Requiem for the National Guideline Clearinghouse

Absent a last-minute, lifesaving intervention, after 20 years of reviewing and summarizing clinical practice guidelines in a continuously updated database, the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC) will go offline on July 16th. Prior to its untimely death due to budget cuts, the NGC not only served as a one-of-a-kind online resource for clinicians, researchers, and educators, but raised the bar on guideline development, recently introducing the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) assessment tool to evaluate how well guidelines meet the National Academy of Medicine's (formerly Institute of Medicine) standards for trustworthiness.

To be sure, some will not mourn the deaths of the NGC and its companion online resource, the National Quality Measures Clearinghouse (NQMC). Front-line clinicians have viewed guidelines with increasing suspicion as recommendations with tenuous links to patient-oriented outcomes that matter (e.g., lower hemoglobin A1c targets) have been unwisely converted into formal performance measures that are linked to physician compensation. The Performance Measurement Committee of the American College of Physicians recently evaluated the validity of 86 primary care-relevant measures included in the 2017 Medicare Merit-based Incentive Payment System (MIPS) Quality Payment Program and found that only 37% were valid, 35% were invalid (the majority due to insufficient supporting evidence), and 28% had uncertain validity.

It is also clear that the universe of medical quality, especially in primary care, is not and cannot be restricted to adherence to recommendations in evidence-based guidelines. Dr. Richard Young and colleagues have previously critiqued the application of traditional quality improvement processes to the "complex adaptive systems" of primary care practices and proposed some reasonable alternatives for assessing quality:

Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

That being said, the premature ends of the NGC and NQMC will make it more difficult for clinicians to identify good clinical practice guidelines and are unlikely to slow the momentum of the "paying for value" movement, which aims to reward clinicians for their outcomes of care rather than the volume of services they provide. Killing these resources to save a few hundred thousand dollars per year is a penny-wise, pound-foolish decision, and your health and mine will be poorer for it.

Few family physicians are delivering babies, and few women are having VBACs. What's stopping them?

In 2017, fewer than one in five members of the American Academy of Family Physicians (AAFP) reported providing obstetric care. In a previous Graham Center Policy One-Pager, Dr. Tyler Barreto and colleagues reported that between 2009 and 2016, the percentage of family physicians practicing high-volume obstetrics (more than 50 deliveries per year) fell from 2.1% to 1.1%. A subsequent study in Family Medicine by Dr. Sebastian Tong and colleagues found that 51% of recent family medicine residency graduates intended to provide prenatal care, and 23% intended to deliver babies; however, less than 10% were delivering after 1 to 10 years in practice.

In a recent policy brief in the Journal of the American Board of Family Medicine, Dr. Barreto and colleagues analyzed data from the 2016 Family Medicine National Graduate Survey to identify barriers faced by residency graduates who stated interest in delivering babies but did not do so in practice. Almost 60% of respondents cited the lack of opportunity to do deliveries in the practice they joined and lifestyle considerations as the most important factors. Fewer than 10% felt that inadequate training or reimbursement were major issues.

Although these recent studies did not specifically focus on family physicians who perform surgical deliveries, prior research has established that Cesarean delivery outcomes are comparable whether performed by family physicians or obstetrician-gynecologists. To support women who choose to attempt labor and vaginal birth after Cesarean delivery (VBAC), the AAFP published a 2015 guideline that was largely based on an Agency for Healthcare Research and Quality review of the benefits and harms of VBAC versus elective repeat Cesarean. I summarized the key findings of this review in American Family Physician's "Tips From Other Journals":

The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). ... The evidence suggests that most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant.

Access to VBAC remains limited or nonexistent in many parts of the U.S., and debates continue about its safety for mothers and babies. This month in CMAJ, Dr. Carmen Young and colleagues analyzed a Canadian hospital database containing information on women with a single prior Cesarean between 2003 and 2015 and a second singleton birth at 37 to 43 weeks gestation. They found that rates of the composite outcomes "severe maternal morbidity and mortality" and "serious neonatal morbidity and mortality" were significantly higher after attempted VBAC compared to elective repeat Cesarean. However, absolute differences in these outcomes were low, with NNTs of 184 and 141, respectively.

This new study may give some hospitals and maternity care providers pause about continuing to support women who desire VBAC, and, together with the dwindling numbers of family physicians providing delivery services, could push the overall U.S. Cesarean rate of 32% higher in future years.

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This post originally appeared on the AFP Community Blog.

Top primary care research studies of 2017

In the most recent installment in an ongoing series, my family physician colleagues Mark Ebell, MD, MS and Roland Grad, MD, MSc summarized research studies of 2017 that were ranked highly for clinical relevance by members of the Canadian Medical Association who received daily summaries of studies that met POEMs (patient-oriented evidence that matters) criteria. This year's top 20 studies included potentially practice-changing research on cardiovascular disease and hypertension; infections; diabetes and thyroid disease; musculoskeletal conditions; screening; and practice guidelines from the American College of Physicians and the U.S. Preventive Services Task Force.

The April issue of Canadian Family Physician, the official journal of the College of Family Physicians of Canada, also featured an article on "Top studies relevant to primary care practice" authored by an independent group that selected and summarized 15 high-quality research studies published in 2017. Not surprisingly, some POEMs ended up on both lists:

1) Home glucose monitoring offers no benefit to patients not using insulin

2) Treatment of subclinical hypothyroidism ineffective in older adults

3) Pregabalin does not decrease the pain of sciatica

4) Steroid injections ineffective for knee osteoarthritis

The common theme running through these four studies is "less is more": commonly provided primary care interventions were found to have no net benefits when subjected to close scrutiny.

On the other hand, in a randomized trial that appeared on CFP's but not AFP 's list, adults and children with small, drained abscesses who received clindamycin or trimethoprim-sulfamethoxazole were more likely to achieve clinical cure at 10 days than those who received placebo, although the antibiotics also caused more adverse events, particularly diarrhea (number needed to harm = 9 to 11). As Dr. Jennifer Middleton explained last year, these findings challenge a previous Choosing Wisely recommendation from the American College of Emergency Physicians that states, "Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up." More can sometimes be, well, more.

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This post first appeared on the AFP Community Blog.

Obstacles to stopping cancer screening in older adults

I recognized a glitch in my electronic medical record's decision support software when it prompted me to consider prostate and colorectal cancer screening in a 93 year-old man, who, though remarkably vigorous for his age, was unlikely to live for the additional 10 years needed to benefit from either test. Although deciding not to screen this patient was easy, determining when to stop cancer screening in older patients is often more challenging. In a 2016 article in American Family Physician, Drs. Brooke Salzman, Kathryn Beldowski, and Amanda de la Paz presented a helpful framework for decision making in these clinical situations, where population-level guidance derived from studies of screening younger patients "generally do not address individual variations in life expectancy, comorbid conditions, functional status, or personal preference."

The authors recommended that clinicians take into account not only average life expectancy at a given age, but also significant variations in life expectancy linked to functional impairment and comorbid conditions, using one or more validated prognostic tools. Although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence about screening mammography in women 75 years or older, modeling studies suggest that women with projected life expectancies of greater than 10 years may still benefit from this test - with these important caveats:

Although the sensitivity and specificity of mammography increase with age, overdiagnosis also increases because of reduced life expectancy and an increased proportion of slower-growing cancers. In other words, women with breast cancer diagnosed at an older age are more likely to die of something else, compared with younger women. In addition, treatment of breast cancer in advanced age is associated with greater morbidity, including an increased risk of postoperative complications and toxicity from chemotherapy.

Similar considerations apply to screening for colorectal cancer, which the USPSTF made a "C" grade recommendation (small population-level benefit, use individual decision making) for adults 76 to 85 years of age and recommended against screening adults older than 85 years, when the harms clearly exceed the potential benefits. Nonetheless, surveys have found that 31% of adults age 85 years and older, and 41% of adults with a life expectancy of less than 10 years, received screening colonoscopies. To discourage overuse of cancer screening without alienating patients, the authors advised: "It is important to convey that a decision to stop cancer screening does not translate into decreased health care. Rather, discussions can focus on health promotion strategies that are most likely to benefit patients in the more immediate future, such as exercise and immunizations."

A qualitative study in JAMA Internal Medicine explored the reluctance of primary care clinicians to explicitly incorporate long-term prognosis in the care of older adults. Most study participants relied on their own clinical experience, rather than validated tools, to estimate a patient's life expectancy, and were reluctant to stop screening in relatively younger patients even with limited life expectancies. Barriers mentioned by participants included inadequate training, time constraints, concern about negative patient reactions, competing practice incentives, and fear of lawsuits. Readers, how should we communicate with older adults whose age or life expectancy warrant stopping cancer screenings because harms outweigh benefits?

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This post first appeared on Common Sense Family Doctor on April 26, 2016.