Measuring and minimizing low-value health care

Hospitals and health systems have often needed to restrict nonemergent care during COVID-19 surges, with mixed effects on patients. Some patients may experience worse outcomes when necessary treatment or surgery is postponed, while others may avoid receiving unnecessary and potentially harmful (low-value) care. Of course, relying on a pandemic to reduce low-value care is not a strategy; at best, it's a blunt instrument that will be discarded when the public health emergency ends. Recent studies of pre-pandemic low-value care have further demonstrated the need for sustainable interventions.

Dr. Ishani Ganguli and colleagues described the use of 41 low-value medical services in a retrospective cohort of more than 11 million Medicare beneficiaries across 556 health systems. They found that the most common services were preoperative laboratory testing, prostate-specific antigen testing in men older than 70 years, and antipsychotic medications in patients with dementia. Characteristics of health systems associated with greater low-value care (based on a composite measure of the 28 most common services) were having a smaller proportion of primary care physicians, a larger proportion of patients of color, no teaching hospital, higher health care spending, and headquarters in the Southern or Western U.S.

Another recent study of Medicare claims data examined the prevalence and costs of hospital-acquired conditions and patient safety indicator events associated with a selection of low-value inpatient procedures. The investigators identified 231 hospital-acquired conditions and 1,764 patient safety indicator events associated with these procedures from 2016 to 2018, resulting in $3.16 million and $26.7 million in additional health care costs, respectively. For example, hospital-acquired conditions occurring during an admission for percutaneous coronary intervention extended length of stay by an average of 17.5 days and increased the cost of hospitalization by $22,000. Those are impressive amounts given that the procedure may have been unnecessary in the first place!

The Cochrane Library has created a special collection of systematic reviews on resource-intensive interventions "for which there is high or moderate certainty evidence that they confer clinically small or no effects, and for which there is some evidence of harm to patients." Examples include preoperative testing for cataract surgery, percutaneous vertebroplasty for vertebral compression fractures, and intensive follow-up strategies after treatment of non-metastatic colorectal cancer.

As Dr. Jennifer Middleton pointed out in a 2018 editorial, changing physician behavior to minimize low-value care requires creating new workflows and systems of care. A systematic review of 131 articles on Choosing Wisely interventions in the U.S. through June 2019 found that the most effective interventions target clinicians rather than patients, are active rather than passive, and include multiple components. The type of low-value service targeted did not affect outcomes. Components of effective clinician-focused interventions included behavioral nudges, feedback / report cards, clinical decision support, electronic health record enhancements, clinician champions, education and academic detailing, and creating new clinical pathways.

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This post first appeared on the AFP Community Blog.

The past, present and future of cancer screening

I've given a lecture in Georgetown University School of Medicine's Evidence-Based Medicine course on evaluating screening tests every fall for the past decade, and for several years prior to that I taught these principles to public health students at Johns Hopkins University. I link the origin of evidence-based assessment of clinical preventive services to the creation of the U.S. Preventive Services Task Force (USPSTF) in 1984, first under the aegis of the U.S. Public Health Service and later, the Agency for Healthcare Research and Quality. In doing so, I imply that prior to that date, screening in primary care was in the stone ages. As it turns out, that's not exactly true.

The recent digitization of archives of The Journal of Family Practice dating back to 1974 allowed me to discover a 4-part series of previously inaccessible papers by Drs. Paul Frame and Stephen Carlson titled "A Critical Review of Periodic Health Screening Using Specific Screening Criteria." These historical articles, published before I was born, analyzed screening tests for 36 selected diseases using criteria that would be familiar to anyone studying screening today:

1. The disease must have a significant effect on quality or quantity of life.

2. Acceptable methods of treatment must be available.

3. The disease must have an asymptomatic period during which detection and treatment significantly reduce morbidity and/or mortality.

4. Treatment in the asymptomatic phase must yield a therapeutic result superior to that obtained by delaying treatment until symptoms appear.

5. Tests must be available at reasonable cost to detect the condition in the asymptomatic period.

6. The incidence of the condition must be sufficient to justify the cost of screening.

Here are some of their recommendations for screening in adults that remain essentially unchanged half a century later: Take a smoking history. Measure height and weight. Check blood pressure every 2 years. Don't routinely do EKGs in asymptomatic people. Measure cholesterol levels. Don't screen for lung cancer with chest x-ray or sputum cytology (these days we screen high-risk persons with CT). Don't screen for brain tumors. Don't screen for COPD. Don't screen for cirrhosis (advanced liver disease). Don't screen for oral cancer, stomach cancer, or pancreatic cancer. Perform fecal occult blood testing to screen for colorectal cancer (this remains an option although many patients now choose screening colonoscopy). Don't screen for bacteriuria in nonpregnant patients. Screen for syphilis in at-risk persons. Don't screen for testicular cancer, bladder cancer, or kidney cancer. Do Pap smears for cervical cancer in women older than age 20 (today we may add or substitute HPV testing in certain patients). Don't screen for endometrial or ovarian cancer.

In terms of screening for cancer, there were only two substantial changes from these 1975 guidelines to today's accepted practices. For breast cancer, we now recommend biennial mammography for all women starting at age 50 (or age 40 if desired) and discourage routine breast self-examination, which Frame and Carlson endorsed due to it being a benign intervention - it hadn't yet been shown to be harmful in terms of increasing false positive results and biopsies. And while Frame and Carlson discouraged prostate cancer screening, the current USPSTF thinks that selective screening is acceptable in men age 55-69 years (although I disagree).

The fact is, though, most cancers aren't diagnosable or diagnosed through screening. A a recent National Academies workshop, Dr. Chyke Doubeni noted that less than half of all cancer deaths are potentially preventable through current screening techniques. Dr. Elizabeth Sarma's research showed that only one-third of estimated new cancer cases this year are potentially screen detectable. For example, data show that 67 to 82 percent of colorectal cancers are detected after patients present with symptoms, not due to an abnormal screening test result. This imbalance would improve a little if 100% of eligible adults got screened, but the fact is that current technology can't prevent every cancer, or even the majority of them.

That's a quick tour of the past and present. What about the future of cancer screening? There is a lot of optimism these days about multicancer early detection (MCED) tests, also called "liquid biopsies." Imagine this: your doctor would be able to take a single blood sample and test it for multiple cancers simultaneously, including cancers that currently have no effective standard screening test. That sounds great, but there are lots of potential pitfalls, including the inability of some tests to identify cancer tissue of origin (so you could get a result back that essentially says "You have cancer somewhere in your body, we just don't know where"). Lots of smart people, including yours truly, are trying to figure out the best way to evaluate the benefits and harms of MCED tests and to create regulatory frameworks for the companies that are developing them.

An update on multisystem inflammatory syndrome in children

In May 2020, I wrote a blog post that described an emerging COVID-19 associated, Kawasaki disease-like syndrome that became known as multisystem inflammatory syndrome in children (MIS-C). (The Centers for Disease Control and Prevention later identified a similar inflammatory syndrome in adults, MIS-A.) Over the past year, as family physicians, pediatricians, and children's hospitals have gained experience with treating patients with MIS-C, we now know more about differentiating it from Kawasaki disease and managing its major complications. A review article by Drs. John Darby and Jennifer Jackson in the September issue of American Family Physician provided an overview and comparison of Kawasaki disease and MIS-C. Although Kawasaki disease primarily occurs in toddlers, MIS-C has been observed in patients from one week to 20 years of age, with a median age of 7 to 9 years. In the U.S., Hispanic and non-Hispanic Black children have been disproportionately affected by MIS-C, comprising 62% of all cases. Vomiting, diarrhea, and abdominal pain occur in 80% of patients, while neurocognitive symptoms affect about 20%. Additional symptoms of MIS-C can include hypotension secondary to cardiac dysfunction and systemic vasodilation.

Two observational studies of patients with MIS-C published in June 2021 added to the knowledge base but did not definitively identify the most appropriate treatment. A propensity-score matched analysis of 518 patients admitted to U.S. hospitals for MIS-C between March 15 and October 31, 2020 found that initial treatment with intravenous immune globulin (IVIG) plus glucocorticoids, compared to IVIG alone, was associated with a reduced risk of new or persistent cardiovascular dysfunction (a composite outcome of left ventricular dysfunction or shock resulting in the use of vasopressors) on or after day 2 of admission. In contrast, an international cohort study of 614 children with suspected MIS-C from 32 countries treated from June 2020 through February 2021 found no differences in a composite outcome of inotropic support or mechanical ventilation by day 2 or later between children who received IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone.

A longitudinal cohort study of 50 patients admitted to a single U.S. medical center between April and June 2020 reported outcomes of MIS-C at 6 months. 31 patients required intensive care, and 33 developed left ventricular dysfunction, coronary dilation, or aneurysms. The mean length of stay was 5 days. After two weeks, only 9 patients had persistent ventricular dysfunction or other coronary abnormalities, though nearly half reported fatigue with ordinary activities. All 25 patients who presented for a 6-month follow-up visit were asymptomatic, with a single patient having left ventricular diastolic dysfunction. Although the rapid resolution of symptoms and cardiac abnormalities seen in this study is good news, it is unclear if these outcomes will persist given the much greater number of children with COVID-19 infections who were hospitalized during the summer of 2021. The best approach to preventing MIS-C remains reducing the risk of SARS-CoV-2 infection through vaccinating adolescents and - pending regulatory approval in the next few weeks - younger children.

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This post first appeared on the AFP Community Blog.