparing early (within 10 weeks of the injury) ACL reconstructive surgery plus physical rehabilitation to rehabilitation plus optional delayed reconstruction up to 2 years after the injury found similar outcomes between the groups. 61 percent of the optional reconstruction group did not require surgery. More than 100,000 ACL reconstructions are performed in the U.S. each year.

5) Partial medial meniscectomy for adults with knee osteoarthritis and no mechanical symptoms - A randomized trial found no benefit of partial meniscectomy compared to sham surgery in adults with degenerative meniscal tears and no osteoarthritis. A systematic review of 7 trials came to the same conclusion. In adults with osteoarthritis, surgery plus physical therapy was not more effective than physical therapy alone. Arthroscopic partial meniscectomy is the most commonly performed orthopedic procedure in the U.S., with 700,000 operations annually.

Finally, a randomized trial just published in JAMA suggested that another procedure whose use is increasing worldwide provides no benefits.

6) Surgery for adults with displaced proximal humerus fractures - Patients who underwent fracture fixation or humeral head replacement within 3 weeks of sustaining a displaced fracture of the proximal humerus had no better outcomes than patients assigned to nonoperative management (sling immobilization) after 2 years.

What accounts for the continued popularity of ineffective orthopedic procedures? Excessive magnetic resonance imaging (MRI) plays a role; immediate MRI is rarely indicated for common musculoskeletal conditions, and may often provide deceptive or confusing results, such as identifying meniscal tears that are unlikely to be the cause of patients' chronic knee pain. Some primary care clinicians' lack of comfort with the orthopedic examination may lead to unnecessary referrals. Patients who perceive surgery to be a "quick fix" may not have the patience to stick with physical therapy and rehabilitation. And there is the inescapable reality that, necessary or not, these procedures pay well.


This post first appeared on the AFP Community Blog.