What do the Air Force and family medicine have in common? AI

This year, I did a lot of reading about current and future applications of artificial intelligence (AI) in health care - for example, how it will reduce the grunt work of selecting future physicians; become a required competency in medical education; provide relief from overflowing primary care electronic in-baskets; and provide clinical decision support for treating patients with depression. I've read pessimistic commentaries about chatbots and large language models being a "Pandora's box" and more optimistic pieces arguing that generative AI can overcome the "productivity paradox" of information technology: that is, it won't take decades to see large gains in health care quality and efficiency, as we haven't seen with implementation of electronic health records. Meanwhile, regulatory authorities are still struggling to catch up to ensure the safety of AI products without discouraging technological innovation. (And while I was retrieving these articles online, Microsoft Bing's AI-enabled search engine kept trying to take over writing this blog post.) But the most interesting article that I read about AI this year had nothing to do with health care. It was about the U.S. Air Force.

"AI brings the robot wingman to aerial combat," declared the science fiction-sounding headline of this August 2023 New York Times story. It discussed the XQ-58A Valkyrie, a pilotless "collaborative combat aircraft" described as "essentially a next-generation drone." Eying a seemingly inevitable armed conflict with China over the disputed island of Taiwan, U.S. Air Force war planners hope that these robot wingmen (wingAIs?) will not only be far less expensive to produce than conventional piloted warplanes, but also spare the lives of many human pilots who would otherwise be shot down by China's vast antiaircraft apparatus. Why expect our flying servicemen and women to become casualties while performing exploits of derring-do when a fearless AI can complete the same mission at a fraction of the risk?

Military AI raises ethical dilemmas, of course. Behind every drone attack on suspected terrorists is a human being who has judged (rightly or wrongly) that the target is indeed a wartime adversary and fair game. But "the autonomous use of lethal force" - the idea that AI could be making kill decisions without any human signoff - makes many people uneasy. The Pentagon, naturally, dodged a reporter's question about whether the Valkyrie aircraft could eventually have this capability.

Similarly, I could imagine that in the next decade or two (before the end of my career) AI could be developed to perform many of the basic functions of a physician assistant in primary care: ordering recommended screening tests and vaccines, titrating medications for hypertension and diabetes, and deciding whether or not to prescribe antibiotics or antiviral drugs for patients with acute respiratory illnesses. Physician supervision would probably consist of reviewing charts and signing off on them at the end of a clinical session rather than double-checking the AI's decisions in real time. Would that mean that AI would be autonomously practicing health care? Sure it would. Would this application be easier or harder to adjust to than formations of armed Valkyries using machine algorithms to identify enemy personnel and shooting to kill?

My favorite public health and health care books of 2023

This year's annual list of my favorite reads includes two works of fiction and eight real-life narratives about cancer, the history of medicine, rural family practice, and urban street medicine. As usual, I have listed them alphabetically by title rather than in any order of preference. For more great titles, feel free to peruse my lists from 2022, 2021, and 2015-2020. Other than the occasional free book to review for Family Medicine, I don't receive anything for reading or sharing them.

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1. Chasing My Cure: A Doctor’s Race to Turn Hope into Action, by David Fajgenbaum



2. From Whispers to Shouts: The Ways We Talk About Cancer, by Elaine Schattner

3. Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine, by Jim Downs



4. The Masters of Medicine: Our Greatest Triumphs in the Race to Cure Humanity’s Deadliest Diseases, by Andrew Lam



5. Medicine and Miracles in the High Desert: My Life Among the Navajo People, by Erica Elliott



6. The Other Dr. Gilmer: Two Men, A Murder, and an Unlikely Fight for Justice, by Benjamin Gilmer



7. Rough Sleepers: Dr. Jim O’Connell’s Urgent Mission to Bring Healing to Homeless People, by Tracy Kidder



8. Take My Hand, by Dolen Perkins-Valdez

 

9. That Time I Got Cancer: A Love Story, by Jim Zervanos

 


10. 2060, by Richard Young

Will the high price of gene therapy for sickle cell disease put this cure out of reach?

On December 8, 2023, the U.S. Food and Drug Administration (FDA) approved Casgevy, the first gene therapy utilizing clustered, regularly interspaced short palindromic repeats (CRISPR) for the treatment of sickle cell disease in patients 12 years and older. Mimicking a protective mutation that causes fetal hemoglobin (HbF) to persist into adulthood, Casgevy uses the CRISPR-Cas9 enzyme to edit a patient’s own blood stem cells to intentionally disable a DNA “brake” on HbF production. The modified stem cells are transplanted back to the patient and result in the production of high levels of HbF, preventing the sickling of red blood cells and eliminating or greatly reducing future painful vaso-occlusive (VOC) crises. In an ongoing single-arm trial—initial results were published in 2020—29 out of 31 treated patients had no severe VOC episodes for at least 12 consecutive months during the 24-month follow-up period.

The approval of Casgevy, which has a list price of $2.2 million for the single course of treatment, had been anticipated for months. However, the number of the estimated 100,000 Americans affected with sickle cell disease who will be able to afford it is unclear. Although the lifetime medical costs associated with sickle cell disease average $1.7 million, insurance companies may be unwilling to pay the exceptionally high up-front cost of this curative therapy. Compared with standard of care, one analysis found gene therapy to be an equitable strategy for U.S. patients per distributional cost-effectiveness analysis standards. Obstacles in addition to cost include needing to undergo chemotherapy and being hospitalized for months until the patient’s immune system recovers.

In Africa and India, which are home to most of the world’s population living with sickle cell disease, many patients die in childhood because of lack of access to standard-of-care treatments. For example, hydroxyurea, which reduces the frequency of VOCs and prolongs survival, was approved by the FDA in 1998 but remains unavailable to most patients. Experts recently proposed expanding the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to provide hydroxyurea therapy for $67 per person to sickle cell patients in sub-Saharan Africa at a total cost of less than $100 million per year. That modest budget would barely begin to meet the needs of those potentially eligible for gene therapy, even if they were able to travel to one of the only three centers for bone marrow transplants in Nigeria, Tanzania, and South Africa.

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This post first appeared on the AFP Community Blog.

As goes college, so goes health care?

My oldest child is applying to college this year. He is an outstanding student and likely to be offered significant scholarships, so my wife and I are not concerned about him (and us) being able to afford the tuition to the college he ultimately chooses. Tuition and fees at U.S. colleges actually increased at a lower rate than general inflation from 2022-23, breaking a 20-year trend that saw tuition increases for private and out-of-state public schools far outpace concurrent rises in incomes and costs of living. As a result, college has become less and less affordable, particularly for students who end up relying mostly on loans and rack up gigantic debt loads even if they don't complete their degrees.

But college-educated adults earn a lot more money than those without college diplomas, so going to college still makes economic sense, right? Maybe not. A few months ago, a New York Times Magazine story by Paul Tough (whom I've quoted previously on my blog) discussed "the new economics of higher ed." He cited the work of three researchers at the Federal Reserve Bank of St. Louis who found that looking at wealth accumulation rather than income, college graduates born in the 1980s or later had little advantage over their peers who didn't gradate from (or even start) college, with Black and Latino college graduates worse off than White college graduates. Data on postgraduate degrees was even more bleak: there seemed to be no wealth advantage at all.

Millennials with college degrees are earning a good bit more than those without, but they aren’t accumulating any more wealth. How can that be? ... The likely culprit, [one researcher] said, was cost: the rising expense of college and the student debt that often goes along with it. Carrying debt obviously diminishes your net worth through simple subtraction, but it can also prevent you from taking important wealth-generating steps as a young adult, like buying a house or starting a small business. And even if you (or your parents) were able to pay your tuition without loans, the savings you used are gone when you graduate, and thus are no longer available to serve as a down payment on a starter home or the beginning of a nest egg for retirement.

Fueled by skyrocketing tuition costs, total student loan debt more than tripled from $500 billion in 2007 to $1.6 billion today, and in an even more stunning statistic, "among student borrowers who opened their loans between 2010 and 2019, more than half now owe more than what they originally borrowed."

It's possible that demographic trends will act to moderate tuition costs in the future; as the pool of students finishing high school shrinks, colleges may need to keep tuition increases low to compete financially. For the sake of my pocketbook (my high school senior son is the oldest of four children), I certainly hope so. But reading about higher education made me think about another sector where costs and fees have been rising exponentially while the return on investment is middling and the quality of the product remains opaque: health care.

Since 1980, the U.S. has spent more on health care as a percentage of its gross domestic product than any other country in the world; today, nearly 1 in 5 dollars generated by the American economy goes to the purchase of health care. Yet average life expectancy stopped rising in 2010 and plummeted during the first two years of the COVID-19 pandemic, far more than in comparable countries where the average resident lives 5-6 years longer than we do. Further, U.S. men now are expected to die 6 years earlier than women, the widest gender gap in nearly 30 years, according to a recent study in JAMA Internal Medicine. The biggest drivers of this gap were deaths from COVID-19 and drug overdoses, which medicine can prevent with highly effective interventions: vaccines, medications to treat opioid use disorder, and the opioid reversal agent naloxone.

It's not that patients aren't enthusiastic about prevention. We spend $35 billion per year on largely worthless over-the-counter dietary supplements. According to a recent analysis of data from the National Ambulatory Medicare Care Survey, the proportion of primary care visits "with a preventive focus" increased from 12.8% in 2001 to 24.6% in 2019. But the services doctors provide at those "wellness" visits - mammograms, PSA tests, colorectal cancer tests, and CT scans for lung cancer - generally don't help people live longer and often lead to unintended harms. While discrete medical services don't save lives, we know that having a relationship with a primary care physician does. Good luck getting in to see one, though, when the pay gap between primary care and subspecialists discourages medical students from becoming family physicians, and the percentage of health care dollars invested in primary care nosedived from 2013 to 2020.

Will the U.S. eventually reach a "breaking point" when, like college today, people realize that they are being fleeced by a self-perpetuating sick care system and demand greater value for their money? Such as sending more of the trillions of dollars spent on health care toward primary care? Some states are starting to recognize the wisdom of increasing primary care spending, but progress has been slow. Our country would do well to heed this advice that I've adapted from food writer Michael Pollan: Get real health care. Not too much. Mostly primary care.

Bariatric surgery and other AAP recommendations for children with obesity

A recent article in The New York Times Magazine profiled a 16 year-old girl with severe obesity who underwent bariatric surgery at a children’s hospital in Texas. In January 2023, the American Academy of Pediatrics (AAP) published a clinical practice guideline that suggested referring all children 13 years and older with a body mass index (BMI) greater than or equal to 120% of the 95th percentile for age and sex for bariatric surgery evaluations. Although only a tiny fraction of eligible U.S. adolescents undergo surgery, the number of procedures increased from fewer than 800 in 2016 to 1,349 in 2021. (In comparison, more than 200,000 adults had bariatric surgery in 2021.)

In an editorial in the October issue of American Family Physician, Dr. Kathryn McKenna and I analyzed the quality and quantity of evidence supporting the AAP guideline recommendations. Notably, few studies have evaluated short-term outcomes of the most commonly performed metabolic surgery procedures in adolescents, and long-term outcomes are unknown. Similarly, although semaglutide (Wegovy) was approved by the U.S. Food and Drug Administration in December 2022 for treating obesity in adolescents, we pointed out that “only 5 out of 27 randomized controlled trials [of pharmacotherapy] included results beyond six months.”

The desire of family physicians and pediatricians to make an impact on the obesity epidemic, which affects 22% of adolescents, is understandable. To date, the results of nonpharmacologic, nonsurgical weight interventions recommended by the U.S. Preventive Services Task Force have been mostly disappointing. A 2017 Cochrane review of 70 randomized, controlled trials concluded that diet, physical activity, and behavioral interventions in elementary school age children (age 6 to 11 years) have modest short-term effects on weight and BMI compared to no treatment or usual care. A more recent Cochrane review confirmed this finding but also found low-quality evidence that these interventions did not change BMI in children 13 years and older.

Could intensive weight management of children with obesity cause unintended harms such as increasing rates of disordered eating? This possibility hasn’t been well studied, but anecdotes suggest it is a real concern. A STAT News story about the AAP guideline interviewed an eating disorder specialist at Boston Children’s Hospital who “has seen weight fluctuations evolve into serious and possibly life-threatening eating disorders,” and the New York Times Magazine article related the story of another patient who developed life-threatening anorexia after she was referred to a weight management program by her pediatrician. Although the AAP guideline authors discussed several expert-recommended approaches to mitigate this risk (use nonstigmatizing language, eliminate blame, and focus on improving health status rather than weight or BMI), these approaches are implemented inconsistently in primary care practice, where adults with obesity often experience weight stigma and bias.

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This post first appeared on the AFP Community Blog.

Medical debt is a moral failure of our health care non-system

When I changed employers in 2022, I also changed the health insurance plan for my family from traditional coverage to the "consumer" option: a high-deductible plan with a health savings account option (HDHP/SO). This type of plan used to be called catastrophic coverage because except for certain preventive services, it doesn't cover any health care expenses incurred during the plan year until (in my case) the insured person(s) meets a deductible of over $4000 in claims. The plan makes sense for us because the lower premiums almost exactly offset the deductible over the course of a year, and we have more than enough cash to pay for care expenses less than that amount. But according to the Kaiser Family Foundation's Employer Health Benefits Survey, HDHP/SO type plans now cover 29% of all private sector employees with health insurance. Since 63% of workers are unable to pay a $500 emergency expense without borrowing, it's doubtful that all of the people covered by these plans have $4000 in easily accessible savings. So for them (and for tens of millions of uninsured Americans), an unexpected emergency room visit or hospitalization will likely lead to medical debt.

A recent article in the New England Journal of Medicine reviewed the history of medical debts in the U.S., which "since the 1980s ... have shifted from obligations negotiated by doctors, patients, and hospitals to assets bought and sold by people with no role in patient care." After the Emergency Medical Treatment and Active Labor Act (EMTALA) passed in 1986, requiring hospitals to provide emergency care to patients regardless of their insurance status or ability to pay, hospitals became more aggressive about referring patients with unpaid balances to debt collections, to such an extent that "by 1993, hospitals were the source of more business for debt-collection companies than any other industry."

A Commonwealth Fund survey of working age adults found that 32% had medical or dental debts that they were paying off over time. As one might expect, uninsured persons (41%) and persons who incomes of less than 200% of the federal poverty level (44%) were more likely to be in debt, but 30% of persons with employer-based insurance were also in debt. These debts caused substantial percentages to delay or avoid getting needed health care or prescription drugs (36%), cut back spending on food, heat, or rent (39%), and worry about how they were going to pay off the debt (78%). Rather than making payments to collection agencies or banks, two-thirds of people with medical debt were making payments directly to hospitals or care providers. Similarly, a study of pre-pandemic data from the 2018-19 Medical Expenditure Panel Survey found that 27 to 45 percent of adults younger than age 65 spent more than 10% of household after-tax income on out-of-pocket health care costs, were unable to pay medical bills without going into debt, or went without medical, dental, or prescription drug care because they could not afford it.

In the past, I would have said that having the national uninsured rate fall to a record low of just 7.7% during the first quarter of 2023 would be cause for celebration. But the majority of these gains, which resulted from the COVID-19 pandemic era prohibition of Medicaid disenrollment until the end of the public health emergency, are currently being undone, with many eligible persons having their health insurance terminated due to paperwork errors or misdirected mail notices rather than any change in their economic status. And as I've explained here, having health insurance is no guarantee of protection against medical debt.

Medical debt is a moral failure of our health care non-system. If the fire department comes to put out an accidental fire at my house, I will need to pay for the damage out of my home insurance policy, but I won't incur any fire department debt. If the police respond to a break-in at my office and eventually catch the burglar (or not), my employer won't incur any police department debt. The debt we owe our military veterans for protecting our country is arguably priceless, but you won't ever receive an itemized bill to pay your share in monthly installments of the cost of their domestic or overseas service. Medical debt will only cease being a problem when our country finally recognizes that health care for people younger than age 65 is a community and national responsibility, rather than an individual one.

Health journal editors and the Pope call for action on the climate crisis

Last month, two major documents – one by a coalition of more than 200 health journal editors, the other from the leader of the Roman Catholic Church – invoked science and faith to advocate for aggressive action to address the climate crisis. On October 25, an editorial published simultaneously in participating journals declared that “climate change and biodiversity loss are one indivisible crisis and must be tackled together to preserve health and avoid catastrophe.” As previous group editorials have outlined, climate change poses ongoing threats to human health by creating “shortages of land, shelter, food, and water,” particularly in poorer countries that generate far fewer greenhouse gas emissions per person than the United States. Further, the authors argued that the climate and nature crisis meets World Health Organization criteria to be designated a global health emergency.

Three weeks earlier, on October 4, Pope Francis issued an apostolic exhortation “to all people of good will on the climate crisis,” warning that “the world in which we live is collapsing and may be nearing the breaking point.” After refuting disinformation that human activities are not responsible for our warming planet, he declared that “the world … is not an object of exploitation, unbridled use and unlimited ambition.” Reviewing the limited progress in reducing emissions following past global climate conferences and looking ahead to the 28th United Nations Conference of the Parties (COP28) in Dubai at the end of November, Francis acknowledged that “the most effective solutions will not come from individual efforts alone, but above all from major political decisions on the national and international level.”

An International Energy Agency report released in September projected that worldwide demand for fossil fuels will peak before 2030 due to the accelerating transition to solar and wind energy. This movement creates a narrow path to achieve the international goals of net-zero emissions by 2050 and limiting global warming to 1.5 degrees Celsius (2.7 degrees Fahrenheit). Remaining below this temperature threshold reduces the risk of catastrophic climate events such as this summer’s Canadian wildfires, which not only burned more than 45 million acres (the country’s previous single-year record was 19 million), but released an estimated two billion tons of carbon dioxide into the atmosphere.

The U.S. health care industry remains one of the world’s largest climate culprits, producing one quarter of global health care emissions and 8.5 percent of all U.S. emissions in 2018. U.S. hospitals are half as efficient as European hospitals and cause air pollution that leads to an estimated 77,000 excess deaths annually. Overuse of single-use disposable plastic devices is an important part of the problem, a recent JAMA Viewpoint observed:

In addition to personal protective equipment (masks, protective gowns, and gloves), everyday items such as blood pressure cuffs, catheters, complex surgical instruments, and even bed linens, pillows, and patient gowns are laden with plastic and commonly discarded after a single patient encounter. … However, there is a dearth of evidence of benefit from most single-use devices—especially for infection prevention—and dependency on them increases supply chain vulnerabilities.

Aligning infection control guidelines with evidence and prioritizing reusables in medical device regulation could incentivize health care organizations to purchase more durable, reusable patient care products.

More broadly, overdiagnosis and unnecessary medical treatment not only waste money and energy and expose patients to harm, but also increase the carbon footprint of health care. The scientific committee of this year’s Preventing Overdiagnosis conference called on decision makers to embrace sustainable health care approaches and acknowledge that “our global medical culture has driven excessive diagnostic testing, overmedicalisation, and overtreatment across many conditions that may harm patients, exhaust health care resources, and harm the planet.”

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This post first appeared on the AFP Community Blog.

Task Force to revisit prostate cancer screening recommendations

The U.S. Preventive Services Task Force (USPSTF) is inviting public comments on a draft research plan to update its 2018 recommendation statement on screening for prostate cancer. As I wrote in a previous blog post, the USPSTF’s decision to partially reverse its previous stance recommending against PSA-based screening was based on little new data. Since then, follow up of trials of localized prostate cancer treatments has shown no mortality benefits for immediate surgery or radiotherapy compared with active surveillance for 15 years after diagnosis. In the October issue of American Family Physician, a POEM on the UK ProtecT study results reports that 40 out of every 100 trial participants who selected active surveillance avoided surgery or radiotherapy, with no increase in the risk of death and a small increase in the risk of developing metastatic disease.

New questions that the USPSTF intends to review for this update involve the impact of pre-biopsy prostate cancer risk calculators or magnetic resonance imaging (MRI) on prostate biopsy rates, morbidity and mortality, quality of life, and function. A 2022 Diagnostic Tests article examined the utility of multiparametric MRI (mpMRI) for the evaluation of prostate cancer. A subsequent study found that routinely performing MRI prior to prostate biopsy in Sweden reduced biopsy rates, increased the detection of higher-grade (Gleason score 7 or higher) tumors, and decreased the detection of lower-grade (Gleason score 6) tumors. However, a UK study found that 1 in 6 asymptomatic men between the ages of 50 and 75 invited for a “prostate health check” had a prostate lesion detected on MRI, raising concern that this test may not be a panacea for reducing overdiagnosis.

The American Urological Association (AUA) updated its guidelines on prostate cancer screening and considerations for a prostate biopsy earlier this year. The AUA continues to recommend offering PSA screening every 2 to 4 years to patients aged 50 to 69 years and repeating a newly elevated PSA test before further testing, imaging, or biopsy. It gives a conditional recommendation for use of mpMRI prior to initial biopsy:

In anticipation of more definitive data, it is reasonable to obtain an mpMRI in biopsy-naïve patients prior to their first biopsy, but such a practice cannot be regarded as the standard approach based on the currently available evidence.

In the meantime, how should primary care physicians approach patients who are potentially eligible for screening? The current issue of the Annals of Family Medicine includes a scoping review on patient communication preferences for prostate cancer screening discussions. Based on an analysis of 29 studies, the researchers identified four main themes of successful discussions: using everyday language, receiving enough information, spending sufficient time, and having a trusting and respectful relationship. Notably, they found that without physician prompting, “men rarely considered possible downstream consequences if they screened positive.” Obstacles to robust screening discussions included patients having already decided to pursue screening, being passive in medical encounters, and perceiving threats to masculinity and longevity in these conversations.

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This post first appeared on the AFP Community Blog.

Coronary artery calcium is a common finding in older adults

The 2018 American College of Cardiology/American Heart Association cholesterol management guidelines advised that for patients with an intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk (7.5% to 19.9%), a coronary artery calcium (CAC) score can be used to guide the decision to start or defer statin therapy:

If the CAC score is zero, statin therapy should be withheld or delayed unless the patient is a cigarette smoker, has diabetes, or has a strong family history of premature ASCVD. A CAC score of 1 to 99 suggests statin therapy, particularly for patients 55 years and older. If the CAC score is 100 or greater or in the 75th percentile or greater, statin therapy is indicated for any patient unless otherwise deferred by the outcome of the physician–patient risk discussion.

This recommendation to selectively incorporate CAC scoring into ASCVD risk management has been controversial; the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence that adding the CAC score to traditional risk assessment improves patient-oriented outcomes. In a previous American Family Physician editorial, Drs. John Mandrola and Andrew Foy argued that “it is unclear if knowing the coronary artery calcium score would improve decision quality or adherence to statin therapy.” However, a recent Diagnostic Tests article by Dr. Hu Ying Joanna Choi concluded that “CAC score is a strong predictor of coronary heart disease, CVD, and mortality risk and provides risk discrimination and stratification beyond that provided by traditional risk factor models.”

Incidental detection of CAC on chest computed tomography (CT) scans performed for other reasons in persons without clinical ASCVD was demonstrated in a previous study to increase statin prescriptions, cardiology clinic visits, and stress tests. Until recently, however, the prevalence of CAC in asymptomatic adults was not known. Using data from the National Institutes of Health-sponsored Multi-Ethnic Study of Atherosclerosis in persons aged 45 to 84 years without ASCVD symptoms at baseline, Dr. Matthew Tattersall and colleagues calculated CAC prevalence by age, sex, race, and ethnicity. They found that across all groups, most men in their early 60s had detectable CAC, and the majority of women had CAC by their early 70s. Nearly all (96 to 98%) non-Hispanic White adults in their early 80s had CAC.

The study authors concluded the following:

[A]lthough CAC presence is associated with increased ASCVD risk regardless of age, CAC is common as age increases. Its detection provides an opportunity to discuss ASCVD risk but should avoid provoking unnecessary patient anxiety.

Further,

given the high prevalence of CAC at older ages, a finding of CAC on a CT scan should not reflexively result in a specialist referral or a prescription for a statin and/or aspirin, but rather a comprehensive ASCVD risk assessment with consideration of competing risks and patient preferences.

Clinical summaries of current USPSTF recommendation statements on statins and low-dose aspirin for primary prevention of ASCVD in adults are available on the AFP website.

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This post first appeared on the AFP Community Blog.

Prescribing food as medicine lowers weight, blood pressure, and blood sugar

At the health system where I work, I can refer patients with food insecurity and chronic health conditions that are sensitive to diet quality to a “Food Farmacy” to meet with dietitians and receive free produce from local food pantries. Similar “food as medicine” programs have been piloted throughout the United States, including several led by family medicine residencies. As Dr. Jen Middleton wrote on the American Family Physician Community Blog, the 2022 White House Conference on Hunger, Nutrition and Health made a number of policy recommendations to improve the accessibility of nutritious foods, including “accelerat[ing] access to ‘Food Is Medicine’ services to prevent and treat diet-related illness.” However, research on the health outcomes of such programs has been limited.

In a recent study published in Circulation: Cardiovascular Quality and Outcomes, researchers evaluated the impact of produce prescriptions on food insecurity and health status in nearly 4000 adults and children at 22 sites located in 12 states. 63 percent of households were enrolled in the Supplemental Nutrition Assistance Program (SNAP), and 83 percent were enrolled in the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC). Clinicians referred patients for enrollment in nutrition classes, and individuals or households received paper vouchers or electronic cards averaging $63 per person per month to purchase fruits and vegetables from participating grocery stores and farmer’s markets. Program durations varied from 4 to 10 months.

Compared to pre-program enrollment, the daily fruit and vegetable intake of adults and children increased by 0.85 and 0.26 cups, respectively. Produce prescriptions were associated with decreased food insecurity (odds ratio, 0.63) and improvements in self-reported health status in 85 percent of patients. Adults with diabetes saw their absolute hemoglobin A1c levels drop by 0.29 percent, and adults with overweight or obesity had average decreases in body mass index of 0.36 kg/meters squared. Adults with hypertension had lower systolic and diastolic blood pressures of 8.4 mm Hg and 4.9 mm Hg, respectively, at the end of the program.

Although health insurers have not historically paid for patients to fill healthy food prescriptions, a few Medicare Advantage and Medicaid programs now cover produce purchases and other nutrition-focused interventions in high-risk patients. In addition to health gains, the economic case for expanding and sustaining these programs in the long term is strong. A microsimulation modeling study projected that over a lifetime,

implementing produce prescriptions in 6.5 million US adults with both diabetes and food insecurity would prevent 292 000 (95% uncertainty interval, 143 000–440 000) cardiovascular disease events, generate 260 000 (110000–411 000) quality‐adjusted life‐years, cost $44.3 billion in implementation costs, and save $39.6 billion ($20.5–58.6 billion) in health care costs and $4.8 billion ($1.84–$7.70 billion) in productivity costs. The program was highly cost effective from a health care perspective (incremental cost‐effectiveness ratio: $18 100/quality‐adjusted life‐years) and cost saving from a societal perspective (net savings: $−0.05 billion).

A 2018 AFP editorial provided other practical information for clinicians to help patients with food insecurity, including a list of food assistance programs for children and adults.

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This post first appeared on the AFP Community Blog.

CMS announces “top 10” costly drugs list selected for price negotiations

Two weeks ago, the Centers for Medicare & Medicaid Services (CMS) announced the first 10 brand name medications that it will negotiate Medicare Part D prices directly with drug manufacturers to take effect starting in 2026. Several of these medications are commonly prescribed by primary care physicians and were discussed in American Family Physician’s STEPS (Safety, Tolerability, Efficacy, Price, Simplicity) New Drug Reviews feature from 2007 to 2020. Each drug received U.S. Food and Drug Administration (FDA) approval for at least one indication before September 2016 and currently faces no generic competition.

Apixaban (Eliquis)

Empagliflozin (Jardiance)

Rivaroxaban (Xarelto)

Sitagliptin (Januvia)

Dapagliflozin (Farxiga)

Sacubitril/valsartan (Entresto)

Etanercept (Enbrel)

Ibrutinib (Imbruvica)

Ustekinumab (Stelara)

Insulin aspart (Novolog/Fiasp)

Although Medicare began paying for prescription drugs in 2006, the legislation that created the Part D drug benefit prohibited the federal government from using its purchasing power to negotiate prices directly with pharmaceutical companies, as most government health programs in other countries do from the time of market entry. This changed with the passage of the Inflation Reduction Act in August 2022, which not only gave CMS the authority to negotiate prices of selected brand-name drugs, but also penalizes companies that increase prices faster than inflation and caps Medicare beneficiaries’ annual out-of-pocket drug spending starting in 2024.

Manufacturers have until October 1, 2023 to decide if they will participate in negotiations with CMS to establish a “maximum fair price” for the designated drugs in Medicare Part D or accept financial penalties for not doing so. Negotiations that will take place over the next year will ultimately establish a discounted price that is at least 25 to 60% lower than the drug’s list price. Collectively, the federal government is expected to save $100 billion over the next decade. That’s because a small number of brand-name drugs have an outsized budget impact, with the 10 most expensive drugs accounting for 22 percent of gross Medicare Part D spending in 2021. In addition, there may be “spillover” effects from negotiated lower prices because competitors in the same therapeutic class may decide to lower their prices or risk being left off of Part D drug formularies.

Given potentially large financial impacts on the companies involved (Eliquis, Jardiance, and Enbrel comprise 23 to 33 percent of U.S. prescription drug sales of their respective manufacturers, according to STAT), the pharmaceutical industry has already filed multiple lawsuits seeking to stop price negotiations before they take effect in 2026. Although the industry warns that less revenue could discourage innovation and new drug development, the nonpartisan Congressional Budget Office has estimated that price negotiations would have a small impact on FDA new drug approvals, with 15 fewer drugs approved over the next 30 years out of about 1300 projected.

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This post first appeared on the AFP Community Blog.

For accurate blood pressure measurement, cuff size matters

A thought-provoking editorial in the August issue of American Family Physician discussed the reasons for the divergence in treatment guidelines for mild hypertension that followed the publication of the Systolic Blood Pressure Intervention Trial (SPRINT). Dr. Stephen Martin noted that “in SPRINT, blood pressure was measured using ideal techniques that are unlikely to be replicated using standard practice.” These blood pressure (BP) measurement practices, described in a 2018 editorial about the American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline and reiterated in a clinical review article on home BP monitoring, include using an appropriately sized blood pressure cuff:

To determine cuff size, patients should measure their arm circumference at the midpoint of the upper arm. The bladder length should be 75% to 100% of the arm circumference, and bladder width should be 37% to 50% of the arm circumference.

Four adult BP cuff sizes are available in the United States: small (20 to 25 cm mid-arm circumference), regular (25.1 to 32 cm), large (32.1 to 40 cm), and extra-large (40.1 to 55 cm). Although most primary care offices have cuffs in multiple sizes, home BP monitors sold in pharmacies typically use the regular cuff size, which is too small for many adults.

Just how inaccurate is an automated BP reading in an adult patient wearing a cuff that is too small or too large? To answer this question, researchers from Johns Hopkins University performed a randomized crossover trial in 195 community-dwelling adults. The mean age was 54 years, and about one-half had a BP higher than 130/80 mm Hg when using an appropriately sized cuff. Researchers determined that a regular size cuff was appropriate for 54 study participants, whereas 35 required a small cuff and 106 required a large or extra-large size.

Each participant had four sets of triplicate BP measurements, using a cuff size that was appropriate, too small, or too arge in random order, followed by an appropriately sized cuff. Participants for whom a large or extra-large cuff size was appropriate had their systolic BPs overestimated by about 5 and 20 mm Hg, respectively, when using a regular size cuff. Diastolic BP overestimations were smaller but still statistically significant (1.8 and 7.4 mm Hg). Conversely, participants for whom a small cuff size was appropriate had their systolic BP underestimated by 3.6 mm Hg when wearing a regular size cuff. A recent analysis found that more than half of U.S. adults need a large or extra-large size, and the study authors noted the immense global implications of using cuffs that are too small:

In this context, 40% or more U.S. consumers would obtain BP readings overestimated by almost 5 mm Hg when conducting home BP monitoring. On a global scale, an error in SBP measurement of 5 mm Hg could lead to the misclassification of 84 million people to either undertreatment or overtreatment of hypertension.

In a table summarizing lessons learned and cautions raised by SPRINT, Dr. Martin warned, “Prevention and associated overdiagnosis can divert our attention from sick patients to healthy patients.” Whether family physicians and their patients are aiming for the ACC/AHA guideline’s lower BP targets or the 140/90 mm Hg target recommended for most people by the American Academy of Family Physicians, using an appropriately sized cuff is critical to avoid overdiagnosing healthy adults with hypertension.

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This post first appeared on the AFP Community Blog.

Preventing Overdiagnosis: do Americans have too many cancer screening choices?

At the Preventing Overdiagnosis Conference in Copenhagen last week, I joined nearly four hundred like-minded family and subspecialist physicians, health professionals, and researchers who are concerned about reducing the harms to patients of widening disease definitions and resulting overdiagnosis and overtreatment. After the American Board of Internal Medicine Foundation's discontinuation of logistical support for the Choosing Wisely campaign and the retirement of JAMA Internal Medicine editor and "Less Is More" champion Rita Redberg (who also attended the conference), it was reassuring to hear that the vital work of doing less to patients and more for them will go on. In addition, the international composition of conference attendees allowed me to learn more about different medical practices in Europe and around the world. Although overuse isn't the only reason that the U.S. spends by far the most per capita of any nation on health care, it does play an important role.

In Germany, where family doctors have an average of just 9 minutes (!) per patient consultation, the German College of General Practice and Family Medicine nonetheless found time to develop a prioritized guideline on “Protection against the overuse and underuse of health care.” Although we have a little more time per patient in the U.S., much of this extra time is spent administering standardized questionnaires to screen for depression and anxiety, a practice that doesn't occur in Canada or the United Kingdom and may, despite the U.S. Preventive Service's Task Force (USPSTF)'s endorsement, lead to more harm (opportunity costs and overdiagnosis) than good.

Another area where the U.S. and Canada differ is screening for osteoporosis in primary care. While the USPSTF recommends that all women aged 65 years and older undergo bone measurement testing for osteoporosis (a disease-oriented outcome), the Canadian Task Force on Preventive Health Care recommends “risk assessment–first” screening for prevention of fragility fractures (a patient-oriented outcome) in the same age group, and recommends against screening younger women or men at any age. Not only is the Canadian approach more efficient than universal screening, Roland Grad and colleagues have determined that it requires less clinician time. When there isn't nearly enough time for prevention in primary care, argued Sweden's Minna Johansson and the Mayo Clinic's Victor Montori, guidelines should consider clinicians' time needed to treat.

How much time do Danish general practitioners spend discussing various colorectal cancer screening options? None! In the U.S., a substantial part of every health maintenance visit with a patient aged 50 years (or, perhaps, 45) or older is devoted to having an individual shared decision making discussion about the pros and cons of fecal immunochemical testing (FIT), fecal DNA and FIT co-testing, and screening colonoscopy, then either ordering their preferred test or documenting that they declined to be screened. In Denmark, the public health system identifies age-eligible patients and sends them a FIT test in the mail every 2 years. As a result, the COVID-19 pandemic had only modest effects on Danish adults' participation in colorectal screening and adherence to colonoscopy following a positive test. In the U.S., many practices and health systems are still catching up on the backlog.

Although Americans supposedly value choice in health care, our non-system restricts choice at every turn, through narrow preferred provider networks, limited drug formularies, and the bane of every U.S. family physician's existence: prior authorization. Sometimes it seems that the only area where my patients have choices is cancer screening; male patients of a certain age can even choose to have a PSA test, even though most of the world has rightly concluded that the harms of prostate cancer screening outweigh any benefits. And look out for the multicancer early detection blood tests in development; even though these tests have no proven health benefits and will almost certainly increase false positives and overdiagnosis, no doubt Americans will be among the first to embrace them. There is such a thing as having too many cancer screening choices, if most of them are bad.

Get out the vote: supporting civic health in primary care

The national organization Vot-ER has designated August as Civic Health Month, “a time to showcase the link between voting and health and celebrate efforts that ensure each and every voter has the opportunity to support their community’s health at the ballot box.” Partners, including the Association of American Medical Colleges, encourage clinicians and health care organizations to support an inclusive democracy by providing patients with nonpartisan education and voter registration services.

A recent narrative review in The Milbank Quarterly explored the role of primary care in advancing civic engagement and health equity. Research shows that poorer population health is associated with lower voter turnout, with stronger associations occurring in early adulthood rather than in middle age. On the other hand, voting is associated with positive mental health and health behaviors, and higher levels of individual happiness strongly predict future civic engagement. Similarly, volunteers are less likely to be hospitalized and more likely to receive preventive care, even after controlling for age, gender, race, income, education, and insurance status: “In one study of US adults, volunteers spent 38% fewer nights in a hospital and were more likely to receive services such as flu shots, cholesterol screening, mammograms, and prostate exams as compared with nonvolunteers.”

Primary care physicians have successfully engaged patients with “civic health check-ups” at federally qualified health centers and other outpatient locations. In a voter registration project in the waiting areas of two family medicine residency clinics in the Bronx, volunteers registered 114 of 128 eligible patients during a 12-week period, 65% of whom were younger than 40 years. During the COVID-19 pandemic, a general internal medicine clinic in North Carolina used its patient portal to disseminate a REDCap survey containing embedded links to voter resources, including safer alternatives to in-person voting during the 2020 elections.

Outside of these and other individual case studies, voter enfranchisement remains, to borrow from the title of a 2020 perspective article in the Journal of General Internal Medicine, “an underused treatment strategy." To make voting a “standard of care,” Vot-ER and its partners are hosting several online events this month for clinicians who are interested in empowering patients to support their community’s health at the ballot box.

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This post first appeared on the AFP Community Blog.

Current prescriptions for addressing health-related social needs fall short

According to one recent estimate, cumulative poverty (earning less than 50% of median household income in at least one of the past 10 years) and current poverty are the fourth and seventh leading causes of death in the United States, respectively, on par with obesity and dementia and behind only heart disease, cancer, and tobacco use. The knowledge that financial insecurity and resulting social needs have profound effects on health has inspired organized medicine initiatives aimed at identifying and meeting those needs, such as the American Academy of Family Physicians’ (AAFP) The EveryONE Project.

In a 2019 editorial, Dr. Kevin Sherin and colleagues asserted that “family physicians have a leadership role in identifying and addressing issues that affect patients beyond the clinical setting.” They highlighted the AAFP’s Neighborhood Navigator tool (formerly Aunt Bertha/findhelp), which clinicians and primary care teams can use to link patients to available community resources for different types of social needs. A recent Graham Center Policy One-Pager found that the most common Neighborhood Navigator searches since 2018 were for food, housing, and health care.

Some practices and health care systems have begun screening patients for social needs using print or electronic health record-embedded questionnaires. Two articles in FPM (A Practical Approach by Drs. David O’Gurek and Carla Henke and Screening in Daily Practice by Dr. Vinita Magoon) reviewed the logistics of designing a practice workflow for screening and coding and payment considerations. Gaps in the evidence regarding the effectiveness of screening remain, however. Although the U.S. Preventive Services Task Force considers social risk in the majority of its recommendation statements, it has not found sufficient evidence to recommend screening for social needs. In a 2019 editorial, Dr. Alex Krist and colleagues discussed the research that still needs to be performed:

These recommendations highlight what is needed before recommending routine screening for social needs: an accurate screening test to identify patients with the social need, an effective treatment to address the social need once identified, and evidence demonstrating a meaningful health outcome improvement for patients.

In 2017, the Centers for Medicare and Medicaid Innovation launched the Accountable Health Communities Model, a five-year demonstration project that evaluated whether a proactive approach to identifying and addressing patients’ health-related social needs could reduce care utilization and spending. Although primary care referrals to community services increased for eligible patients, an independent evaluation found that they were no more likely to utilize these services or have their needs met than patients in a randomized control group. Patients often had a hard time reaching community service providers, were deemed ineligible for their services, or did not receive sufficient help from the provider to resolve their need (e.g., continued to have food insecurity despite receiving food assistance). A Health Affairs Forefront commentary pointed out the need to solve the “last mile problem”:

Even when patients received navigation and social service providers had capacity, gaining access to timely social services required some combination of hours of free time to make phone calls, important paperwork at one’s fingertips to apply, and a PhD in social work to understand eligibility rules.… Meaningful navigation support must … not only connect patients to appropriate services, but to ensure the patient’s social needs are met.

Equally important, many community organizations have inadequate resources and funding to serve their populations. A microsimulation study in JAMA Internal Medicine estimated the costs of implementing interventions to address social needs identified in primary care practices. Existing federal funding mechanisms (e.g., the Supplemental Nutritional Assistance Program) covered less than half of the cost of providing food, housing, transportation, and care coordination support for patients with at least one of these four needs. Clearly, the health care system cannot address health-related social needs on its own. As the unwinding of Medicaid’s COVID-19 continuous enrollment condition (which expired on March 31, 2023) proceeds, the need for social policy as health policy has never been greater.

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This post first appeared on the AFP Community Blog.

Increasing recognition of Parkinson disease in Black patients

A recent news story in The Philadelphia Inquirer profiled a Black woman who visited her primary care physician for upper body pain, stiffness, and an unusual gait and was surprised when she was ultimately diagnosed with Parkinson disease. Known by many as an “old White man’s disease,” Parkinson disease affects around 1 million Americans but historically has had low visibility in the Black community, with rare exceptions such as the late boxer Muhammad Ali, who lived with it for 34 years before his death.

Although some studies have suggested that Parkinson disease occurs less often in Black patients than in White patients, a 2020 review found mixed evidence that incidence and prevalence differ significantly by race and pointed to disparities in accessing health care at similar degrees of symptomatology as possible explanations for discordant study findings. A study of 74 patients with newly diagnosed Parkinson disease at a Veterans Affairs medical center concluded that Black patients were less likely than White patients to self-report disability, possibly leading to delays in diagnosis.

According to a 2020 article in American Family Physician, Parkinson disease most commonly presents with “a unilateral resting tremor, often localized to the distal muscles of the hand, causing a pill-rolling motion.” Other key features include cogwheel rigidity and bradykinesia, such as shuffling steps and a freezing gait. Nonmotor symptoms “include rapid eye movement sleep disorder, depression, constipation, fatigue, and olfactory dysfunction” and may precede motor symptoms in many cases. Postural instability and falls occur later in the course of illness. In cases of diagnostic uncertainty, a dopamine transport single-photon emission computed tomography scan (DaTscan) may be used to distinguish Parkinson disease from atypical essential tremor and drug-induced Parkinson-like syndromes.

Recommended therapies for motor symptoms (summarized in a Table and treatment algorithm) include carbidopa/levodopa for significant symptoms, monoamine oxidase-B inhibitors or non-ergot dopamine agonists for milder symptoms, and anticholinergic agents and amantadine for patients younger than 65 years with tremors only. Another Table summarizes pharmacologic management of common nonmotor symptoms. Unfortunately, no therapies have been shown to slow disease progression. On average, patients with Parkinson disease progress from impairment to loss of independence between three and seven years after diagnosis. In patients with Parkinson disease, 40% develop dementia, 20% to 40% develop psychosis, and some eventually have swallowing impairments, aspiration pneumonia, and weight loss due to loss of appetite and difficulty eating.

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This post first appeared on the AFP Community Blog.

To break the UK's National Health Service, roll out prostate cancer screening

The United Kingdom's National Health Service (NHS) is celebrating its 75th anniversary this month. Long hailed as a model health system that provided universal coverage and high-quality care without overly taxing the national budget, the NHS has fallen on hard times. It faces challenges of underfunding, an aging and unhealthy population, an inadequate and increasingly exhausted workforce, and a projected shortage of hospital beds. The headline of a New England Journal of Medicine article asked if the NHS was "at breaking point or already broken?" The widely reported failures of the system to meet patients' basic needs since December 2022 - a time when it should have been recovering from the stresses of the pandemic - has caused public confidence to plummet:

The unspoken agreement between the NHS and U.K. residents was that despite some rationing of care, regional differences in service availability, and the often aging and less-than-sparkling premises, in the event of a medical emergency, an ambulance would arrive promptly and high-quality care would be available at a hospital without anyone requiring an insurance card. That agreement has been broken, and satisfaction with the service is at record lows.

It likely provides little consolation to our neighbors across the pond that the U.S. is in an even sorrier state despite spending twice as much of our gross domestic product per capita on health care services. But the U.K. seems determined to add insult to injury. Despite the resoundingly negative result of the country's only major randomized trial of PSA-based screening, the NHS seems poised to roll out a population-based prostate cancer screening program. (Currently, U.K. men over age 50 can request to have PSA testing, but doctors are not encouraged or incentivized to provide the test routinely to their eligible patients.) They need only look to the U.S. to see that this decision would be a public health disaster that would produce millions of new (mostly overdiagnosed) cancer patients and divert resources away from other primary care preventive care services with a much better likelihood of improving health.

As Dr. Andrew Vickers and colleagues wrote in a recent BMJ article, the prevailing approach to PSA screening in the U.S. and other high-income countries of "informed choice" or "individual shared decision making" drives high rates of testing in older patients who are least likely to benefit and most likely to be harmed, leading to overdiagnosis and inequities:

Approaches to PSA testing that rely on people making an informed choice are likely to reflect and reproduce health inequities in preventive healthcare. Data from Canada, the US, and Switzerland suggest PSA testing is inversely associated with income and education; in Canada and the US, PSA testing is less common in people from ethnic minorities. In the UK and Switzerland, rates of PSA testing are lower in economically deprived areas. Although the effects of disparate rates of PSA testing on health outcomes are still unclear, countries should decide who gets offered screening based on a risk assessment rather than leaving it to individuals.

Vickers and colleagues went on to advise that countries either set up government-sponsored, comprehensive, risk-based programs for prostate cancer detection or, alternatively, make a "clear recommendation against PSA-based screening" - a situation that existed in the United States between 2012 and 2018 when the U.S. Preventive Services Task Force gave this service a "D" (don't do) recommendation grade. The former would presumably maximize benefits by only testing persons at the highest risk of dying from prostate cancer, while the latter would minimize harms by declining to prematurely diagnose prostate cancer in well men. Since 2018, the U.S., and now potentially the U.K., have made the worst choice of all.

Many areas of the U.S. lack integrated behavioral health in primary care

A Graham Center Policy One-Pager in the June issue of American Family Physician overlaid the geographic locations of integrated behavioral health clinics in primary care over a color-coded map of U.S. counties’ percentages of residents reporting poor mental health. In an ideal world, these clinics, which are associated with better health outcomes, higher patient satisfaction, and lower costs, would cluster in regions with greater mental health distress. Unfortunately, the Graham Center analysis found that the opposite was frequently the case, with such clinics “notably lacking in … rural Kentucky, Louisiana, Tennessee, and West Virginia.”

What factors could account for this apparent mismatch between integrated behavioral health supply and demand? A recent Health Affairs Forefront article noted that obstacles to widespread adoption include an ongoing debate about the need for high fidelity to the evidence-based Collaborative Care Model, which can be difficult to implement, and inadequate fee-for-service payment relative to costs of practice re-design and ongoing services. Successful efforts to improve behavioral health integration in Rocky Mountain Health Plans, Blue Cross Blue Shield of Michigan, Rhode Island, and Minnesota have relied on multiple approaches customized to primary care structures and community needs.

A 2022 study in the Journal of General Internal Medicine examined characteristics of integrated behavioral health associated with primary care clinician confidence in managing depression in a network of community health centers (CHCs) in 10 mid-western states. Primary care clinicians reported more confidence when their CHCs had depression tracking systems; when they were satisfied with the accuracy of depression screening; when they had access to behavioral health treatment plans; and when they cared for more patients with depression. In contrast, clinicians working at CHCs with more patients living below the poverty line had lower confidence in prescribing antidepressants, while those at CHCs with more Black patients had lower confidence in diagnosing depression.

Integrated behavioral health clinics may or may not provide treatment for persons with opioid use disorder or other substance use disorders, even though these commonly co-occur with mental health problems. In a Substack post, Ben Miller explained that shared vulnerability, dual diagnosis, and bidirectional influence support pairing mental health and addiction treatment. Obstacles to concurrent treatment in primary and specialty care settings include societal stigma, diagnostic classification systems, health system fragmentation, and different treatment philosophies.

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This post first appeared on the AFP Community Blog.

Housing matters for good health

What does a "renter's utopia" in Vienna have to do with optimal treatment of asthma?

Francesca Mari's recent New York Times Magazine article about public housing in the capital city of Austria features images of beautiful, well-maintained apartment buildings with rooftop swimming pools, lots of green foliage and attractive playgrounds. 80 percent of the city's residents qualify for public housing, a staggeringly high percentage that might imply to an American that the vast majority of people living there are poor. Actually, Vienna makes its plentiful supply of municipal housing (which they call "social housing") available to a large portion of the middle class, and tenants cannot be turned out no matter how much their incomes increase after signing the initial rental contract.

To American eyes, the whole Viennese setup can appear fancifully socialistic. But set that aside, and what’s mind-boggling is how social housing gives the economic lives of Viennese an entirely different shape. ... Imagine having to think about [housing expenses] to the same degree that you think about your restaurant choices or streaming-service subscriptions. Imagine, too, where the rest of your income might go, if you spent much less of it on housing. Vienna invites us to envision a world in which homeownership isn’t the only way to secure a certain future — and what our lives might look like as a result.

In contrast, wrote Mari, one of several "fatal" compromises to the real estate industry in the Housing Act of 1937, restricted eligibility for public housing in the U.S. to "those so poor that they could never secure decent housing in the private market." These units were deliberately underfunded and poorly constructed. As millions of past and current residents of American urban housing projects could testify, "America's public housing was designed to fail: to be unappealing to anyone who could afford to rent."

Which brings me to patients with asthma who live in American public housing projects or neighborhoods in similar states of disrepair. In West Philadelphia, the Children's Hospital of Philadelphia (CHOP) partnered with community organizations to implement Community Asthma Prevention Program Plus, a program that performed home inspections of CHOP patients with asthma and completed repairs to 97 homes that were deemed likely to benefit these patients, including carpet removal, roof and plumbing repairs, improving ventilation, and eradicating mold.

That's great, but what if the home is located next to an interstate highway, factory, or power plant emitting pollutants that can't be easily remediated by a contractor? Or if these patients' asthma exacerbations are triggered by the stress of living in a violent neighborhood? The logical next step is to move to a different home. The case settlement for a 1995 lawsuit against the U.S. Department of Housing and Urban Development for discriminatory public housing practices created the Baltimore Regional Housing Partnership (BRHP), which as of October 2020 had provided housing vouchers to more than 5,200 households to move to privately-owned housing in low-poverty neighborhoods. A research team followed 123 children with persistent asthma whose families moved with BRHP's assistance from 2016 to 2020. Compared to a control group, these children experienced fewer exacerbations, fewer days with symptoms, and lower measures of stress.

Hospitals and health systems are now investing in affordable housing to improve health in many areas of the country, reasoning that being homeless or housing insecure presents a huge obstacle to attaining control of asthma, diabetes, and other chronic diseases. Health care payers are also taking notice. In an ambitious experiment, California's Medicaid program is spending $12 billion over the next 5 years on "a new kind of safety net that provides housing and other services for [145,000] people who are homeless or at risk of becoming homeless and have complicating conditions like mental illness or chronic disease." Whether the experiment will achieve its aim of moderating the program's soaring health care costs remains to be seen, but even if it doesn't, giving people access to decent housing is a worthy end in itself. Kudos to Philadelphia, Baltimore, and California for thinking outside of the health care box, but I'd rather be in Vienna: a city where grinding poverty and housing vouchers aren't necessary for persons of modest means to afford a clean and safe apartment for as long as they want to live there.

Patient portals and electronic health record transparency: pros and cons

After completing my fellowship, I considered taking a job filling in for a family physician on sabbatical who had been in solo practice for thirty-plus years. Even for these pre-electronic health record (EHR) days, his written notes were telegraphic. A typical example: "Patient doing fine. Labs normal. Continue current meds and follow up in 6 months." That was it. What he recorded in the chart was for his eyes only. No need to write an essay, or even a paragraph, when the only purpose was to jog his memory for the next time he saw the patient.

A few years later, the federal government handed tens of billions of dollars to physicians and health care organizations to convert their paper charts to digital form in exchange for requirements to use these records to measure quality of care and increase transparency of health information to patients through so-called “patient portals.” Notes became longer and more detailed. The negative effects of EHRs on physician burnout and health care team communication have been well-documented. Aside from initiatives such as OpenNotes, however, transparency was not fully implemented until last year, when the Office of the National Coordinator for Health Information Technology re-interpreted a previous rule against “information blocking” as an expectation that patients would have real-time online access to their office notes and test results rather than having to request them. With little fanfare, the floodgates opened.

In an insightful article in The New Yorker, Dr. Danielle Ofri, a general internist, admitted her newfound reluctance to list an extensive differential diagnosis for anemia in the EHR because she worried that mentioning colon cancer or a duodenal ulcer could scare the patient. After all, she observed, “my inbox was already jammed with panicked messages from people convinced that they had catastrophic illnesses, based on minuscule lab discrepancies and panic-inducing Google searches.” Comparing EHR transparency to the “C-SPAN effect,” in which live, nonfiltered television coverage of Congress made lawmakers more likely to grandstand to the camera, Ofri noted that granting patients instant access to test results has also had unintended consequences:

In one devastating stretch of twenty-four hours, two of my patients learned of their cancers’ metastatic reappearance by way of the portal. Their inboxes pinged with new test results; they read them before either their oncologist or I had even seen the scans, let alone called. … In the past, I’d do the legwork [for the evaluation] before I called the patient. Now that buffer is gone, and I am pressured to act immediately: the patient has seen the result, and further delay would be unconscionable. This timbre of rush imperils thoughtful analysis, and I worry incessantly about missteps.

In contrast to the mixed feelings of primary care clinicians and staff about patients having online access to their health records, research suggests that patients overwhelmingly prefer to see test results immediately, even though those marked as abnormal increased worry prior to discussions with health professionals. Sometimes, portals save time. Rounding on my practice’s adult inpatient service last month, I was pleasantly surprised that in several cases I could skip through the text of a recently resulted blood or imaging test finding – which the patient or their designated decision-maker had already seen on a smartphone app – and jump straight into the implications for their condition and care plan. Finally, portals allow patients to proactively correct or update medications, allergies, and problem lists outside of office visits, rather than taking up precious minutes with medical assistants or physicians in the examination room.

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This post first appeared on the AFP Community Blog.