Wednesday, January 30, 2013

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 December and January:

1) False alarms and unrealistic expectations in preventive care (12/22/12)

2) Overdiagnosis and the epidemic of snipers on rooftops (1/2/13)

3) Too much medical care: do we know it when we see it? (1/21/13)

4) Yes, family medicine is an affordable career choice (12/4/12)

5) Cancer epidemiology 101 for urologists (and others) (12/12/12)

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

Thursday, January 24, 2013

The staggering costs of too much medical care

Although I intentionally didn't mention financial costs in my previous post on too much medical care, informed readers might wonder if my specialized glaucoma testing was covered by health insurance (it was), and if any provisions of the Affordable Care Act restrict use of non-beneficial or low-value screening tests (it doesn't, despite plenty of political noise to the contrary). The Institute of Medicine recently estimated that $765 billion of the $2.5 trillion the U.S. spends on health care services is wasted, with more than half of that total ($400 billion) lost in providing unnecessary services and excessive administrative costs.

Too much medical care drains dollars away from other programs and services that produce health and happiness. In an illustrative thought exercise, researchers in the American Journal of Preventive Medicine suggested how the $337 billion in excessive healthcare costs that are currently paid by public insurance programs might be otherwise saved or spent as a "health dividend for America." (If the video is slow to load, you can also view it here.)

Dr. Jeffrey McCullough and colleagues propose devoting half ($168 billion) of the health dividend to federal debt reduction (which, they point out, is more than the goal of $1.5 trillion over 10 years that the Congressional "Supercommittee" failed to achieve in 2011 budget negotiations); $104 billion to education initiatives such as smaller classrooms, anti-smoking programs, and universal preschool education; and $61 billion to infrastructure such as public library expansions, career training, and transportation upgrades.

The point isn't that you or I necessarily agree with these specific choices - one might decide to devote every penny saved from eliminating medical waste to debt reduction or tax cuts, for example - but that reducing too much medical care leads to true savings, rather than simply shifting public spending to the private sector (by raising the Medicare eligibility age or cutting Medicaid payments).

Monday, January 21, 2013

Too much medical care: do we know it when we see it?

The year after I moved to Washington, DC, I visited an ophthalmologist for a routine vision examination and prescription for new glasses. Since undergoing two surgical procedures to correct a "lazy eye" as a child, I hadn't had any issues with my eyesight. Part of my examination included measurement of intraocular pressures, a test used to screen for glaucoma. Although my work for the U.S. Preventive Services Task Force was in the future, I already understood the lack of evidence to support performing this test in a young adult at low risk. Not wanting to be a difficult patient, though, I went along with it.

My intraocular pressures were completely normal. However, the ophthalmologist saw something else on her examination that she interpreted as a possible early sign of glaucoma, and recommended that I undergo more elaborate testing at a subsequent appointment, which I did a couple of weeks later. The next visit included taking many photographs of my eyes as I tracked objects across a computer screen, as well as additional measurements of my intraocular pressures. These tests weren't painful or very uncomfortable, but they made me anxious. Glaucoma can lead to blindness. Was it possible that I was affected, even though no one in my family had ever been diagnosed with this condition? Fortunately, the second ophthalmologist who reviewed my results reassured me that the tests were normal, and admitted had probably been overkill in the first place. "Dr. X [the first ophthalmologist] is a specialist in glaucoma," he said, by way of explanation. "Sometimes we tend to look a little too hard for the things we've been trained to see." (I appreciated his candor, and he has been my eye doctor ever since.)

I was reminded of this personal medical episode while reading a recent commentary on low-value medical care in JAMA Internal Medicine by Craig Umscheid, a physician who underwent a brain MRI after questionable findings on a routine vision examination suggested the remote possibility of multiple sclerosis, despite the absence of symptoms. Although Dr. Umscheid recognized that this expensive and anxiety-inducing test was low-value, if not worthless, he went along with it anyway. "Despite my own medical and epidemiologic training," he wrote, "it was difficult to resist his [ophthalmologist's] advice. As my physician, his decision making was important to me. I trusted his instincts and experience."

If physicians such as Dr. Umscheid and I didn't object to receiving what we recognized as too much medical care when we saw it, it should not be a surprise that, according to one study, many inappropriate tests and treatments are being provided more often, not less. 5.7% of men age 75 and older received prostate cancer screening in 2009, compared to 3.5% in 1999. 38% of adults received a complete blood count at a general medical examination in 2009, compared to 22% in 1999. 40% of adults were prescribed an antibiotic for an upper respiratory infection in 2009, compared to 38% in 1999. (If you usually have blood counts done at your physicals or swear by the Z-PAK to cure your common cold, we can discuss offline why both of these are bad ideas.)

One of the obstacles to reducing unnecessary medical care (also termed "overuse") is that outside of a limited set of tests and procedures, physicians and policymakers may disagree about when care is going too far. The American Board of Internal Medicine Foundation's Choosing Wisely initiative is a good start, but these lists consist of low-hanging fruit accompanied by caveats such as "low risk," "low clinical suspicion," "non-specific pain." To a clinician who feels for whatever reason that a certain non-recommended test or treatment is needed for his patient, these qualifications amount to get-out-of-jail free cards. It's easy to say that payers should just stop paying for inappropriate and potentially harmful medical care, but as a recent analysis from the Robert Wood Johnson Foundation explains, this is much easier said than done. If a panel of specialists convened to review the medical care that Dr. Umscheid and I received, would they unanimously deem it to have been too much? I'm doubtful.

Similarly, although endoscopy for uncomplicated gastroesophageal reflux disease is widely considered to be unnecessary, that didn't stop an experienced health services researcher from undergoing this low-value procedure after a few days of worsening heartburn. Comparing her personal experience to the (superior) decision-making processes that occur in veterinary medicine, Dr. Nancy Kressin wrote in JAMA:

Until patients are educated and emboldened to question the value of further testing, and until human health care clinicians include discussions of value with their diagnostic recommendations, it is hard to foresee how we can make similar progress in human medicine. Patients may be fearful that there is something seriously wrong that needs to be identified as soon as possible, they are often deferential to their clinicians' greater knowledge of the (potentially scary) possibilities, and some patients want to be sure that everything possible is done for them, without recognizing the potential harms of diagnostic tests themselves, the risks of overdiagnosis, or the sometimes limited value in knowing the cause of symptoms in determining the course of therapy.

Regardless of future insurance payment reforms, both doctors and patients will have key roles to play in recognizing when medical care is too much. More widespread uptake of shared decision-making, while hardly a panacea, would call attention to the importance of aligning care with patients' preferences and values and the need for decision aids that illustrate benefits and harms of often-overrated interventions. Changing a medical and popular culture that overvalues screening tests relative to their proven benefits may be more challenging. A survey study published last month in PLOS One affirmed previous findings that patients are far more enthusiastic and less skeptical about testing and screening than they are about medication, even though the harms of the former are often no less than the latter. I agree with the authors' conclusions:

Efforts to address overuse must involve professional medical associations, hospital systems, payers, and medical schools in modifying fee-for-service payment systems, enabling better coordination of care, and integrating lessons about overuse into training and continuing education. But the preferences of active patients nonetheless merit attention. Both the mistrust of pharmaceuticals and the enthusiasm for testing and screening reflect individuals’ efforts to take care of their health. The challenge is to engage patients in understanding the connection between over-testing and over-treatment, to see both as detrimental to their health, and to actively choose to do less.

Friday, January 18, 2013

Conflicting views on the need for more family physicians

Researchers at the American Academy of Family Physicians' Robert Graham Center (which produces the Policy One-Pagers series for American Family Physician) recently predicted in the Annals of Family Medicine that a combination of population growth, aging, and insurance expansion from the Affordable Care Act will create the need for an additional 52,000 primary care physicians by the year 2025 - an increase of nearly 25 percent over the current workforce. Since the vast majority of internal medicine residents plan to pursue subspecialty rather than generalist careers, family medicine will be called on to supply the bulk of this looming gap in physician supply and demand. Recent efforts to increase the supply of family physicians include emphasizing community-based clinical training in medical school and temporarily increasing Medicaid and Medicare primary care fees.

Another strategy for bolstering the family medicine pipeline, contained in the Affordable Care Act, is mandating redistribution of unused residency positions to primary care programs. Unfortunately, an analysis published this month in Health Affairs concluded that a similar Medicare graduate medical education reform in 2005 not only failed to significantly boost primary care, but actually resulted in training twice as many new subspecialists. Dr. Candace Chen and colleagues conclude:

Our findings suggest that redistribution [of unused residency positions] largely supported hospitals in growing their specialty training. Some hospitals even converted primary care positions to specialty positions after receiving newly redistributed positions. ... This shifting collectively perpetuates the nation's physician workforce maldistribution, and our analysis demonstrates that Medicare continues to support these hospitals and even increases its support for them, regardless of the specialty mix of residents trained.

Not everyone agrees that meeting the future health needs of the U.S. population will require a massive influx of family physicians, however. Other researchers have argued that the widespread adoption of team-based care, "advanced access" scheduling, and replacing some in-person with electronic visits could provide enough new patient capacity to prevent a family physician shortage. Still, much uncertainty surrounds this and other projections. What steps is your doctor's practice taking, if any, to meet the anticipated needs of so many new patients? Hiring more physicians? Re-designing how they provide care? Please feel free to share your thoughts and stories.


The above post first appeared on the AFP Community Blog.

Monday, January 7, 2013

How long does a cough last? (longer than you'd think)

At December's annual meeting of the North American Primary Care Research Group (NAPCRG), fellow American Family Physician editor Mark Ebell, MD, MS presented the findings from a study that provided an original take a seemingly simple question: how long does a cough last? This study compared patient expectations with a systematic review of the medical literature.

Dr. Ebell's team surveyed a sample of patients and consulted "Dr. Google" to determine public perceptions of how long a cough from an acute upper respiratory infection is supposed to last. Although estimates varied, the most common answer was one to two weeks. His team then proceeded to review the medical literature for studies of the natural history of acute cough, using the control groups from randomized trials testing an intervention such as an antibiotic. The weighted mean duration of cough in these patients was actually 17.8 days.

Since antibiotics are prescribed for at least 50 percent of patients who visit doctors for acute cough, Dr. Ebell suggested that the substantial discrepancy between patients' expectations and the actual duration of acute cough caused by respiratory infections may be a driver of excessive antibiotic prescribing. If more patients knew that a cough could normally last for two weeks or more, perhaps fewer of them would seek medical care for self-limited illness. (As one of my colleagues observed with a smile after hearing about Dr. Ebell's presentation, "Cough from acute bronchitis is expected to last for 2 weeks. With antibiotics, it only lasts 14 days.")

Update (1/15/13): this research study was just published in the January/February issue of Annals of Family Medicine.


A slightly different version of the above post first appeared in the AFP Community Blog.

Saturday, January 5, 2013

PSA testing: excerpts from a roundtable discussion

Last fall, the editor of the Journal of Lancaster General Hospital invited me to participate in a roundtable discussion of implications of recent evidence on the prostate-specific antigen (PSA) test. An edited transcript of that discussion appears as an article in the Winter 2012 issue of the journal. Thanks to oncologist Randall Oyer, MD and urologist Paul Sieber, MD for a valuable and insightful discussion. Read the whole article, if you can; key excerpts from my side of the transcript are included below.

On the conflicting PLCO and ERSPC randomized trials of PSA-based screening:

I think a lot of people in the urology community sort of dismissed the PLCO and said it was hopelessly contaminated and we should just pay attention to the ERSPC; conversely, there might be people saying “we should only pay attention to the PLCO because it is the U.S. study.” I think both studies have things to tell us, and the truth is somewhere in between.

It’s important to emphasize that in the PLCO study, the “contamination” caused by opportunistic screening in the control group would have narrowed any apparent differences between the controls and the study group, and would have minimized any apparent benefit in the study group. Also, “contamination” would not cause what the PLCO continues to show, namely that there seems to be more harm from the screening than good. Furthermore, you would think that even if “contamination” made the benefit seem smaller than it really is, if you followed the groups long enough any real benefit would show up. But that hasn’t happened.

With the ERSPC, there are concerns about the variation among individual countries in the trial. A few had very impressive results while several of the others didn’t show a statistically significant benefit. The variation is problematic because, at least in the Goteborg Sweden portion of the ERSPC, which was published separately because its results were so impressive, men in the group assigned to screening were – for obscure reasons – more likely [than those in the control group who were diagnosed with prostate cancer] to get their treatment from university centers. That doesn’t necessarily mean they got better care, but it is a little bit problematic.

On the intersection of lead-time bias and clinical experience:

The observation that the practice of urologists has changed is obviously not something we can experience as primary care physicians, but their experience of seeing more men with treatable cancers can be misleading in that overall we are diagnosing more men with prostate cancer than we did before. Many of these are men who never would have found out they had prostate cancer. It is estimated that up to 50% of men in the ERSPC study were over-diagnosed in that their prostate cancer probably would not have presented in their lifetime. So it dilutes the groups because you are adding a lot of men who thought they were healthy, but as a result of the screening they have been diagnosed with prostate cancer. We treat the prostate cancer and feel good about it because these men do well, but maybe they would have done well anyway.

On the challenges of measuring morbidity in prostate cancer:

Morbidity is important but it is very, very hard to measure in an unbiased way in a screening trial. We actually looked for that information in 2008; we discussed a center in the ERSPC that tried to measure cancer metastases as an outcome and, in fact, showed that men in the control group were more likely to have metastatic prostate cancer than men in the screening group.

The problem is that it is hard to avoid bias when you are measuring that, because although for some men metastasis would present as bone pain, and then you would do appropriate diagnostic studies to confirm the diagnosis, for others the reason they had a metastasis discovered was because their physician knew they had prostate cancer and then ordered a bone scan and found it, though the patient didn’t have any symptoms. That would be more likely to occur in the screening group because they are the ones who are getting PSA tests, whereas in the control group you could have men walking around for some time who wouldn’t know that they had metastatic prostate cancer. So, I agree that if we could measure the morbidity it would be an important outcome, but it is very challenging to do that and be assured that we are not overweighting it on one side or the other.

On screening younger and "high risk" men (e.g., African Americans)

Young men have longer life expectancies, and theoretically would be more likely to benefit [from PSA screening], but I don’t think we know enough about the differences between the tumors that young men get versus the tumors that older men get. There was an intriguing finding in the ERSPC that men between 50 and 54 actually did not experience a decrease in mortality from prostate screening. Though that may have been an artifact of statistical power related to how many men were in that group, it does suggest that it may not be correct to automatically think that the younger the men are, the more likely they are to benefit.

We often tell African-American men and men with a family history, “you are at high risk and you should get screened.” The problem is that although they are indeed at higher risk, we are not certain that we can benefit them more by screening. Even though it sounds intuitive to say “well they are at higher risk, they should be targeted for screening," none of the trials have shown more benefit from screening in those patients than in the general population.

For physicians who don't want to abandon PSA screening:

I hope that, at a minimum, even if people don’t follow the [U.S. Preventive Services] Task Force recommendations and completely discontinue prostate screening, we will have improved the quality of discussions the patients are supposed to be having with their physicians about what their risk is, what outcomes they value, and what they are willing to endure to make sure that they don’t develop late stage prostate cancer.

Wednesday, January 2, 2013

Overdiagnosis and the epidemic of snipers on rooftops

An editorial by two oncologists in the New Year's issue of Annals of Internal Medicine discusses overdiagnosis, a controversial health problem that some have called "a modern epidemic" but others, including the editorialists, feel is a minor concern. Although many chronic conditions are overdiagnosed, cancer is the most thoroughly studied, as well as the most emotionally charged.

I am a generally healthy man with no family history of significant health problems. Yet increasing numbers of men like me who are approaching middle age may be shadowed by a sniper on a rooftop, each armed with a highly accurate loaded rifle pointed directly at our heads. By age 70, nearly half of all men will be shadowed by a sniper, though in only 3 percent of us will he actually take the fatal shot. A 1 in 30 chance of being assassinated without warning still seems too high, and therefore health authorities concerned about the problem of snipers on rooftops recommend that all men after age 50 (or perhaps 40) be offered routine surveillance to determine if there's a sniper up there. If there is, perhaps he can be safely disarmed.

The  trouble is, the disarmament team is successful at best, 21 percent of the time (reducing a man's chance of being shot from 3 percent to a barely more reassuring 2.4 percent), and at worst, hardly ever. In addition, attempts to subdue snipers by force often lead to unwanted consequences: stray shots fired in the scuffle that cause non-lethal but persistent injuries to the bladder and reproductive system. In about 1 in 300 men, the attempt to disarm the sniper goes terribly wrong, causing the gunshot to miss the head but deliver an equally fatal round through the heart.

Oncologists and others whose careers primarily consist of treating cancer argue that the true problem is not one of overdiagnosis but overtreatment, and that a more conservative approach to management (rather than less diagnosing) of indolent cancers will solve the problem. Let's not rush in to disarm all of the snipers, they say - instead, let's watch them for signs of aggressiveness and act later if necessary (termed "watchful waiting" or "active surveillance"). Men who choose this option live the rest of their lives with the anxiety-provoking knowledge that guns are pointed at their heads, however small the possibility of a shot. They and their physicians may become so obsessed with the sniper, constantly scanning the tops of tall buildings, that they forget to look both ways when crossing the street and succumb to some other preventable cause of death.

A reasonable objection to my analogy of the sniper on the rooftop is that unlike a bullet to the head, death from cancer is neither quick nor painless. By measuring deaths averted as a primary outcome, the argument continues, one minimizes the benefit of sparing patients the symptoms and treatment of metastatic disease (in other words, "there is more to life than death.") This argument only holds in cases when cancer was destined to progress enough to cause symptoms (not overdiagnosed). I don't discount it, having witnessed firsthand the suffering that metastatic prostate cancer inflicts on patients, but cancer is hardly unique in this regard. There is, unfortunately, a great deal of suffering involved in slow deaths from non-cancerous causes such as congestive heart failure, chronic obstructive pulmonary disease, multi-infarct or Alzheimer's dementia. To be worth the price of overdiagnosis, cancer screening should do more than replace one cause of death for another.

Back to the Annals editorial about overdiagnosis in breast cancer. The authors write:

We believe that the term "overdiagnosis" in the context of breast cancer places this problem in an inappropriate light, suggesting that these patients do not have cancer. The question is not whether we should find early, more easily treatable cases of breast cancer but rather how to treat early-stage cancer found on mammography. ... For the individual patient, the question is not whether to have a mammogram that might "overdiagnose" breast cancer but how to treat the early-diagnosed non-invasive or invasive breast cancer once we have found it.

Essentially, this boils down to: overdiagnosis be damned, let's find all of the cancers we can, and then worry about what to do about them later. (Let's find every single one of those snipers on the rooftops and then decide if and when they should be disarmed!) On the contrary, I believe that individual women (and men, in the case of prostate cancer) should be presented statistical information about overdiagnosis along with potential benefits and then offered a choice, rather than a default option. Some - perhaps most - women will choose to be screened, despite evidence that more than 3 in 10 breast cancers are overdiagnosed. Others will not. The latter should have their choices respected, rather than be harangued or fired.

Finally, I apologize to any of you who were offended by my explicit comparison of overdiagnosis to gun violence, given the recent tragedy that has drawn belated attention to the latter as a public health problem. Although not as immediately devastating or newsworthy, overdiagnosis is a formidable public health problem in its own right, an epidemic that has affected millions of men and women over the past few decades in cancer alone. It deserves attention, not dismissal, in the pages of major medical journals.