Mismeasuring quality in primary care

After several years of doing family medicine commentaries for Medscape as part of a collaboration with Georgetown University Medical Center, I recently wrote my first commentary as a clinician and faculty member at the Lancaster General Hospital Family Medicine Residency Program about my mostly unsuccessful pursuit of elusive "quality" bonuses and the problems with current metrics used to judge care provided by primary care physicians. Here's an excerpt that discusses another notable perspective that inspired me to write about this topic: 

In a recent commentary, Drs. Christine Sinsky and Jeffrey Panzer distinguished "solution shop" from "production line" work in primary care and argued that though the medical training physicians receive makes us uniquely qualified to do the former, we end up spending most of our time and energy on the latter. Similarly, they observed that "most quality-improvement efforts have focused on improving production line–type measures and not on improving the conditions for sound medical decision-making and relationship building." Being able to correctly diagnose and treat patients who come in for chest or abdominal pain, for example, counts less (or not at all) toward my quality score compared with the percentage of patients who receive lead screening or diabetic eye exams.

Peanut allergy: prevention and treatment advances

People with severe peanut allergy are at risk of life-threatening anaphylaxis from unintentional ingestion of small amounts of peanuts. A new drug review in American Family Physician discussed oral immunotherapy with peanut allergen powder, which increases tolerance for ingesting the amount of peanut protein in a single peanut by 63% but has important downsides: 1 in 10 patients need to use epinephrine after administration (compared to 1 in 20 in a placebo group); common short-term adverse effects include abdominal pain, throat irritation, and oral pruritus; and a price of approximately $3000 annually.

Although it was once believed that children should not consume peanuts early in life, a United Kingdom randomized trial in infants 4 to 11 months of age at high risk of developing peanut allergies found that early consumption of peanuts reduced the risk of developing peanut allergy by age 5 years by 80% (absolute risk reduction=14%, NNT=7). This finding led the National Institute of Allergy and Infectious Diseases to recommend in 2017 that peanut-containing foods be introduced into the diet of infants with severe eczema, egg allergy, or both at 4 to 6 months of age. In 2021, a consensus document on the primary prevention of food allergy from three North American professional allergy societies recommended introducing peanut-containing products to all infants around 6 months of age, regardless of their risk of developing peanut allergy.

A similar change to infant feeding guidelines in Australia occurred in 2016, recommending that all infants be introduced to peanuts before age 12 months. A recent study in JAMA evaluated changes in feeding practices and the prevalence of peanut allergy across two population-based cross-sectional samples recruited in 2007-2011 and 2018-2019. Although infants in the later sample were much more likely to have consumed peanuts before 12 months than infants in the earlier sample (86% vs. 22%), overall there was no statistical difference in peanut allergy prevalence. Noting that East Asian ancestry is considered a risk factor for peanut allergy, the authors hypothesized that the increased representation of infants with parents from East Asia in the later sample may have contributed to finding no effect. Another possible explanation is that early introduction of peanut-containing foods does not significantly modify peanut allergy development in infants not at high risk.

In a previous paper on identifying and using clinical practice guidelines, Dr. David Slawson and I observed: "The ultimate test of a good guideline is whether or not it has been prospectively validated; that is, has its adoption been shown to improve patient-oriented outcomes in real-world settings?" Based on the JAMA study, infant feeding recommendations to prevent peanut allergies have not yet passed this test. On the other hand, an accompanying editorial argued that "given the potential for benefit and the low risk of harm, the [study results] should not dissuade clinicians from following current consensus guidance that recommends early peanut introduction for infants." The challenge of identifying children at increased risk for peanut allergy (as noted in the consensus document, definitions have varied across studies and guidelines) and the inherently artificial nature of previous guidance restricting what an infant would otherwise naturally eat make this a reasonable course of action in the face of imperfect evidence.

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This post first appeared on the AFP Community Blog.

Race-based medicine and routine PSA screening in Black men

Five years ago on this blog, I asked whether routinely screening African American men for prostate cancer was warranted when evidence suggested that harms exceeded benefits in the general population. Even though many experts felt that it was, I disagreed:

What troubles me about this position is that race is as much a social construct as it is a biological one. Much of the disparity in prostate-cancer mortality between African-American and Caucasians can be explained by lower access to and quality of care, rather than a genetic predisposition for more aggressive and/or lethal cancers. In contrast to national data, studies of equal-access healthcare systems in the U.S. such as the Veterans Health Administration and the Department of Defense found no differences in prostate cancer mortality between Black and White men.

Since that time, the U.S. Preventive Services Task Force partially reversed itself and now states that "for men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one." Individual decision-making relies in part on assessing risk factors for potentially fatal prostate cancer, but aside from family history, the only other known risk factor is Black race.

Race-based medicine's drawbacks have become increasingly evident, however, and groups across the spectrum of medicine have been working to eliminate the inappropriate use of race from clinical decision-making. In this context, a group of urologists and oncologists recently updated a 2009 analysis of the effects of PSA screening in the U.S. and concluded that the benefit to harm ratio of screening over the past 3 decades was considerably more favorable in Black men than in the American population as a whole.

So was I wrong about not approaching Black men differently in PSA screening? Or as the title of the accompanying editorial asked, "Should recommendations for cancer screening differentiate on race?" Drs. Gil Welch (who authored the original analysis of PSA screening) and Adewole Adamson observed that assuming that the effectiveness of PSA screening or the harm of overdiagnosis are not substantially modified by race, then the higher prostate cancer death rate in Black men suggests that they would be more likely to benefit from screening than men of other races.

On the other hand, they argued, "in the context of addressing health disparities, cancer screening is a massive distraction. ... Cancer-associated health disparities not biased by early detection are related primarily to unequal treatment after diagnosis, not screening." All but a small fraction of the increased risk of lethal prostate cancer in Black men is likely to be mediated by social determinants of health and structural racism rather than genetics. Shockingly, "in Black men, the median age of prostate cancer death is 76 years, 4 years older than their average life expectancy [emphasis mine]," which is a strong argument for devoting more resources to improving the lives of the >95% of Black men who die from something other than prostate cancer (e.g., heart disease, lung cancer, chronic kidney disease).

I will continue to inform Black and multiracial patients in the age group highlighted by the USPSTF about population-level risks and the (increasingly inexcusable) paucity of empiric data on the benefits and harms of PSA screening in Black men. Some will choose to be screened, some will not. But I continue to believe that race-based screening for prostate cancer - i.e., screening a man only because of the color of his skin - is the wrong approach.