No Common Sense Family Doctor post this week

I will be busy preparing a presentation on blogging and using social media tools for the Family Medicine Education Consortium's Northeast Region Meeting in Hershey, PA and also laying the groundwork for a big announcement early next week (how's that for a teaser)? If you can't wait that long to get your blog fix, there will be a new post on my Healthcare Headaches blog on USNews.com tomorrow or Wednesday. See you all in November!

Improving care with electronic health records

For most of my career, I kept track of my patients' health histories by scribbling hand-written notes in a paper chart. For a healthy child, I'd include dates when vaccines were given; for an adult with, say, diabetes, I'd make sure to jot down a recommended schedule of blood and urine tests as well as foot and eye exams. A majority of primary care physicians, in fact, still use this kind of tracking system—despite research suggesting that these handwritten flowsheets aren't just inefficient, but extremely vulnerable to errors. Some say the solution lies in simply switching to electronic medical records.

After all, paper charts don't automatically update themselves when, say, the Centers for Disease Control and Prevention makes a new vaccine recommendation. An electronic medical record system can do that and can also allow test results to be emailed or transferred automatically into a patient's chart; paper charts rely on office administrators to input them by hand, which can lead to mistakes. I, myself, have occasionally forgotten to record that a vaccine was administered during the chaos of a busy work day. Nor did I have any systematic way of knowing how many of my patients were actually receiving the preventive and chronic care they needed.

But the latest research suggests that electronic health records don't necessarily improve care unless they include interactive features: They should make it easier for doctors to implement proven guidelines for good care, providing the necessary shots and screenings, follow-up exams and treatments to help patients live longer with chronic diseases or to prevent these diseases altogether. Ideally, these records should include a software tool that periodically culls through patients' records looking for gaps in care such as who is overdue for a cholesterol screening or flu vaccine. The system would then send out reminders to patients to come in for a test or appointment.

Kaiser Permanente added such a tool to their electronic medical record system several years ago and found that it works to improve care. A study published last month in the American Journal of Managed Care found that the support tool brought more diabetes and heart disease patients in for health screenings, vaccinations and medication adjustments. After three years, for patients with diabetes, the percentage of care recommendations met every month increased from 68 percent to 73 percent; for heart disease patients, the percentage rose from 64 percent to 71 percent. Another study found that the tool helped more healthy patients get recommended screening and exams for preventive care. Bottom line: This support tool lowers the rate of skipped appointments and gaps in care.

This is great news if you use Kaiser Permanente for medical care, but what if you don't? Well, you can probably expect to see some significant changes at your doctor's office over the next three to five years. Physicians who take advantage of government financial incentives to set up electronic medical record systems must prove they're making "meaningful use" of the data from the health records, meaning that they've improved patient care as a result.

But now is a good time to ask your doctor about how your records will be handled in the future. Will a fail-safe system be implemented to ensure that you don't miss crucial office visits or screenings? If you see more than one doctor on a regular basis, find out if your primary care clinician—the one responsible for coordinating all of your care—uses a system that's compatible with the systems your specialists use. This will make it far easier to transfer test results and updates to prescriptions back and forth between various offices. Otherwise, the responsibility for keeping your medical chart up to date will fall on your shoulders. If you're not satisfied that your doctor is staying abreast of all these technological changes, you might want to consider switching to another practice.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Family medicine leadership

A recent commentary in the New England Journal of Medicine by family physicians Thomas Bodenheimer and David West examines how the city of Grand Junction, Colorado has managed to provide above-average quality health care with Medicare costs that are 24% lower than the national average. The explanation that Grand Junction residents are simply healthier that residents of other U.S. jurisdictions doesn't hold water. So what differences in the health care system of this community can be credited for its remarkable results - and applied to other communities across the country? Bodenheimer and West answer:

We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adapted elsewhere. These are

leadership by the primary care community;

a payment system involving risk sharing by physicians;

equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients;

regionalization of services into an orderly system of primary, secondary, and tertiary care;

limits on the supply of expensive resources, including specialists, beds, and equipment;

payment of primary care physicians for hospital visits; and

robust end-of-life care.

Although these innovations are mostly common sense, the perverse financial and political incentives that drive the U.S. health system (before and after the implementation of this year's reforms) present obstacles to many of them, from equalization of physician payment (requiring fresh infusions of dollars from tight state and federal budgets) to the appallingly inaccurate portrayal of end-of-life care as "death panels" (see my previous posts here and here).

We're just two weeks away from a midterm election that will likely alter the national political landscape, but no matter which party ends up with a legislative majority, patients and physicians can't look to the parties for sensible health policy solutions. To improve population health in this country, the professionals who care for the "folks" - family physicians and other primary care clinicians - need to lead the way by advocating for changes that will give every community a fighting chance to replicate the successes of Grand Junction.

Guest Blog: Advocating for change at community health centers

Dr. Keisa Bennett is a family physician in Lexington, Kentucky who previously saw patients at a community health center in Washington, DC while completing a fellowship in primary care health policy. The following piece was originally posted on her blog, Ruminations of a Family Doctor.

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I had a bright spot listening to the head of DC Primary Care Association criticize community health centers, the very entities her organization exists to support (in a way). Sharon Baskerville's beef with the CHC model (and she makes it well known, so I'm not "outing" her here), is its arrogance and self-righteousness. "We're doing good things for poor people," we say, but what we mean is: "We're doing better than nothing for people no one else cares about." We who reject a "cush" job in the 'burbs with a well-educated, well-insured patient population are sure we're saints. And to be sure, many people who work in CHC's have indeed made great personal sacrifices to work with and advocate for their patients.

The danger in this arrogance, however, is the "better-than-nothing" mindset. It makes us work hard and feel justified, even if our patients wait for hours to see us only to be turned away or told they need to go to the emergency room. Even if our clinic looks dingy and has folding chairs and no toys or magazines during those waits. Even if we skimp on using phone translation because it's so darn slow and seeing more patients must mean we're doing "better".

We get so caught up in doing better care for the indigent, we excuse the fact that we don't question why medical indigence even exists. We doctors don't want to admit that a few trained community health workers could do at least half of the services we're doing more efficiently. No one wants to ask the patients what they really want because we already know the answer. They want what we want, and we wouldn't want to travel by bus and by foot for 30 minutes just to sit in a dingy waiting room all day only to be told that our baby's horrible, scary cough doesn't need any treatment and then be scolded for not using the thermometer correctly.

We would want a trusted person or persons we could call on when we were afraid of a symptom or unsure whether to go to the doctor. Someone who would gather community members together to help everyone figure out how to make the whole environment healthier. When we did need a doctor, we would want to go to a warm, welcoming place where the staff greeted us as a friend and enjoyed serving us and we were happy to pay for their care in one way or another. We want a relationship with at least one person in this office who we can trust to be our advocate. We want these people to communicate well with any higher-level or specialty care we might need.

And if some of us deserve this, all of us deserve it. Shouldn't we all work for it? We would have to give up a system of "better than..." The trouble with trying to make things good for everyone is that a lot of better than disappears. Martyrdom and crusades have to be let go of, given up. We crusaders don't think we are holding up change, but as long as we work for CHCs existing in their present form, we are part of the inertia.

- Keisa Bennett

Challenging conventional clinical wisdom

Over the past few years, I've been invited to speak twice at Lancaster General Hospital (PA) about studies of the effects of screening for colorectal and prostate cancer. Recognizing the need to further explore the controversies surrounding the evidence for these tests, Dr. Larry Bonchek kindly asked me to write a scientific commentary about these topics for the Journal of Lancaster General Hospital, which he edits. The result was the article "Challenging the Conventional Wisdom on Colorectal and Prostate Cancer Screening," just published in the journal's Fall 2010 issue. You are more than welcome to read the full article online, but here are my bottom-line conclusions for clinicians and patients:

The decision to perform screening for colorectal or prostate cancer can be complex, and should take in account evidence-based recommendations, the implications of recent studies, and patient preferences. In order to give patients accurate information on the benefits and limitations of cancer screening tests, physicians should discard “conventional wisdom” that has not been supported by scientific evidence. To briefly review:

1) Collecting a fecal occult blood sample for screening during the digital rectal examination is not “better than nothing at all.”

2) FOBT and flexible sigmoidoscopy have comparable benefits and fewer harms than screening colonoscopy.

3) Benefits of PSA screening on mortality are likely small to none.

4) Overdiagnosis and overtreatment of PSA-detected prostate cancers cause substantial harms.

Recent evidence on low-carbohydrate diets

I first heard of the Atkins diet back in medical school 12 years ago when one of my classmates abruptly began eating steak without potatoes and hamburgers without the bun. I was skeptical that this odd regimen would work, but his experience and subsequent research has shown that low-carbohydrate diets are as effective as traditional low-calorie, low-fat diets for losing weight.

A more important question is whether a low-carbohydrate diet, which includes higher amounts of protein and fat than the typical higher-carb diet, is as good for your heart in the long run. Two recent studies published in the journal Annals of Internal Medicine seem to provide conflicting answers. In the first study, researchers randomly assigned 307 overweight adults to a low-carbohydrate or a low-fat diet, in addition to exercise counseling. After 2 years, participants in both groups had lost an average of about 15 pounds, but the low-carbohydrate group had a significantly greater increase in HDL "good" cholesterol.

The second study, though, found that all low-carbohydrate diets aren't created equal. This one followed 100,000 male and female health professionals over a period of 20 years or more to see whether the amount of carbohydrates, fat and protein they ingested had any impact on their health. Participants whose diets were classified as the lowest in carbohydrates were 12 percent more likely to die during the study than those who consumed the highest amount of carbohydrates. But it was the low-carb, meat-loving folks who had the highest risk of death from heart disease and cancer compared to low-carb dieters whose protein sources were mostly vegetables.

So which study should you believe? Unfortunately, neither provides a definitive answer about whether low-carb diets are good or bad in the long run. Although the first study confirms that low-carb diets lead to weight loss and an increase in HDL cholesterol, that doesn't mean followers of these diets will wind up with less heart disease down the road. Also, participants in the first study had access to trained health counselors who met with them 37 times over two years to make sure that they rigorously adhered to the diet and exercise plan—a valuable resource that most people can't afford. While the second study provides more long-term data on low-carb diets, the researchers couldn't control for every factor that might affect a person's risk of dying such as, for example, exposure to air pollution. Rural folks might be more likely to eat more plant proteins like soybeans, while also having less exposure to air pollution than urban folks who might gravitate towards meat-based meals. So the type of protein people ate may not have been completely responsible for the difference in death risk.

If you're thinking of trying a high-protein, low-carb diet to lose weight or improve your health, consider the following factors based on the latest research.

1) You have a good chance of losing weight if you follow the diet faithfully, and you will most likely find it easier to stick with than a low-fat diet.

2) In order to keep off any weight you lose, you need to increase your physical activity. Aerobic exercise (walking, jogging, swimming) produces better results for weight maintenance than strength-building exercises (pushups, lifting weights), though a combination of both types may offer additional health benefits, such as prevention of injuries.

3) Although low-carb diets have been shown to improve cholesterol in some people, we don't know if they protect against heart problems in the long run. One thing I do know: If a diet sounds too good to be true, it probably is. In this case, current research is consistent with common sense. Replacing carbs with tofu and steamed vegetables is likely to be better for your health than baby-back ribs and pork loins.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

A different perspective on screening for breast cancer

A nurse practitioner and writer living in Washington, DC, Veneta Masson contributed a guest post to Common Sense Family Doctor earlier this year. This month, she published a thought-provoking piece in the journal Health Affairs, titled "Why I Don't Get Mammograms." Explaining her decision to stop receiving yearly mammograms after age 56, she eloquently articulates her perspective as a patient informed by clinical experience and syntheses of scientific evidence regarding the benefits and harms of screening for breast cancer. In doing so, she challenges the public and medical consensus that routine mammography is an unqualified societal good. Ms. Masson concludes:

I accept that sooner or later, I’ll die of something. It could be breast cancer. It’s also possible that I’ll die with cancerous changes in my breast (or some other location) that never progressed enough to cause harm. ... It’s been ten years since my last mammogram. I don’t have to wonder whether this will be the year for a false alarm, false reassurance, or discovery of a cancer that might or might not require treatment. I accept the fact that life is uncertain.

I’m grateful for the gift of good health, recognizing that that’s what it is: a gift. I will always mourn my sister’s untimely death, which took place three years after her [breast cancer] diagnosis despite state-of-the-art treatment. If it were in my power, I’d honor her by redirecting the $5 billion this country spends each year on screening mammography to other purposes. I’d direct those sums instead to the study of how breast cancer starts, and what we can do to treat it more effectively.

This piece is especially timely in light of a recent study in the New England Journal of Medicine that suggested that nearly two-thirds of the reduction in breast cancer mortality observed after the implementation of routine screening mammography in Norway was actually the result of advances in treatment, rather than earlier detection. Both articles are must-reads for clinicians and patients who want to better understand the limitations and tradeoffs associated with breast cancer screening and screening for cancer in general.

Complexities of cardiac risk assessment

One of the most powerful patient education tools I've used in practice is the Framingham Heart Study's coronary risk calculator, which estimates the 10-year risk of having a heart attack using age, sex, smoking status, cholesterol and blood pressure levels. I've frequently used this calculator to illustrate that quitting smoking is far more effective at lowering one's heart attack risk than taking drugs to lower cholesterol and blood pressure to recommended levels.

It turns out, though, that not all risk calculators are created equal. A recent study published in the Journal of General Internal Medicine found that many online heart risk calculators, including the one on the American Heart Association's website, use a simplified algorithm (a point-based tool, rather than an equation) that ends up estimating an artifically high risk for 10% of adults and an artificially low risk for 5%. Worse, using the faulty calculator, 39% of patients with high cholesterol would have met criteria for more intensive therapy (either a higher drug dose or the addition of a new drug) than necessary. Since most doctors are unaware of differences between the calculators, it's possible that millions of patients might be misclassified and subjected to more treatment than they really need.

While the solution to this problem is fairly obvious - toss the point-based tool, which was created to help docs do pen-and-paper calculations in the days before widespread Internet access - the solution to another problem of estimating cardiac risk is much less clear. As it is with many other health conditions, socioeconomic status (i.e., being poor) is an independent risk factor for heart attacks that isn't counted by the Framingham calculator.

But it's clearly impractical (and ethically questionable) to practice primary prevention of heart disease on the basis of an individual patient's family income. So a group of researchers publishing in the current issue of Annals of Family Medicine suggested a somewhat more workable alternative: substituting individual incomes with residential income quartiles derived from census areas, since people of similar income levels tend to live in the same neighborhoods. They suggest that electronic health records might be programmed to automatically incorporate the patient's street address into the coronary risk calculation, or conversely, lower the risk thresholds for cholesterol-lowering treatments.

I was attracted to family medicine partly out of a desire to reduce health disparities, but I honestly hadn't imagined that doing so would potentially involve prescribing more cholesterol-lowering drugs to people just because they happened to live in poor neighborhoods. On the other hand, it seems unethical to expose poorer patients to higher heart attack risks just because I feel uneasy about differentiating patients based on socioeconomic status. I'd very much enjoy hearing other clinician and patient perspectives on this issue.