Stirring the (policy) pot: nutrition and dietary guidelines

At first glance, federal nutrition policy seemed to be an unusual topic for our Georgetown Health Policy Seminar for family physicians. As described in a recent JAMA Internal Medicine editorial, future doctors receive little formal instruction about healthy dietary habits. An accompanying commentary noted that to promote effective change, nutritional education in medical school should encompass much more than memorizing facts about biochemistry and metabolism:

Medical students and residents must also develop competence in the interpersonal and communication skills needed to counsel patients about behavior change and to perform motivational interviewing. ... They must learn to work in interprofessional teams with dietitians and other skilled health professionals to help patients make needed dietary changes. ... Just as medical students and residents must be taught to become antismoking advocates, they need to be taught how to advocate for healthier food environments as part of their role as future physician-citizens.

The USDA Food Pyramid, circa 1990.

Every five years beginning in 1980, the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services (HHS) have jointly issued the Dietary Guidelines for Americans, which serve not only to help citizens make healthy dietary choices but also to guide federal programs that support school lunches and supplemental nutrition assistance for low-income individuals and families. However, a recent analysis suggested that adhering to recommendations of the 2010 Dietary Guidelines to consume more potassium, dietary fiber, vitamin D, and calcium would add hundreds of dollars to an average person's annual food budget; potassium alone would add $380. In contrast, increasing intakes of saturated fat and added sugar are associated with lower food costs.

Current (2010) U.S. Dietary Guidelines.

Last year, former U.S. Secretaries of Agriculture Dan Glickman and Ann Veneman argued in Health Affairs that there is a "disconnect" between federal food and farm policies and evidence-based dietary recommendations:

On one hand, with obesity-related health costs rapidly rising, the federal government has encouraged people to make healthy dietary choices through efforts such as Let's Move! and MyPlate. On the other hand, the federal government spends billions of dollars on traditional agricultural commodity programs that fail to reinforce the kind of healthy dietary choices outlined in federal dietary guidelines.

Providing greater access to nutritious food options at affordable prices doesn't mean that people will purchase them, but is a necessary first step in realizing the potential of nutrition policy to reduce obesity and improve population health.

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This post first appeared on The Health Policy Exchange.

Guest Post: Invitation to the 2014 Direct Primary Care Summit

Dear Colleague,

I am writing to ask that you consider attending or send a colleague to the 2014 Direct Primary Care National Summit. As you may know, the Family Medicine Education Consortium played the role of “first follower” of the Direct Primary Care movement. We took this position because we believe that the current RVU-driven fee for service system is crushing Family Medicine and primary care. The DPC approach is one of the best strategies for “unchaining” the vision and passion of Family Medicine.

We have learned that the Direct Primary Care model will be one of the models to be endorsed by the seven Family Medicine organizations in the Future of Family Medicine 2.0 report (Family Medicine for America’s Health). While this is a very positive step for Family Medicine, I am very concerned about the response that will accompany the report’s roll out.

Many current Family Medicine leaders have a negative bias against the DPC model. They hear DPC and they think "concierge." Those leaders who believe that only through integrated systems can there be real improvement in health outcomes also see DPC as a threat. I have been told by FP leaders that DPC is “the enemy” of real reform. This is not a minor issue. I would say the vast majority of FPs I talk to about DPC have had one or the other of these responses.

I have been talking with many senior Family Physician leaders about the exciting changes that are happening. I’ve been surprised by the cynicism I’ve encountered. Many mid-career and senior FP leaders have told me “we heard this before” and “I’ll believe this time is different when I see real results.”

After some reflection I came to this. Many of our current senior and mid-career leaders hit a wall in the 90s during the last periods of change. As young FPs they thought the managed care era was finally going to lead to real change. They also thought all the hoopla over the PCMH would lead to real change. They feel burned and will dampen and perhaps even blunt the potential for change at this time.

This is a serious issue and needs to be addressed in a substantive way now. I have a recommendation.

When we held the first DPC Summit last October, I sat in the audience and listened to the innovators share their stories about how they had built practices that served their patients and communities. I heard them speak of their joy in practicing medicine. The students and residents in the room heard the same thing and it lit a passion in their minds. Speaker after speaker served as powerful role models. In fact, the entire event was full of speakers and participants who exuded hope for the future.

We need a “full court press” to get faculty, health system leaders, residents and students to the DPC Summit 2014. I guarantee the following:

· Students who attend the Summit will return to their schools and become ambassadors for Family Medicine/primary care.
· Residents who attend the Summit will return to their programs and revitalize the hope for the future of practice as a Family Physician. They will even turn around the negative perceptions held by many faculty.
· Faculty members (FP or behavioral) who attend the Summit will feel validated and hopeful for the future.
· Health system leaders (either from a hospital/ACO based or FQHC environment) who attend the Summit will see that DPC is one of the best strategies to improve the health of the population and their organization’s bottom lines.

Please help us to use the DPC Summit 2014 to build a community of solution that will support the roll out of Family Medicine for America’s Health.

Here are a few things your organizations could do:

Encourage your colleagues to come to the DPC Summit 2014. Be as vocal as possible.

Also consider sponsoring student/resident scholarships to the meeting. Primary Care Progress has publicly sponsored $2000.00 in scholarships. They attended the first Summit and know the positive impact attendance has had on students and residents. We created a discounted rate for students and residents and also created a one day rate for them. We want them to attend in large numbers. They will become ambassadors of hope.

It is going to take more than a report issued in the fall to energize the Family Medicine movement. Please use the DPC Summit 2014 to start building momentum now.

Sincerely,

Larry Bauer, MSW, MEd

Founding CEO, Family Medicine Education Consortium

Family physicians are natural health system leaders

Last week, the subtitle of a JAMA editorial on accountable care caught my attention: "the paradox of primary care physician leadership." The authors observed that although a typical family physician's or general internist's patient panel accounts for about $10 million in annual health care spending (of which only $500,000 is primary care revenue), primary care physicians have been "underused" as role players in health system reform. They further suggested that claiming leadership positions in accountable care organizations could be "a powerful opportunity [for family physicians] to retain their autonomy and make a positive difference for their patients - as well as their practices' bottom lines."

The American Academy of Family Physicians recently launched Family Medicine for America's Health, also known as Future of Family Medicine 2.0. One of the key questions considered by this ambitious initiative is "What are the core attributes of family medicine today?" Dr. Robert L. Phillips, Jr. and colleagues from seven U.S. family medicine organizations answer in a special article on the future role of the family physician in the current issue of Annals of Family Medicine:

Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.

This forward-looking definition of family physicians as natural health system leaders contrasts with the "foil definition" that the group envisioned family physicians becoming if they accept passive roles and allow themselves to be acted on by various forces that are changing American health care:

The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill-defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient panel management, community health, or collaboration with public health.

Are tomorrow's family physicians prepared to be leaders instead of followers? A research study published in Family Medicine explored relationships between specialty plans and clinical decision making in a national survey of 4,656 senior medical students. Students were asked to choose between management options in patient vignettes that exemplified principles of health reform: evidence-based care, cost-conscious care, and patient-centered care. Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle change counseling to starting medication for a mild chronic condition. Future family physicians were also more likely to prefer U.S. Preventive Services Task Force recommendations on preventive care to those from disease-oriented or patient advocacy groups, although this finding was not statistically significant.

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This post originally appeared on the AFP Community Blog.

Perspectives on preventable causes of death

A few years ago, I blogged about varying definitions of "actual" causes of death, which include disease-specific causes (the top five in the U.S. being heart disease, cancer, chronic lower respiratory diseases, stroke, and unintentional injuries); behavioral causes (tobacco, poor diet/physical inactivity, alcohol, infectious agents, environmental toxins); or socioeconomic determinants (low education, racial segregation, low social support, poverty, income inequality). Prevention-minded clinicians and policymakers understand that reducing premature deaths from diseases requires addressing unhealthy behaviors and social problems that influence them.

Researchers at the Centers for Disease Control and Prevention recently examined state-level differences between the top five disease-specific causes of death between 2008 and 2010, then took this data one step further and proposed that disparities in death rates between the best-performing states (i.e., states with the lowest disease-specific death rates) and all the others were "potentially preventable" deaths. The researchers acknowledge that actually preventing these deaths would by necessity involve reducing or eliminating health disparities:

The majority of these risk factors do not occur randomly in populations; they are closely aligned with the social, demographic, environmental, economic, and geographic attributes of the neighborhoods in which people live and work. However, the calculation of potentially preventable deaths in this study did not account for differences in the attributes of states that might influence risk factors and ultimately death rates, such as proportion of the population below the poverty level. If health disparities were eliminated, as is called for by Healthy People 2020, all states should be closer to achieving the lowest possible death rates for the five leading causes of death.

A couple more caveats about this study. First, since we can't defeat death (as Atul Gawande famously wrote, "the enemy has superior forces"), reducing death rates from one cause leads to increasing death rates from another. Also, there's no reason to believe that the best-performing states represent the very best we can do. (See any one of a number of depressing international comparisons.)

For those of you who prefer visuals to data crunching, here is a neat infographic put together by the company Zweena Health. The only part that I disagree with is their assertion that "routine medical visits can save lives." Not that it isn't true (I wouldn't still be practicing medicine if I didn't think I save lives now and then), but routine social work visits and public policies that spur economic growth, reduce unemployment, and increase access to decent, affordable housing make a much bigger difference in health outcomes than do medical preventive services.

How to avoid dropping the baton on patient care handoffs

As a long distance runner on my high school track team, I won few accolades in individual events, but shone in relays. My teammates and I spent hours perfecting our baton exchanges, which must occur within a limited area of the track, until these handoffs felt smooth and effortless. In contrast, world class athletes focused on individual performances are often assigned to relay teams at the last minute, a practice that led to stunning disqualifications for dropped batons of both the U.S. men's and women's 4 X 100 meter relay teams at the Beijing Summer Olympics.

Dropped handoffs in medicine can expose patients to harm, too, even if individual clinicians are exceptionally skilled. An editorial in the May 1st issue of American Family Physician reviewed studies of programs designed to improve care transitions from hospital to home and found mixed evidence that such programs improve health outcomes:

Although some programs reduced 30-day rehospitalization rates, a systematic review found that no single intervention is reliably helpful, and successful readmission reduction programs generally occur only in single institutions.However, it seems that programs that focus on the whole patient rather than a specific diagnosis are more successful in reducing readmissions. This concept is in keeping with the focus of primary care physicians. To solve the challenge of care transitions, the primary care physician should have a prominent role at three times: at admission, immediately after discharge, and at the postdischarge follow-up visit.

Research on improving inpatient handoffs has evaluated the varying effectiveness of electronic handoff tools, standardized communication training, verbal mnemonics, structural changes, and "handoff bundles" that include one or more interventions. Several residency programs at my institution recently found that an electronic template for graduating residents to hand off their "high risk" outpatients to other clinicians did not improve handoff quality or clinician satisfaction compared with free-text handoff notes.

What other kinds of tools can be used to assure uninterrupted transitions of patient care from hospital to home, between clinicians in inpatient and outpatient settings, or between primary care physicians and subspecialists?

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This post originally appeared on the AFP Community Blog.

Cancer epidemiology 101

I've had many Twitter conversations with cancer screening advocates who fear that the U.S. Preventive Services Task Force's "D" (don't do it) recommendation against PSA-based screening for prostate cancer will lead to a dramatic spike in prostate cancer deaths as primary care physicians screen more selectively, or perhaps stop screening at all. I seriously doubt these apocalyptic forecasts (for one thing, prostate cancer causes only 3% of deaths in men, and the decline in the U.S. prostate cancer mortality rate since 1990 hasn't had any appreciable effect on overall life expectancy). However, I recognize that reasonable people disagree with my review and the USPSTF's interpretation of the evidence. The American Cancer Society, for example, continues to support screening if men are adequately informed of the known risks and uncertain benefits. But it's one thing to argue from evidence, and quite another to argue from ignorance. Many of the tweets I've seen from urologists, unfortunately, represent the latter.

When I went to medical school, biostatistics and epidemiology was the course that no one took seriously. Things have changed for the better over the years - today I teach a rigorous course in evidence-based medicine and population health at Georgetown University School of Medicine - but there's still an appalling lack of basic knowledge about these topics among practicing physicians of all specialties. Below are a few key concepts in cancer epidemiology that anyone should understand before getting into a dispute about the value of prostate cancer screening.

Lead-time bias - "Prostate cancer survival has improved since we started PSA screening, so screening must work!" The first clause of this sentence is absolutely true: in the 1970s, about 70 percent of men diagnosed with prostate cancer were still alive 5 years after diagnosis, while today that figure is closer to 99 percent. The second clause could be true, but does not invariably follow from the first. By finding prostate cancers in men long before they become symptomatic (if they ever become symptomatic), screening advances the time of diagnosis, but could have no impact on mortality. In other words, 5-year survival always increases when a screening test is implemented, but its effect might only be giving patients an earlier cancer diagnosis without affecting their disease course. See chest x-ray screening for lung cancer (which was unfortunately a common practice for years) for an example of this phenomenon.

A variation on the above statement is the observation made by older urologists that "Before PSA testing, we used to see men with prostate cancer only when they came in with metastatic disease; today we see them with much less advanced tumors so that they can be cured." Much of this clinical experience reflects the effect of lead time, as well as overdiagnosis of cancer that didn't need to be found in the first place. In the words of urologic oncologist Willet Whitmore, "For a patient with prostate cancer, if treatment for cure is necessary, is it possible? If possible, is it necessary?"

Association does not equal causation - "Prostate cancer mortality has declined by 30 percent since 1990, which must be due to PSA screening." It's tempting to make sweeping conclusions based on observational data - the press has been doing this forever, linking caffeine use to cancer today, then reversing itself when a new headline is needed tomorrow. It's certainly possible that some of the decline in mortality is due to screening, but it's just as likely that some other factor is responsible. For example, men who smoke are less likely then male non-smokers to die from prostate cancer. Does that mean that tobacco use has a protective effect? Of course not; these men are dying prematurely from heart attacks and chronic obstructive pulmonary disease, and therefore not dying of prostate cancer. Also, the temporal association between the mortality decline and the PSA screening doesn't make any sense, since the only randomized trial to show that PSA screening reduces prostate cancer mortality (more on this later) found that it takes at least 9 years to do so. Since PSA screening was not widespread in the U.S. until the early 1990s, any benefit of screening wouldn't have changed the mortality statistics until 2000. But that's not what happened.

The most favorable study represents "the truth" - "Prostate cancer screening reduces prostate cancer mortality by 20 percent." If you only speak to urologists, you might come away thinking that there's only been one randomized trial of PSA screening: the European Randomized Study of Screening for Prostate Cancer (ERSPC), which reported this result in 2009 and again in 2012 after 11 years of follow-up. The usual description of the ERSPC as a single "trial" is problematic (it's actually a combined analysis of screening results from 7 European countries), but even allowing for that, it's only one of 5 randomized trials of screening, and (guess what?) the only one of the 5 to show a benefit.

In the old days, the process of writing reviews and guidelines went as follows: write up recommendations that you already know to be correct from clinical experience, then go to the literature to select evidence that supports your positions. A less biased approach is to evaluate all of the available evidence, regardless of one's preexisting biases, which is what my colleagues and I did and what independent reviewers did for the both the Cochrane Collaboration and BMJ. Here's what the Cochrane reviewers concluded: "Prostate cancer screening did not significantly decrease all-cause or prostate cancer-specific mortality in a combined meta-analysis of five RCTs."

Specialist-authored guidelines are superior to generalist-authored guidelines - "The USPSTF guidelines are invalid because there were no urologists on the panel." Let's put aside for the moment the fact that more prostate cancer diagnoses invariably lead to more business for urologists, and that guidelines authored by specialty societies are of lower quality than those authored by generalists. Dismissing the USPSTF recommendation on the basis of its primary care membership is still nonsense, pure and simple. The vast majority of prostate cancer screening occurs in primary care settings, and therefore primary care clinicians are the most appropriate experts to evaluate and weigh the evidence about screening. (The same can be said about mammography guidelines and radiologists.) Several urologists were, of course, consulted at multiple stages during and after the writing of our evidence review to make sure that no important studies were missed.

As I've said, I welcome debates with well-informed advocates of PSA screening, who tend to view this imperfect test as a glass half-full rather than half-empty (or shattered beyond repair). For the less-informed, I get it that you don't have time to go back to medical school for remedial epidemiology lessons. So consider this post your Cliff's Notes.

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This post originally appeared on Common Sense Family Doctor on December 12, 2012.