The best recent posts you may have missed

Every other month or so, 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 March, April, and May:

1) The future of medicine is low-tech and high-touch (5/8/13)

2) Preventive health advice for the new Pope (3/14/13)

3) Breast cancer and the Angelina Jolie effect (5/15/13)

4) Medicaid expansion is in the eye of the beholder (5/12/13)

5) The worst kind of [prostate cancer screening] guideline (4/18/13)

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

How do family physicians provide cost-effective care?

Research studies have documented strong associations between U.S. primary care physician supply, better population health outcomes, and lower health care spending. Among adult primary care specialties, national survey data suggest that family physicians provide more cost-effective care. However, little research has examined how family physicians provide effective care at lower cost than other physicians. Is it because we are more likely to follow evidence-based guidelines? Order fewer inappropriate imaging tests? Are less likely to offer non-beneficial tests and treatments?

In the May issue of Family Medicine, Dr. Richard Young and colleagues reported a qualitative analysis of interviews with 38 Texas family physicians about decision-making practices that may contribute to delivery of cost-effective care. Participants provided examples of experiences that they felt exemplified differences in the ways they approached patients compared to approaches of less cost-effective specialists. Two major themes emerged from these interviews: 1) cost-effective care is an inherent value in family medicine; 2) knowledge of the whole patient through continuous relationships enabled efficient decision-making.

Family physicians in this study emphasized the importance of the history and physical examination, conservative testing strategies in low-risk patients, being comfortable with managing complexity, and assigning less importance to "making the diagnosis" than relieving patients' symptoms. Physicians were also attuned to potential behavioral causes of physical symptoms and placed considerable weight on financial and medical harms that could result from aggressive care.

As the authors point out, these findings are limited by the relatively small number of participants, who may or may not represent the general attitudes of family physicians in other areas of the U.S. Do you think that Dr. Young and colleagues identified all of the important ways that family physicians provide cost-effective care? If not, what other factors would you add from your own patient care experiences?

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The above post was first published on the AFP Community Blog.

Vitamin D screening: few pros, many cons

The U.S. Preventive Services Task Force recently announced its intent to review the evidence and issue recommendations about screening for vitamin D deficiency, after finding insufficient evidence to recommend routine supplementation for the prevention of fractures in adults. According to a 2009 review published in American Family Physician, up to half of U.S. adults 65 years and older have inadequate vitamin D levels, which places them at increased risk of falls and fractures. Two editorials in the April 15th issue of AFP debate the pros and cons of screening for vitamin D deficiency in asymptomatic persons.

Dr. Leigh Eck makes the case for targeted screening for vitamin D deficiency in at-risk populations, which include, but are not limited to, persons with malabsorption syndromes, persons with chronic kidney disease, pregnant and lactating women, and older persons with a history of falls. "Most of these factors put patients at risk of osteoporosis," Dr. Eck argues. "Given the role of vitamin D in bone mineralization, patients who are at risk of or who have osteoporosis should be considered as candidates for vitamin D screening."

On the other hand, Dr. Colin Kopes-Kerr identifies several problems with measurement of serum vitamin D levels in asymptomatic persons, regardless of risk level: lack of test standardization; disagreement about what constitutes a "normal" vitamin D level; unclear treatment implications; and uncertain cost-effectiveness. Finally, he points out, "No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone."

The Endocrine Society recommends against population-based screening for vitamin D deficiency, and the American Society for Clinical Pathology included this screening test in its list of "Five Things Physicians and Patients Should Question" for the Choosing Wisely campaign.

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The above post was first published on the AFP Community Blog.

Breast cancer and the Angelina Jolie effect

There is nothing like a celebrity to call attention to a preventable disease, especially if that disease is cancer. In March 2000, then-Today Show host Katie Couric, whose husband Jay Monahan died of colorectal cancer in 1998, underwent a live colonoscopy to promote uptake of colorectal cancer screening. Over the next 9 months, national colonoscopy utilization rates rose by 20 percent, a phenomenon that researchers dubbed "The Katie Couric effect." A decade later, a National Institutes of Health conference on enhancing use and quality of colorectal cancer screening identified few strategies that were as effective as this single celebrity endorsement at increasing appropriate use of screening.

Although many people undoubtedly benefited from the Katie Couric effect, one thing about it troubled me: at the time of her colonoscopy, Couric was only 43 years old. No major medical organization recommends that colorectal cancer screening start before age 50, absent certain risk factors (African American race or a first-degree relative diagnosed with colorectal cancer before age 60). The Katie Couric effect increased appropriate cancer screening, but probably promoted a lot of inappropriate screening too. For example. a 2005 Veterans Health Administration study found that one-third of fecal occult blood tests performed for colorectal cancer screening purposes were unnecessary, since they were performed in patients who were too young, too severely ill to benefit, or were within 5 years of a negative colonoscopy. Screening colonoscopy is also being performed too early and too often. Though the recommended repeat screening interval after a negative colonoscopy is 10 years, 1 in 4 Medicare patients underwent a repeat colonoscopy within 7 years without a medical indication. This isn't to say that only patients are responsible for excessive screening - doctors are certainly to blame, too.

Yesterday, the actress Angelina Jolie revealed in a New York Times Op-Ed that she had recently undergone a preventive double mastectomy after learning that she carried the BRCA1 gene, which increases a woman's lifetime risk for breast and ovarian cancer severalfold. Explaining why she chose to go public with this very personal decision, she wrote:

Cancer is still a word that strikes fear into people’s hearts, producing a deep sense of powerlessness. But today it is possible to find out through a blood test whether you are highly susceptible to breast and ovarian cancer, and then take action. ... I choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.

Will the Angelina Jolie effect turn out to be a spike in the rates of women being tested for the mutations in their BRCA genes? If so, it's likely that many more women will be harmed than helped. BRCA mutations are rare, affecting 2 to 3 per 1000 women. The vast majority of women who develop breast cancer do not carry these mutations and will not benefit from testing. Since the BRCA mutation test is costly, challenging to interpret, and likely to be positive only in women with a very strong family history of breast or ovarian cancer, the U.S. Preventive Services Task Force discourages routine genetic counseling or BRCA testing in most women. For women without Ashkenazi Jewish heritage, a "very strong family history" generally means a minimum of two affected first-degree relatives, three affected second-degree relatives (cousins don't count), a relative with bilateral breast cancer, a relative with breast and ovarian cancer, or a male relative with breast cancer. A patient with a family history that suggests a possible BRCA mutation should consult her family physician, complete a validated risk stratification tool, and receive genetic counseling from a trained professional before deciding to undergo testing. (It's unclear if Jolie's family history of cancer warranted BRCA testing - although she only mentions her mother in the Op-Ed, it is possible that other family members had breast or ovarian cancer also.)

Ample evidence indicates that most women overestimate both their personal risk of developing breast cancer and the potential benefits of screening, driven in part by well-intentioned advocacy campaigns to raise "cancer awareness." A recent New York Times Magazine article reviewed how these efforts can backfire, by exaggerating the modest benefits of screening and downplaying common psychological and physical harms of false positives and overdiagnosis.

This isn't to say that Jolie was wrong to speak out on behalf of women with BRCA mutations; patients who suffer from rare diseases suffer all the same. What we need to take away from this story - and what I encourage fellow physicians, journalists, and public health professionals to emphasize in communicating with patients about The Angelina Effect - is that screening for hereditary breast and ovarian cancer is beneficial only in very specific situations. Outside of these situations, screening is bad medicine, pure and simple.

Medicaid expansion is in the eye of the beholder

To supporters of the Affordable Care Act, legislative expansion of the Medicaid program is a welcome financial and health care bonanza for states and uninsured patients. To the ACA's detractors, Medicaid expansion is a hostile government takeover that must be opposed in principle, regardless of potential benefits of an infusion of federal dollars. The stage for these state-level clashes was set by a surprising Supreme Court decision last summer that upheld most major provisions of the Affordable Care Act, but declared unconstitutional the mandatory Medicaid eligibility expansion that the law's authors had expected would extend coverage to millions of currently uninsured Americans. Instead, the Court gave individual states the option to accept or decline the expansion, which, though far more generous with federal matching funds than the existing program, would still require states to spend more within already strapped budgets.

Medicaid Expansion map courtesy of Avalere Health via The Washington Post Wonkblog 5/5/13

In last month's Georgetown University Health Policy seminar, we discussed the complex role of the Medicaid state-federal partnership (which currently provides health insurance to 1 in every 5 Americans) in improving access to care and health outcomes. In fiscal year 2011, Medicaid spending totaled $414 billion, with two-thirds going to services for disabled elderly persons. Long-term care services (nursing homes, mental health, home health care) accounted for 3 in every 10 dollars that the program spent.

Currently, to qualify for Medicaid coverage, individuals must be not only poor, but belong to one of several "core eligibility groups" defined by federal law: children, pregnant women, people with disabilities, seniors, and adults with dependent children. Income thresholds vary widely across states, especially for working parents, who might find themselves eligible for coverage in more generous states but not in others. Few states provide significant coverage for non-disabled adults without dependent children, whose services were generally excluded from federal matching funds prior to the ACA.

In 2014, states that accept the ACA's Medicaid expansion will be required to extend eligibility to all adults (parents or not) earning less than or equal to 138 percent of the federal poverty level, which works out to annual incomes of $15,856 for an individual and $26,951 for a family of three. According to the Kaiser Family Foundation, more than half of today's 48 million uninsured have incomes below the new Medicaid threshold. In states that decline Medicaid expansion, there appear to be few feasible alternatives to leaving these persons without affordable coverage, except for those earning more than 100 percent of the federal poverty level who may be able to purchase subsidized private plans in state or federal health insurance exchanges. For example, in Florida, whose legislature rejected the Medicaid expansion against the wishes of Republican governor Rick Scott, only one quarter of the 1.3 million low-income residents who would have been covered by the expansion will be eligible for tax subsidies toward private coverage in the federal insurance exchange.

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The above post first appeared on The Health Policy Exchange.

The future of medicine is low-tech and high-touch

Last month, one of my students told me about his experience at TEDMED, the future-oriented medical conference that bills itself as "a celebration of human achievement and the power of connecting the unconnected in creative ways to change our world in health and medicine." He recounted how one speaker showed off the Remote Presence Virtual + Independent Telemedicine Assistant, which news outlets quickly dubbed the "Robo-Doc." This high-priced gadget is designed to provide remote medical services to patients who wouldn't otherwise be able to see real-life doctors, but my student told me that the presentation didn't talk about that much. Instead, he felt, the speaker's message seemed to be: "Robots are cool, so let's make more of them."

Along similar lines, a recent TEDMED blog post on the smartphone physical describes how a team led by an enterprising Johns Hopkins University medical student created a virtual "checkup" from a combination of smartphone-powered devices. These devices measure standard physical examination parameters such as body mass index, blood pressure, and visual acuity; and less routine tests such as oxygen saturation, electrocardiography, lung function testing, and carotid artery visualization. In addition to collecting far more data than the traditional checkup, the smartphone physical touts the advantage of using devices that are "smaller and less invasive" - no more "fumbling" to take a patient's blood pressure, for example. One commenter gushed, "Getting a smart phone physical was so fun. I got an EKG and an ultrasound of my carotids in under three minutes." So what's not to like?

I'm hardly a Luddite when it comes to adopting the latest in medical technologies, including electronic health records and smartphone apps. But I think it's worth asking how likely it is that high-tech innovations such as robo-docs and smartphone physicals will actually improve patients' health outcomes. For the latter, the answer is not likely at all. A comprehensive review of the evidence on traditional checkups in adults found that they increase the number of diagnoses per patient, but have no effects on hospitalization, disability, worry, absence from work, morbidity, or mortality. Based on other systematic reviews, the U.S. Preventive Services Task Force recommends against doing EKGs, spirometry, or carotid artery ultrasound in healthy adults because the harms of these screening tests outweigh any benefits. False positive results on that 3-minute EKG and ultrasound may lead to an unstoppable cascade of costly cardiovascular stress testing and invasive coronary or carotid angiograms, which can cause serious adverse effects.

If you really want to see the future of medicine, skip TEDMED and head over to Camden, New Jersey, where a family physician named Jeffrey Brenner showed that providing intensive primary care to patients with the most complex illnesses dramatically improved disease outcomes, quality of life, and health care costs. Then hit the road for Lancaster, Pennsylvania, where a similar program empowers "super-utilizer" patients to take control of their health care by providing them with comprehensive, multi-disciplinary case management and social support. On your way, stop by Health Quality Partners in Doylestown, PA, which has improved outcomes and reduced hospitalizations and costs for the sickest Medicare patients through the revolutionary innovation of - wait for it - regular nurse home visits. Here's what Dr. Brenner told Washington Post Wonkblog columnist Ezra Klein when asked what he thought of the Doylestown program:

"There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you’d say, ‘Of course I want that.’ But then you’d say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you’d say, no, you just have to have a nurse come visit her every week."

Later in the column, Klein reflects:

We’ve been conditioned by “Grey’s Anatomy” and hospital rooms to believe that saving lives is a complicated, heroic business. And it is — after people get very sick. But keeping them from getting very sick doesn’t necessarily require the discovery of new molecules. It requires someone who has a relationship with them to stop by once a week to see how they’re doing. The problem is, it’s hard to make money off it.

Pop culture and perverse financial incentives inherent in fee-for-service payment reinforce a bias for health care services that are high-tech and low-touch. Yes, robots and smartphones can and will play vital roles in the future of medicine. But if we really want sick patients to have the best chance to get better - and healthy patients to avoid getting sick in the first place - then we should do everything in our power to support low-tech and high-touch interventions too. A logical first step would be for Medicare decision-makers (this means you, Marilyn Tavenner) to reconsider their short-sighted decision to cut off funding for the Health Quality Partners program in June.

Public Speaking Update

Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.com, The Health Care Blog, and Gary Schwitzer's HealthNewsReview, as well as the websites of major national newspapers such as the New York Times, the Wall Street Journal, USA Today, and the Boston Globe. I also wrote the consumer health blog Healthcare Headaches for U.S. News and World Report from August 2010 through September 2011.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.

Past events:

Thinking Like An Editor
- Society of Teachers of Family Medicine Annual Spring Conference, Baltimore, MD

Politics of HIV Testing
- Georgetown University School of Medicine

Burnout Prevention for Healthcare Professionals
- Teaching Prevention 2013, Washington, DC

Evidence-Based Literature Searching: A Primer
- National Capital Consortium Family Medicine Residency, Fort Belvoir, VA

Policy and Funding for Preventive Care Programs
- Georgetown University Health Systems, Policy, and Public Health Elective

Less is More: New Approaches to Cancer Screening in Primary Care
- Primary Care Coalition of Montgomery County, Maryland

2012

Science and Public Policy in Conflict: PSA Screening
- Johns Hopkins University Bloomberg School of Public Health Fall Policy Seminar

Screening Mammography for Women in their 40s: Exploring the Controversy
- National Capital Area Regional Breast Healthcare Improvement Initiative

Why You Should Stop Screening Patients for Prostate Cancer
- Ephrata Community Hospital (PA)

Identifying and Using Good Practice Guidelines
- Temple University School of Medicine 2012 Family Practice Review Course

2011

Cancer Screening: A Primer for Journalists
- National Press Foundation's Cancer Issues 2011

What to Do When Screening Guidelines Conflict: HIV and Mammography
- Grand Rounds, Georgetown University Department of Family Medicine

Overdiagnosed: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health

For Geeks and Geezers: With Social Media Skills You Can Change the World
- Family Medicine Education Consortium Northeast Region Meeting

Screening for Diabetes: What Does the Evidence Say?
- Spanish Catholic Center of Catholic Charities of Washington, DC

Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians

Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Library Association Annual Meeting

2008 - 2010

Medical Blogging and Other Professional Uses of Social Media
- Grand Rounds, Virginia Commonwealth University Internal Medicine

Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine Annual Meeting

COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians