Making wise choices in diagnostic imaging

Many of the primary care-relevant recommendations in the Choosing Wisely campaign advise physicians to think twice before reflexively ordering diagnostic imaging tests in certain clinical situations. Inappropriate imaging increases radiation exposure, leads to overdiagnosis and detection of incidentalomas, and increases costs for patients and health systems. In addition, as Drs. Brian Crownover and Jennifer Bepko observe in the April 1st issue of American Family Physician, increasing radiation exposure is likely to lead to higher rates of cancer diagnoses and deaths:

In 2006, 380 million radiologic procedures (including 67 million computed tomography [CT] scans) and 18 million nuclear medicine procedures were performed in the United States. To highlight the disproportionate use, U.S. patients received approximately one-half of all nuclear medicine procedures worldwide while making up only 4.6 percent of the global population. The volume represents a sixfold increase (from 0.5 to 3.0 mSv [millisieverts]) in annual per capita radiation exposure from 1980 to 2006. ... Increasing recognition of future cancer risk from radiation exposure was illustrated in a 2009 study showing that 2 percent of all future cancer cases will likely come from previous CT exposure, resulting in approximately 15,000 deaths annually.

This article on the appropriate and safe use of diagnostic imaging goes on to review consensus indications for imaging in the central nervous system, chest, abdomen, and lumbar spine based on American College of Radiology appropriateness criteria. It includes a helpful Table on the average effective radiation doses of medical imaging procedures that clinicians may use to weigh the harm versus the potential benefit of a particular diagnostic imaging test. In general, the authors recommend discouraging patients from undergoing whole body scanning, which is associated with numerous health risks and no proven benefits.

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This post was first published on the AFP Community Blog.

Pink ribbons don't cure breast cancer

"I used to believe that a mammogram saved my life," begins breast cancer survivor Peggy Orenstein in a revelatory New York Times Magazine story that every woman (and man) should read before making personal decisions about screening for cancer. Although the ubiquitous spectacle of pink ribbons for "cancer awareness" has certainly raised breast cancer's profile as disease, Orenstein raises serious concerns about whether these campaigns have been good for patients:

Before the pink ribbon, awareness as an end in itself was not the default goal for health-related causes. Now you’d be hard-pressed to find a major illness without a logo, a wearable ornament and a roster of consumer-product tie-ins. Heart disease has its red dress, testicular cancer its yellow bracelet. During “Movember” — a portmanteau of “mustache” and “November” — men are urged to grow their facial hair to “spark conversation and raise awareness” of prostate cancer (another illness for which early detection has led to large-scale overtreatment) and testicular cancer.

“These campaigns all have a similar superficiality in terms of the response they require from the public,” said Samantha King, associate professor of kinesiology and health at Queen’s University in Ontario and author of "Pink Ribbons, Inc.” “They’re divorced from any critique of health care policy or the politics of funding biomedical research. They reinforce a single-issue competitive model of fund-raising. And they whitewash illness: we’re made ‘aware’ of a disease yet totally removed from the challenging and often devastating realities of its sufferers.”

As I've blogged before, there are no easy victories in cancer screening and prevention. Physicians, researchers, politicians, and health advocates who exaggerate the benefits and minimize the harms of early detection of cancer with mammograms and other tests ultimately do patients a disservice. Orenstein makes this case on the personal and public health levels:

The idea that there could be one solution to breast cancer — screening, early detection, some universal cure — is certainly appealing. All of us — those who fear the disease, those who live with it, our friends and families, the corporations who swathe themselves in pink — wish it were true. Wearing a bracelet, sporting a ribbon, running a race or buying a pink blender expresses our hopes, and that feels good, even virtuous. But making a difference is more complicated than that.

It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.

Read the full text of "Our Feel-Good War on Breast Cancer" here.

The worst kind of guideline

Before critiquing the American College of Physicians' recent guidance statement on screening for prostate cancer, I will begin by saying that I generally hold the ACP's clinical guideline development process in high regard. They often base their guidelines on comprehensive and methodologically sound reviews of the evidence produced by Evidence-Based Practice Centers. In some cases, when several good-quality guidelines are already available, the ACP chooses not to reinvent the wheel and instead critically appraises the existing guidelines, as it did this time. The authors of the guidance statement are respected experts in evidence-based medicine, including Informed Medical Decisions Foundation president Michael Barry and current U.S. Preventive Services Task Force member Douglas Owens.

That being said, I won't mince words. On screening for prostate cancer, the ACP's guideline committee laid an egg.

The ACP's appraisal of the evidence on screening with the prostate-specific antigen (PSA) test was remarkably similar to the U.S. Preventive Services Task Force's assessment: harms of the test outweigh benefits. The ACP recommended that clinicians inform men between the age of 50 and 69 years of the rationale behind this conclusion, and provide a helpful, if overly extensive, list of "talking points with patients" which seem designed to discourage men from getting the test. All well and good. But what about men who absorb all of this information and still want to get screened? Well, the ACP says, go ahead and give them the test.

In what other area of medicine are physicians explicitly instructed to provide interventions that are judged do more harm than good because patients request them? To use a counter example, the vast majority of upper respiratory infections are due to viruses. Nonetheless, many of my patients request antibiotics. Antibiotics may benefit individual patients with upper respiratory infections in exceedingly rare cases, but on a population level clearly do more harm than good - leading, for example, to diarrhea, allergic reactions, and increasing bacterial resistance. But what if, after I finish patiently explaining all of these facts, the patient still "expresses a clear preference" for an ineffective and potentially harmful antibiotic prescription? Should I then go ahead and prescribe it? If I applied the ACP's approach to PSA screening, the answer would be yes.

In a thoughtful commentary published this week in JAMA Internal Medicine, L.A. County Department of Health Services Director Mitchell Katz asks the obvious question:

First, when as a profession did we decide that we had an ethical obligation to offer interventions that cause more harm than good? When we offer an intervention that is on the whole detrimental, are we not sending our patients a mixed message? Presumably there are any number of interventions that cause more harm than good. Should we be offering our patients a menu of ineffective interventions on the idea that they are better able than we are to determine effectiveness?

The ACP's guidance statement on PSA screening is even more perplexing when viewed in the context of the organization's participation in laudable efforts to prevent unnecessary or harmful medical care, including the High Value Care Initiative and the Choosing Wisely campaign. The success of these campaigns will depend on the ability of individual physicians and health systems to reduce waste and refocus resources on care that is most likely to benefit patients. Dr. Katz goes on to recount a conversation with a colleague about the hypothetical elimination of PSA screening tests in his health system:

If I cannot eliminate PSA testing, for which there is a USPSTF conclusion that the test cannot be recommended for men of any age, what is the likelihood that I could eliminate any low-value test, given that most things are not so well studied with such clear expert advice? ... Much of why the US health care system is so expensive for the benefits we gain is because we do not treat it like a system. If a new test or treatment is approved, we increase premiums to pay for it. Although we are slowly incorporating cost-effectiveness data into medical choices, especially when choosing among drugs used for the same indication or among diagnostic algorithms for evaluating a particular symptom, there is little dialogue about how to divert money from low-value care to higher-value care.

Good guideline recommendations must be concordant with the evidence upon which they are based. I may disagree vehemently with the American Urological Association about the value of PSA screening, but to their credit, their 2009 guideline at least interpreted the evidence as supporting a net benefit from the test. But to conclude, as the ACP did, that the PSA test causes more harm than good to patients, but allow physicians to provide it anyway, is nonsense. It is a huge step backward from high-value care. It is Choosing Unwisely. It is, in my opinion, the worst kind of guideline.

How to find good health information online

A recent survey found that 60 percent of adults have gone online at least once in the past year to look up health information. Unfortunately, finding high-quality health websites is a challenge. Several years ago, a review of 79 studies published in the Journal of the American Medical Association concluded that online health information for consumers is frequently flawed, inaccurate, or biased. Based on my experience, the situation isn't any better today.

Why do some health websites contain misleading information? One reason is that the group or organization running the site may have a hidden agenda. Drug companies often create consumer demand for expensive new drugs by financing groups that promote awareness of a previously unrecognized health condition, a sales tactic known as "disease mongering." (For example, Dartmouth Medical School researchers have argued that restless leg syndrome became a disease only when a drug was developed to treat it.) Unfortunately, a study published in 2011 in the American Journal of Public Health found that most health advocacy groups that receive drug-company funding don't disclose that on their websites.

Another reason that websites may contain misinformation is that some groups willfully disregard scientific evidence to promote certain health beliefs. For example, even though the U.S. Institute of Medicine found in 2004, after an exhaustive review of the medical literature, that there is no relationship between childhood vaccines and autism, it's easy to find websites that claim otherwise. Similarly, although most researchers have concluded that Morgellons disease—a bizarre skin condition that sufferers believe to be caused by an undiagnosed parasitic infestation—is likely to be a psychiatric delusional disorder, you wouldn't know it by simply Googling "Morgellons."

Because advising my patients to make an appointment every time they have a health-related question isn't a practical solution, I refer them to websites that I trust or that have been certified by an independent, quality rating organization such as the Health on the Net Foundation. This organization's search engine only retrieves results from websites that have agreed to provide objective, scientifically sound information. One such website—Healthfinder.gov, which is a clearinghouse on a variety of general health topics— links to the latest health headlines, and provides interactive health tools that give personalized advice about screening tests and other preventive health issues. Content on Healthfinder.gov is periodically reviewed by U.S. government health experts to assure its accuracy and consistency with results from the latest scientific studies.

When I want to give patients a handout about the basics of a preventive test or newly diagnosed health condition, I turn to FamilyDoctor.org, a nonprofit website supported by the American Academy of Family Physicians. (Full disclosure: I edit a medical journal that is the source of many of these handouts.) One such handout advises that patients ask themselves three questions about every health-related website they visit:

1. Where did this information come from?
2. How current is this information?
3. Who is responsible for the content on this website?

As powerful a tool as the Internet can be in giving people access to health information, it is only a starting point. With few exceptions (for example, management of the common cold), patients should never use online information to self-diagnose or treat a medical problem. However, I believe that patients who visit high-quality health websites are usually better-informed and more capable of making complex choices, such as whether or not to get a screening test for cancer. And in my opinion, that's a good thing.

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The above post was first published on my Healthcare Headaches blog at USNews.com in June, 2011.

Politics and practice guidelines: a volatile mix

Health services research in the United States has historically been the "poor cousin" of biomedical research in federal funding and support. The annual budget for the National Institutes of Health, for example, is typically around 100 times that of the Agency for Healthcare Research and Quality (AHRQ). In last month's Georgetown University Health Policy seminar, we discussed the financial and political challenges that AHRQ and its predecessor, the Agency for Health Care Policy and Research (AHCPR) have faced while trying to improve outcomes and effectiveness of medical care since the latter's founding during the first Bush Administration.

Citing John Wennberg's pioneering geographic analyses of medical practice variations and potentially inappropriate use of health services across the U.S., AHCPR's supporters wanted the new agency to produce practice guidelines to promote evidence-based care. However, when one of those guidelines suggested that spinal fusion surgery was unnecessary for most patients with acute low back pain, AHCPR found its budget under attack. It didn't help that the agency was also identified with the failed Clinton health reform plan and had few defenders left in a Republican Congress after the 1994 elections. Although the agency survived, this experience eventually drove it out of the guideline-producing business for good. When AHRQ was reauthorized in 1999, the word "policy" was removed from its name.

From 2010 AHRQ Annual Conference presentation by Dr. Francis Chesley, Jr.

It's understandable that this episode made future AHRQ leaders reluctant to wade into explosive scientific controversies, especially regarding sacred cows of medicine such as mammography and prostate cancer screening. When the AHRQ-supported U.S. Preventive Services Task Force chose to do so, the political fallout again put the agency in an uncomfortable position. Distancing itself from the USPSTF's recommendation against routine mammography in women younger than 50 and repeatedly delaying the release of another that advised clinicians to stop prostate-specific antigen testing altogether, AHRQ still found itself under heavy fire from health reform opponents on Capitol Hill. In July 2012, it was deja-vu all over again as AHRQ's budget was singled out for elimination by an appropriations subcommittee in the House of Representatives. Supporters of health services research in the U.S. lined up to defend the agency. The bill was not taken up by the Senate, and of this writing, AHRQ appears to have survived another "near death experience."

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The above post first appeared on The Health Policy Exchange. Note: I was employed as a medical officer at AHRQ from October 2006 through December 2010.

Book Review: Fractured

Here are a few excerpts from my less-than-enthusiastic review of Fractured: America's Broken Health Care System and What We Must Do To Heal It, by Dr. Ted Epperly, which appears in the April 2013 issue of Family Medicine.

The book’s chapters on historical health reform efforts in the United States and comparisons to the health care systems of other countries are two of the most lucid that I’ve read. Entire volumes have been written on each of these topics, which the author manages to boil down to just over 50 pages of succinct text supported by a series of informative tables and figures. In one particularly strong passage, the book explains how the United States is effectively divided into the imaginary countries of “Richland” and “Poorland,” separated not only by enormous gaps in income but also life expectancy, out-of-pocket health spending, and access to primary and specialty care services.

By comparison, the chapter that explains “why America struggles with health care for all” is a confusing recitation of pro-ACA talking points. ... After assuring readers in the first chapter that his goal “is not to take one political side or another,” the author then proceeds to do exactly that. ... Aside from a passing mention in the first chapter, the book provides no sense of Dr Epperly’s presumably positive experiences as a military physician. A few representative patient anecdotes could have gone a long way toward distinguishing Fractured from the ever expanding library of tomes written by health policy wonks without the clinical experience of a family physician. As the director of a health policy fellowship program for family physicians, I would be unlikely to include this book on a required reading list.

You can also go to the Family Medicine website to read the full review.