Wednesday, September 24, 2014

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 June, July, and August:

1) There are many ways of "knowing cancer" (6/5/14)

All of us involved in confronting cancer in all its forms - specialist and primary care clinicians, advocates, patients, family and loved ones - know cancer in different ways, and none should be held up as inherently superior to any other.

2) The problem of pain (8/13/14)

Like many doctors, I have complicated feelings about prescribing for chronic pain. On one hand, I recognize that relieving pain has been a core responsibility of the medical profession for ages. On the other hand, deaths and emergency room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years.

3) Don't do stupid sh*t in cancer screening (8/25/14)

Think twice before reflexively doing things to elderly patients that can't possibly help and, therefore, can only hurt. And keep in mind that electronic clinical decision support should never, ever substitute for a physician's brain.

4) Nurturing the next generation of diverse family physicians (7/21/14)

The good news is that family physicians are diversifying; the bad news is that Black and Latino physicians still have a long way to go to "catch up" to their numbers in the population. America's need for the next generation of diverse family physicians has never been greater.

5) Skip the annual pelvic examination? How about the whole checkup? (7/5/14)

As the U.S. faces a worsening shortage of primary care clinicians, are today's family physicians prepared to abandon annual pelvic examinations and well-adult checkups in general? (They should be.)

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

Monday, September 22, 2014

The demise of the small practice has been greatly exaggerated

When I was in high school, a national hardware retailer opened a new franchise down the street from the mom-and-pop hardware store that had served my neighborhood for many years. Since the new store had the advantage of larger volumes and lower costs, it seemed to be only a matter of time before it drove its smaller competitor out of business, the way that big bookstore chains and fast-food restaurants had already vanquished theirs.

But a funny thing happened on the way to the inevitable. By the time I left for college, the new hardware store had folded, and the mom-and-pop operation had moved into their former building. How did this small business manage to retain its customers and win new ones without prior loyalties? The answer was quality of service. I remember visiting both stores when a classmate and I were working on a physics project. At the mom-and-pop store, the owner himself happily held forth for several minutes on the advantages and disadvantages of various types of epoxy adhesive. At the national hardware chain, the staff consisted mostly of kids my age who didn't know much more about glue than I did.

A few years ago, an editorial authored by White House officials in the Annals of Internal Medicine blithely predicted that small primary care practices would eventually be absorbed by "vertically integrated organizations" as a result of health reforms. The editorial prompted the American Academy of Family Physicians to send the White House a letter defending the ability of solo and small group practices to provide high-quality primary care. Despite the migration of recent family medicine residency graduates into employed positions, researchers from the Robert Graham Center estimated in the August 15th issue of American Family Physician that up to 45% of active primary care physicians in 2010 practiced at sites with five or fewer physicians.

The limited resources of small practices seem to put them at a disadvantage relative to integrated health systems and newly formed Accountable Care Organizations. Small practices have less capital to invest in acquiring and implementing technology such as patient portals, and fewer resources (dollars and personnel) to devote to quality improvement activities, such as reducing preventable hospital admission rates. Nonetheless, like the small hardware store of my youth, some small practices are not only surviving, but thriving in the new health care environment. Dr. Alex Krist and colleagues recently reported in the Annals of Family Medicine that eight small primary care practices in northern Virginia used proactive implementation strategies to achieve patient use rates of an interactive preventive health record similar to those of large integrated systems such as Kaiser Permanente and Group Health Cooperative. An analysis of Medicare data published in Health Affairs found that among primary care practices with 19 or fewer physicians, a smaller practice size was associated with a lower rate of potentially preventable hospital admissions.

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement. For example, Dr. Jennifer Brull reported how her practice and four others in north-central Kansas succeeded in improving hypertension control rates in an article and video in the September/October issue of Family Practice Management.

These examples illustrate that the demise of the small primary care practice has been greatly exaggerated. Whether small practices can continue to flourish in the post-Affordable Care Act era remains an open question, but I do know this: the small hardware store in my home town is still thriving, more than twenty years later.

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This post first appeared on the AFP Community Blog.

Monday, September 15, 2014

Preventing overdiagnosis: conference (#PODC2014) and Public Citizen

A year ago, I was fortunate enough to attend the first Preventing Overdiagnosis conference in Dartmouth, New Hampshire. This annual worldwide gathering of researchers, clinicians, and laypersons aims to explore the increasing problem of overdiagnosis in modern medicine and propose strategies to restrict the identification and treatment of disease to those persons who stand to benefit, rather than others in whom unnecessary diagnosis will only lead to harm. Prostate cancer is the "poster child" for overdiagnosis, a condition that I've compared in the past to an epidemic of snipers on rooftops where aggressive efforts to "disarm the sniper" often result in devastating consequences for men who would have otherwise died with, rather than of, the condition.

The second Preventing Overdiagnosis conference in Oxford, UK began today and continues through Wednesday, September 17th. Although I didn't make it this year, I plan to follow the scientific sessions on Twitter (hashtag #PODC2014) and encourage readers to do so as well.

Speaking of overdiagnosis, my colleagues at Public Citizen have recently taken aim at direct-to-consumer cardiovascular screenings offered at 20 hospitals and medical institutions in conjunction with HealthFair, a for-profit company that provides echocardiography, electrocardiography, abdominal ultrasonography, carotid ultrasonography to all comers. As Public Citizen's experts pointed out in letters to the Federal Trade Commission, the Joint Commission, and involved hospitals and institutions, no credible medical organization supports indiscriminately providing these tests to asymptomatic patients, since they are likely to cause more harm than good by producing false positive results or leading to interventions for conditions that would not otherwise produce clinical symptoms (in other words, overdiagnosis). In fact, the U.S. Preventive Services Task Force and several primary care and cardiology groups involved in the American Board of Internal Medicine Foundation's Choosing Wisely campaign recommend against performing many of these tests.

Kudos to the organizers and participants in this year's Preventing Overdiagnosis conference, and to Drs. Michael Carome and Sidney Wolfe at Public Citizen, for their commendable efforts to protect patients from the harms of overtesting, overdiagnosis, and overtreatment.

Monday, September 8, 2014

Why are doctors still prescribing bed rest in pregnancy?

Maternity care providers have traditionally prescribed "bed rest," or activity restriction, for a host of pregnancy complications (including preterm contractions, short cervix, multiple gestation, and preeclampsia) despite evidence that it does not improve maternal or neonatal outcomes. On the other hand, prolonged activity restriction in pregnancy increases risk for muscle atrophy, bone loss, thromboembolic events, and gestational diabetes. Although it did not include this practice in its Choosing Wisely "Five Things Physicians and Patients Should Question" list, the Society of Maternal and Fetal Medicine (SMFM) recently published a strongly worded position paper recommending against activity restriction in pregnancy for any reason.

This isn't the first time reviewers have examined the evidence for activity restriction and found it lacking; a 2013 summary of several Cochrane reviews of therapeutic bed rest in pregnancy also found such poor data to support the practice that the authors concluded its use should be considered unethical outside of the context of a randomized controlled trial.

The message isn't getting through to physicians or patients, though. A 2009 survey of SMFM members found that 71 percent would recommend bed rest to patients with arrested preterm labor, and 87 percent would advise bed rest for patients with preterm premature rupture of membranes at 26 weeks gestation, even though most of them did not believe it would make make any difference in the outcome (the most common answers were "minimal benefit" and "minimal risk"). Unfortunately, the risk may be more than minimal. Not only does activity restriction expose pregnant women to harm, a secondary analysis of a randomized trial of preterm birth prevention found that nulliparous women with short cervices whose activity was restricted were actually more likely to deliver before 37 weeks' gestation than those who were not.

Similarly, a search of the terms "bed rest" on popular pregnancy websites Babyzone and Pregnancy.org yielded the following statements that fly in the face of evidence: "Changing the force of gravity usually helps minimize preterm labor." "It [bed rest] helps keep blood pressure stable and low." "In most cases, bed rest is used to help the body have the best chance to normalize." A handout on WebMD provided a more balanced assessment:

Bed rest has been a way of treating pregnancy complications for more than a hundred years. But there's a problem. While bed rest is a common treatment, there's no proof that it helps. It doesn't seem to protect your health or your baby's. In fact, bed rest has risks itself. Doctors still prescribe it, but more because of tradition than good evidence that it works.


The handout went on to advise patients to question their physicians closely or get a second opinion if bed rest is recommended. That's sensible advice. Doctors who are reluctant to abandon this useless and potentially harmful maternity practice should consult the SMFM paper or the American Family Physician By Topic collections on Prenatal Care and Labor, Delivery, and Postpartum Issues, where no articles recommend activity restriction for pregnancy complications.

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This post first appeared on the AFP Community Blog.

Thursday, September 4, 2014

PSA screening for prostate cancer: a bad idea then and now

Few scientists have been fortunate enough to make a single discovery that ultimately revolutionized the practice of medicine. So one might expect Dr. Richard Ablin, who identified prostate-specific antigen (PSA) more than forty years ago, to take satisfaction in the way his accomplishment has transformed the field of urology and the way clinicians detect and treat prostate cancer in the twenty-first century. A study published last week in JAMA Internal Medicine found that even though three major guidelines – from the U.S. Preventive Services Task Force (USPSTF), the American College of Physicians, and the American Urological Association  raise serious concerns about the PSA test's effectiveness and adverse effects, nearly one-half of all men between the ages of 65 and 74 reported being screened with the PSA test within the previous 12 months.

But after reading Dr. Ablin's 2010 New York Times editorial, "The Great Prostate Mistake," and his revelatory followup book, The Great Prostate Hoax, I think he probably feels that the world would have been better off if PSA had remained undiscovered  or, at least, if his discovery had not been so shamelessly exploited by the medical-industrial complex to cause erectile dysfunction and urinary incontinence in a generation of terrified men who had surgery for screen-detected prostate cancers that otherwise would not have bothered them at all.


As longtime readers know, I played a minor role in this saga. Dr. Ablin mentions me on page 174 of his book, during his recap of the excruciating delay between the USPSTF's initial (and unanimous) vote to recommend against PSA screening and the final publication of that report:

According to Michael L. LeFevre, MD, the vice chairman of the task force that issued the [2012 USPSTF] report, in 2009 he and his fellow panel members had voted to recommended against PSA testing, but knowing they would have to defend themselves against the inevitable firestorm of criticism – from the AUA and advocacy groups – they slowed the process down, issuing their recommendation three years later in 2012. … 

Kenneth Lin, a central researcher on the PSA review panel, resigned in protest. How many men might have been spared an unnecessary life-changing radical prostatectomy during that delay? ... LeFevre’s admission speaks to the culture of fear promulgated by the prostate cancer industry. And in this case the industry won. Between 2009 and 2012, it obtained a three-year window of opportunity during which more than 3 million more men had painful needle biopsies and about 300,000 of those men needlessly had their prostate glands cut out of their bodies.

It wasn't just the "prostate cancer industry" that was supplying fear and pressure. After being thrown under the bus by the Obama administration when the furor over downgrading its recommendation on breast cancer screening for women in their 40s threatened to derail the Affordable Care Act, USPSTF members weren't convinced that they could count on the Department of Health and Human Services to protect them from prostate cancer fallout less than a year later. They were right to worry. In October 2010, my boss at the Agency for Healthcare Research and Quality received explicit instructions from the White House to call off the Task Force's November meeting (where prostate cancer screening would be reconsidered). With no good options, Dr. Ned Calonge, the outgoing Chair, decided to cancel the meeting himself, allowing the USPSTF to save face and not be pigeonholed as a partisan panel that only produced scientific statements supportive of the administration's goals (which, to my jaded eye, boiled down to extolling the benefits of "free" screenings and downplaying or shelving inconvenient evidence of harm).

Today, Dr. Ablin is hardly alone in calling for an end to PSA screening for prostate cancer. Dr. Vinay Prasad, who has written widely about medical reversals, recently chimed in with "It Is Time To Stop Screening for Prostate Cancer," where he observed that "the history of the PSA test will one day serve as a reminder that, although all of us in health care want to do everything possible to reduce the mortality of cancer, the early adoption of screening techniques on the basis of insufficient evidence can lead to more harm than good." I could not agree more. PSA screening is a tragedy born from physicians' good intentions. It was a bad idea when it began in the evidence-free world of the early 1990s, and it continues to do far more harm than good to older men today.

Thursday, August 28, 2014

In U.S. and U.K., statin debate goes on

As previewed in a previous blog post, the August 15th issue of American Family Physician features a concise summary of the American College of Cardiology / American Heart Association updated cholesterol treatment guideline. Key points include an expansion of the role of statins in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); elimination of specific low-density lipoprotein cholesterol (LDL-C) target levels; and a new tool for assessing of 10-year and lifetime risk for ASCVD. An accompanying POEM notes that full implementation of the new guideline would increase the number of U.S. adults eligible to take statins by nearly 13 million, with the percentage of adults 60 to 75 years of age for whom statins are recommended rising from 47.8% to 77.3%.

Two editorials in the same issue further explore the implications of the new guideline. Writing for the members of the guideline panel, Dr. Patrick McBride and colleagues emphasize that the recommendations are largely based on high-quality evidence from randomized controlled trials that measured patient-oriented outcomes. They argue that "these changes should simplify the approach to clinical practice by reducing titration of medication, the addition of other medications, and the frequency of follow-up laboratory testing." In a second editorial, Dr. Rodney Hayward concurs with the panel's decision to abandon LDL-C targets, but disagrees with setting a universal 10-year ASCVD risk threshold of 7.5% for treatment with a statin:

My biggest criticism of the new guideline is that it does not acknowledge a specific gray zone—a range in which the potential benefits and harms of a statin make the “right decision” predominantly a matter of individual patient circumstances and preferences. It may be reasonable to set 7.5% as a starting point for discussion (e.g., for every 33 patients treated for 10 years, roughly one heart attack will be prevented [i.e., number needed to treat = 33]). But these risks and benefits are estimates with a nontrivial margin of error. The guideline does note that shared decision making should be used, but it provides no clear direction on when statins should be recommended rather than just discussed.

A similar debate is taking place in the United Kingdom, where its National Institute for Health and Care Excellence (NICE) recently recommended offering a statin to all persons with a 10-year cardiovascular event risk of 10% or more. An editorial in BMJ observed that doctors need better shared decision making tools to help patients understand the tradeoffs involved in taking medications that have potentially large population health benefits but are unlikely to prevent a bad outcome in an individual patient:

Doctors are unlikely to start giving patients clear numerical information simply because they are told to do so. They might do so if NICE can recommend information tools with the same force as when it recommends drugs, and if it becomes as easy to give contextual numerical advice as it is to print a prescription. ... We will need better data, from bigger trials, and better risk communication than for conventional medical treatment. ... Without such innovation in the use of medical data, we can say only that statins are—broadly speaking—likely to do more good than harm. That is not good enough.

If you are a clinician reading this, have you already integrated the ACC/AHA or NICE cholesterol guideline into your practice? If so, how do you decide whether to "recommend" versus "discuss" statins with patients? If not, what reservations or workflow issues have stopped you from transitioning to the new guidelines?

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This post first appeared on the AFP Community Blog.