tag:blogger.com,1999:blog-15281232839524149482024-03-17T23:04:07.515-04:00Common Sense Family DoctorCommon sense thoughts on public health and conservative medicine from a family doctor in Lancaster, PA.kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comBlogger953125tag:blogger.com,1999:blog-1528123283952414948.post-33932280293468261132024-03-07T09:56:00.002-05:002024-03-07T09:56:45.811-05:00Deadly drivers and the limits of preventive counseling<p>I believe that I'm a pretty safe driver. I don't use my phone in the car except for calls on my Bluetooth hands-free system, I come to a complete stop at stop signs even when no one else is around, and I never get in the driver's seat after I've been drinking. During the fall of 2020 and spring of 2021, though, I paid more attention than usual to driving safely. Our auto insurance company offered a discount for installing a device in my car that monitored my driving behavior, and my then 15 year-old son (in Utah, the minimum age for a learner's permit is 15) began learning to drive.</p><p>There has been a lot of <a href="https://www.nytimes.com/2024/01/10/magazine/dangerous-driving.html">media attention</a> in recent months to the increase in <a href="https://www.vox.com/24078289/us-drivers-distracted-driving-cellphone-road-deaths-pedestrians">distracted driving</a> and its deadly consequences since the start of the pandemic. After falling for decades thanks to legislation mandating safety features such as airbags to a low of 32,479 in 2011, annual traffic-related deaths (including pedestrians) gradually rose, then spiked during the pandemic from 38,824 in 2020 to 42,795 in 2022. This statistic is similar to the <a href="https://www.pewresearch.org/short-reads/2023/04/26/what-the-data-says-about-gun-deaths-in-the-u-s/">48,000 firearm homicides and suicides</a> that occur in the U.S. every year.</p><p>Why have traffic-related deaths been going in the wrong direction? A <a href="https://www.nytimes.com/2024/01/10/magazine/dangerous-driving.html"><i>New York Times Magazine</i> story</a> highlighted deferred road maintenance, larger and more powerful vehicles, aggressive driving and road rage, and the perennial culprit, intoxicated drivers. A <a href="https://publications.aap.org/pediatrics/article-abstract/153/3/e2023064159/196598/Child-Passenger-Deaths-in-Traffic-Crashes?redirectedFrom=fulltext">recent analysis of data</a> from the National Highway Traffic Safety Administration found that 1 in 5 deaths of child passengers in motor vehicle crashes involved an alcohol-impaired driver (blood alcohol concentration > 0.08 g/dL), and the more impaired the driver was, the less likely the child was to be wearing a seat belt.</p><p> A <a href="https://www.vox.com/24078289/us-drivers-distracted-driving-cellphone-road-deaths-pedestrians">Vox story</a> pointed the finger at smartphones, noting that a company that sells a more sophisticated version of the device I installed in my car a few years ago - an app that measures phone motion and screen interaction while driving - found that in 2022, drivers interacted with their phones on nearly 58% of trips (an average of 2 minutes, 11 seconds per hour), more than one-third while driving over 50 miles per hour. This is when they <i>knew</i> the app was monitoring their behavior; one wonders if they would have been on their phones even more without it.</p><p>The difference between a medical and a public health problem is often merely a matter of perspective. For example, the solution to the medical problem of hypertension is to screen patients for high blood pressure and put the ones whom we diagnose on medications and/or encourage them to be more physically active and eat differently. But treating high blood pressure as a medical problem has been an abysmal failure. According to the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9370255/">National Health and Nutrition Examination Survey</a>, of the one-third of Americans who had hypertension from 2017-2020, more than half had uncontrolled blood pressure (>140/90 mm Hg) and even among patients taking blood pressure medication, nearly one-third had uncontrolled blood pressure. Zoom out from the office setting to communities, counties, and states, and it's easy to see that hypertension is really a public health problem: too much sodium in food, too little access to safe places to exercise without a gym membership, difficulty getting a primary care appointment due to insufficient supply and uneven distribution, and so on.</p><p>Is impaired driving a medical or a public health problem? I got a lot of flak from readers when <a href="https://www.medscape.com/viewarticle/985972">I wrote in a Medscape commentary</a> that I would report to law enforcement a patient who declined to stop driving while high on cannabis. <a href="https://www.aafp.org/pubs/afp/issues/2020/1001/p411.html">Clinical guidelines recommend</a> counseling parents and guardians about keeping their children in rear-facing car seats until age two, using age and size-appropriate car and booster seats, and having children age 13 and younger ride exclusively in the back seat. With any adolescent approaching the minimum age for a learner's permit (16 years in Pennsylvania), I spend time during the well-child visit discussing the dangers of driving and texting, substance use before or while driving, and getting into a car with an impaired or distracted driver. Perhaps my counseling has saved a few lives over the past 20 years, but it's never been proven that this type of counseling improves health outcomes.<br /></p><p>However, the evidence is clear that public health interventions and laws reduce motor vehicle crash injuries and deaths. The Community Preventive Services Task Force has evaluated a <a href="https://www.thecommunityguide.org/topics/motor-vehicle-injury.html">long list of interventions</a> that save lives by reducing alcohol-impaired driving and increasing use of child safety seats, seat belts, and motorcycle helmets. The <a href="https://www.vox.com/24078289/us-drivers-distracted-driving-cellphone-road-deaths-pedestrians">Vox story</a> cited data that associated the passage of "hands free" phone laws with reductions in phone motion and driver distractions, but a lack of enforcement may cause these bad habits to reassert themselves over time.</p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-20162083278931199132024-02-27T19:27:00.001-05:002024-02-27T19:27:28.155-05:00Birthday blessings<p>The following is a guest post from my sister-in-law, Dr. Therese Duane, a trauma surgeon who is blogging about her medical mission in Uganda. You can read more about the essential work she and her colleagues have been doing at <a href="https://mercy-trips.com/">Mercy Trips Healthcare Outreach</a>.</p><p>**</p>As a little girl growing up in a big family, there were few things that I could actually call my own. Not only did I share a room, but for a long time my sisters and I even shared a twin bed. Going clothes shopping meant venturing into another sister’s closet for hand-me-downs, and toys belonged to whomever could run away fast enough without tripping and getting tackled by the rest of us. But there was one thing we could call our own, and that was our birthday—although I did share mine with an uncle and George Washington. <br /><br />Still yet, in our home, my mother made an effort for each of her seven children to have a special birthday. I have fond recollections of sleepovers filled with giggles, scary movies, and not enough sleep that always culminated in Mickey Mouse pancakes my mother would prepare especially for me. I knew I was loved. <br /><br />If someone had told me 40 years ago that I would have spent my birthdays in Uganda doing medical mission work, I am not sure I would have believed them. And yet, here I am turning 54 years old and instead of giggles with my girlfriends, I am getting chuckles from children who—despite being far from home undergoing painful procedures—still manage to share their smiles with strangers. <br /><br />Caring for all these families, many of which are large, reminds me how the gift of family is universal. I see many women struggling with fertility with few options. One 42-year-old with only one child came to have her fibroids removed so she could carry another pregnancy to term, as she had previous miscarriages. Sadly, her evaluation demonstrated enormous tumors that were compressing her pelvic organs and causing significant pain. After explaining that her only option was removal of her uterus and more biological children weren’t possible regardless of surgery, I could see the devastation. She left clinic having been informed of the risks of delaying surgery and never returned, choosing instead to be in pain than accept the inevitable. Other women come in with many children, and want more, but need surgery for another complaint. Hence, <a href="https://www.factsaboutfertility.org/">fertility awareness education</a> is incredibly important for this impoverished country so that couples can make healthy decisions for themselves as they cherish their gift of family. <br /><br />So, as this birthday comes to a close, I have already been privileged to bring a baby boy into this world through a c-section for one patient and remove a diseased ovary of a different woman, preserving her other, healthy ovary in the hopes that this will help her future fertility. In Uganda, general surgery is certainly general as we provide a wide array of service to the best of our ability. We strive to ensure that the gift of family is embraced, preserved, and expanded based on God’s will and that every person knows they are loved.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2FlekraDDlMgzSPkUlqoseimbmuH9xJZUx9VLPaw-F2pYBI0FG9BNbw7WBGdASLtyPoBgHIItn2P0130EL2CZ9HEsywGti9_9oNNDfM3i90au1rCuUkDuWuIOsXmARnDyKzyWhPNxr07SFV70zVLB5XwvAj9niuF5ENxnJXoSVuNnSZjiEVPIfyJej7w/s4032/IMG_5041.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2FlekraDDlMgzSPkUlqoseimbmuH9xJZUx9VLPaw-F2pYBI0FG9BNbw7WBGdASLtyPoBgHIItn2P0130EL2CZ9HEsywGti9_9oNNDfM3i90au1rCuUkDuWuIOsXmARnDyKzyWhPNxr07SFV70zVLB5XwvAj9niuF5ENxnJXoSVuNnSZjiEVPIfyJej7w/s320/IMG_5041.jpg" width="240" /></a></div><div><br /></div>Before I rest for the evening in preparation for another long day in the OR tomorrow, I will call my mother to thank her for the gift of my life and family. And as we reminisce about Micky Mouse pancakes, I will remind her that it was her example and that of my father’s that began this call for me. I see the same generosity of spirit in all my siblings and pray to set the right example for my four children just as my parents did for me.kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-51724149776360088272024-02-21T09:04:00.002-05:002024-02-22T21:19:13.174-05:00Appreciation (the changing of the guard)<p>Originally posted on Common Sense Family Doctor on February 7, 2018.</p><p>**</p><p>The February 1, 2018 issue of <i>American Family Physician</i> marked <a href="https://www.aafp.org/journals/afp/about/staffhistory.html">the first time since 1988</a> that a family physician other than Dr. Jay Siwek was serving as the journal's editor-in-chief. Dr. Siwek, who bade farewell to readers in a <a href="https://www.aafp.org/afp/2018/0115/p83.html">poignant, memory-filled editorial</a> in the January 15 issue, will stay on as editor emeritus. This month, Dr. Siwek <a href="https://www.aafp.org/afp/2018/0201/p154.html">introduced his successor</a>, longtime associate editor Dr. Sumi Makkar Sexton. You can read about Dr. Sexton's extensive qualifications and experience in <a href="https://www.aafp.org/afp/2018/0201/p154.html">Dr. Siwek's latest piece</a> and learn about her plans for the future of <i>AFP, </i>which include making journal content more usable at the point of care, in <a href="https://www.aafp.org/afp/2018/0201/p155.html">her introductory editorial</a>.<br /><br />It has been my good fortune to know Jay and Sumi for the past 20 years, since I arrived at Georgetown University School of Medicine as <a href="https://www.aafp.org/afp/2004/0815/p629.html"><i>AFP</i>'s medical editing fellow</a> in the summer of 2004. Both played critical roles in my development as a family physician and medical editor, during and after my one-year fellowship. It was Jay, in his previous capacity as Chair of Georgetown's Department of Family Medicine, who hired me as a junior faculty member and supported each of my subsequent promotions to assistant, associate, and full professor. After I left the department for several years to work as a medical officer at the <a href="https://www.ahrq.gov/">Agency for Healthcare Research and Quality</a> and earn a master's degree in public health, it was Jay who convinced me to return and deploy my new skills to direct the department's health policy fellowship and eventually take on other leadership and teaching positions in population health.<br /><br />On the other hand, it was Sumi, as the editor of Tips from Other Journals (an <i>AFP</i> department that ended in 2013) who continued to hone my writing and evidence-based medicine skills for years after my fellowship ended. Under her supervision, from 2005 to 2010 I wrote more than 60 summaries of primary care-relevant research studies for <i>AFP</i>. And after my first post-fellowship clinical position unexpectedly fell through, it was Sumi who hired me to see patients at her thriving practice, <a href="http://www.premierprimarycare.com/">Premier Primary Care Physicians</a>, which was an early adopter of innovations such as electronic medical records and advanced-access scheduling.<br /><br />As <i>AFP's</i> <a href="https://www.aafp.org/journals/afp/about/staff.html">new deputy editor</a>, I have worked closely with Sumi and Jay for the past several months to support their changing of the guard at editor-in-chief, and I look forward to many more years of collaborating with them both. Moving on from Dr. Siwek to Dr. Sexton is an important transition, but the best-read journal in primary care won't miss a beat.</p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-6911109214280365142024-02-16T14:15:00.005-05:002024-02-16T14:19:47.704-05:00Looking for a balanced approach to America's illicit drug use problem<p>In an <a href="https://commonsensemd.blogspot.com/2011/11/rethinking-war-on-drugs.html">earlier post</a> about my frustrating experience serving on a District of Columbia grand jury that handled indictments for drug-related offenses, I wrote approvingly about Portugal's novel approach to decriminalizing illicit drug use. In short, rather than receiving criminal sentences and jail time, people caught using small amounts of drugs in Portugal receive citations and are offered counseling and medical treatment. Since then, the city of San Francisco and the state of Oregon have both implemented versions of Portugal's non-punitive approach, with mixed results.</p><p>A <a href="https://www.nytimes.com/2024/01/31/upshot/san-francisco-drug-crisis.html">January 31 <i>New York Times</i> article</a> compared Portugal to San Francisco, which saw its overdose death rate spike during the pandemic to more than twice the national average. Addiction treatment in San Francisco is fragmented and rarely accepted by people caught using drugs: "From May 30 [2023] to Jan. 4, just 25 people accepted treatment after an arrest, in a city where tens of thousands of people use drugs regularly." Harm reduction programs in San Francisco, unlike in Portugal, do not always push clients toward treatment. The culture of the California city is more libertarian than conservative Portugal, where drug use is discouraged and stigmatized. Finally, the drug response in San Francisco is not guided by a comprehensive strategy. The public health department and law enforcement agencies are divided on how much of the approach to recreational drug users should be carrots versus sticks, and other than reducing the overuse rate, the city has no clear goal.</p><p>A <a href="https://www.npr.org/2024/02/07/1229655142/oregon-pioneered-a-radical-drug-policy-now-its-reconsidering">February 7 NPR story</a> examined Portland, Oregon's experience with decriminalization of drug possession since a state ballot measure passed in November 2020: "So far, police have handed out more than 7,000 citations, but as of December, only a few hundred people had called the hotline to get assessed for a substance use disorder. And even fewer accessed treatment through the citation system." Opioid-related overdose deaths across the state rose from 280 in 2019 to 956 in 2022, though given the rise of fentanyl and homelessness and the impact of the pandemic on health care services, it's hard to know if the new approach contributed to the difference. The story quoted an addiction medicine physician arguing that the primary drivers of Oregon's rising overdose toll are "our decades-long, underbuilt system of behavioral health, substance abuse disorders, shelter and affordable housing" - not the decision to treat drug use as a medical problem rather than a crime.</p><p>The U.S. health care system is a culprit, too. Not only is a sizeable percentage of our population uninsured at any given time, people with drug use disorders are overrepresented in that group. And if you can afford to see a doctor, you can't necessarily find one willing to prescribe medications for opioid use disorder. My friend and fellow family physician, Dr. Corey Fogleman, recently <a href="https://lancasteronline.com/opinion/columnists/medicine-offers-hope-to-county-residents-addicted-to-opioids-column/article_f1e2a624-c127-11ee-a5cf-abc0ba55a47a.html">co-authored a column</a> in the Lancaster newspaper that observed how and why our county's outcomes have positively diverged from the rest of the state of Pennsylvania:</p><i>Lancaster County health care providers are unique in their willingness to provide buprenorphine treatment for opioid use disorder. Further, the Lancaster General Hospital Family Medicine Residency Program teaches this care to every medical student and medical resident educated in our system. Since 2016, Lancaster County has increased buprenorphine prescribing by 79% compared to a statewide average of 30%.<br /><br />This has paved the way for crucial gains in fighting the opioid epidemic. Lancaster County has observed a notable and consistent downward trend in mortality due to this disease. Overdose deaths reached a peak in 2017, with more than 30 deaths per 100,000 residents that year. In 2022, per capita overdose deaths in Lancaster County dropped below 20 per 100,000 residents (106 total deaths). By comparison, Pennsylvania as a whole continues to observe a gradual upward trend in overdose fatalities, from 35 to more than 40 deaths per 100,000 residents during the same time frame (there were 5,155 total overdose deaths in the commonwealth in 2022).</i><div><i><br /></i></div><div>It's true that local problems often require locally tailored solutions. Perhaps too much wishful thinking went into San Francisco's and Oregon's attempts to duplicate Portugal's successful approach to illicit drugs. On the other hand, Lancaster County has shown that it is possible to improve public health and save lives by engaging physicians and other health care professionals in overdose prevention efforts.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-26437263913191911422024-02-11T14:50:00.003-05:002024-02-11T14:53:20.236-05:00Prenatal and congenital syphilis cases continue sharp rise in the U.S. <p>Last November, the Centers for Disease Control and Prevention (CDC) reported that cases of congenital syphilis in the U.S. had <a href="https://www.cdc.gov/mmwr/volumes/72/wr/mm7246e1.htm?s_cid=mm7246e1_w">soared 755% over the past decade, peaking at more than 3,700 in 2022</a>. The CDC’s review of that year’s cases revealed that nearly 90% were potentially preventable, resulting from a lack of timely testing and adequate treatment. <a href="https://www.ajpmonline.org/article/S0749-3797(21)00623-1/fulltext">An analysis of 2017-2019 Medicaid claims</a> in 6 Southern states (Georgia, Kentucky, Louisiana, North Carolina, South Carolina, and Tennessee) found that despite state laws mandating prenatal syphilis screening, actual screening rates ranged from 56% to 91%. <br /><br />In a <a href="https://commonsensemd.blogspot.com/2020/08/syphilis-and-covid-19-epidemic-within.html">previous blog post</a>, I discussed how the diversion of public health personnel and resources during the COVID-19 pandemic had hampered contact tracing efforts to prevent the spread of syphilis and other sexually transmitted infections (STIs). Since June 2023, syphilis treatment has been affected by a <a href="https://www.npr.org/2023/06/16/1182626821/pfizer-penicillin-shortage">global shortage of injectable benzathine penicillin</a>, leading the CDC to advise <a href="https://www.cdc.gov/std/dstdp/dcl/2023-july-20-Mena-BicillinLA.htm">prioritizing its use</a> for infections in pregnant patients and babies with congenital syphilis (doxycycline can be used for infections in non-pregnant persons). <br /><br />Although the U.S. Preventive Services Task Force recommends <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/syphilis-infection-nonpregnant-adults-adolescents-screening">screening for syphilis in nonpregnant patients at increased risk</a> so that persons testing positive can be treated to break the chain of infection, the number of syphilis cases in the U.S. continues to rise. The CDC’s latest <a href="https://www.cdc.gov/std/statistics/2022/overview.htm">Sexually Transmitted Infections Surveillance Report</a> documented more than 207,000 cases in 2022 – a 17 percent increase over 2021 and the highest number reported since 1950. Few communities were spared; at least one case of congenital syphilis was reported in 47 states and the District of Columbia. <br /><br />An editorial in the January 2024 issue of <i>American Family Physician</i> reviewed the <a href="https://www.aafp.org/pubs/afp/issues/2024/0100/editorial-sti-pregnancy.html">management of STIs during pregnancy</a>. At a minimum, all pregnant patients should receive screening for syphilis in the first trimester, with repeat screening recommended at 28 weeks and delivery for patients at high risk or living in high-prevalence communities. Clinicians should have a “low threshold of suspicion” for atypical presentations: <br /><br /><i>Although the classic syphilitic chancre is a single, sharply demarcated, painless ulcer, only 30% of patients have this presentation. Chancres may be hidden (e.g., in the cervix or rectum) or absent. Opt-out screening is essential because a large National Institutes of Health study found that 49% of pregnant women with syphilis from 2012 to 2016 had no identifiable risk factors. </i><br /><br />A recent <a href="https://www.nejm.org/doi/full/10.1056/NEJMra2202762?query=featured_home"><i>New England Journal of Medicine</i> article</a> reviewed the evaluation and management of neonates with congenital syphilis. <br /><br />As my colleague Dr. Jennifer Middleton wrote, the CDC has proposed <a href="https://www.aafp.org/pubs/afp/afp-community-blog/entry/proposed-postexposure-prophylaxis-for-stis-doxy-pep.html">a novel prevention strategy called doxy-PEP</a> (doxycycline preexposure prophylaxis for syphilis and other STIs) for cisgender men who have sex with men and transgender women who have sex with men with an STI diagnosis in the last year. Unfortunately, a <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2304007">recent trial of doxy-PEP</a> in cisgender women in Kenya who were receiving <a href="https://www.aafp.org/pubs/afp/issues/2023/0900/editorial-hiv-prep.html">HIV PrEP</a> found no reduction in STI incidence, though participants’ overall adherence to doxycycline was low.</p><p>**</p><p>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-83707490986328924112024-02-07T12:13:00.003-05:002024-02-07T12:13:15.131-05:00Research award recognition<p>I've written many papers for academic journals since <a href="https://www.aafp.org/pubs/afp/issues/2004/0101/p75.html">my first article</a> was published during my third year of my family medicine residency. My full-length CV that lists every one of them, which I update meticulously, now stretches to 18 pages in 11-point font. But the "Honors and Awards" section only takes up one-third of a page and includes three awards from residency. Until today, I would have said that the award I'm most proud of is the Article of the Year Award I received in 2009 from the Agency for Healthcare Research and Quality for my <a href="https://www.acpjournals.org/doi/10.7326/0003-4819-149-3-200808050-00009">2008 systematic review</a> of the benefits and harms of PSA screening for prostate cancer. It launched my career in preventive medicine and guideline development and led to lots of invitations to speak and write other papers (like <a href="https://www.aafp.org/pubs/afp/issues/2016/1115/p782.html">this one</a>) on how to approach decision-making surrounding the PSA test in older men.</p><p>Today I learned that a recent <a href="https://www.jabfm.org/content/early/2023/05/11/jabfm.2022.220320R2">systematic review</a> that I co-authored on the harms of screening colonoscopy has won a major research award from the Society of Teachers of Family Medicine. I'm delighted, not only for the surprise recognition, but because earlier versions of this paper were rejected by several different gastroenterology and general internal medicine journals and panned by highly credentialed peer reviewers (who fervently believed that screening colonoscopy could only be a force for good) before it was finally accepted. It is testimony to the persistence of Dr. Alison Huffstetler and the rest of our team that the product of our many hours of slogging through the medical literature ever saw the light of day. Most importantly, I hope that this paper - like my prostate cancer paper in 2008 - makes a meaningful contribution to the conversations that family physicians and their patients have every day about the benefits and harms of cancer screening tests.</p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-30707432400445571402024-02-04T19:19:00.001-05:002024-02-04T19:19:06.601-05:00My next speaking engagement<p><a href="https://www.eeds.com/portal_live_events.aspx?ConferenceID=432091&fbclid=IwAR2b2iU3HOggLC1T4PVl_LeiuxLKIhxkWmng5MjjWFVufFDAFEGqzYnUb7g" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="1800" data-original-width="1440" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgINAKfGl_WdkfQla9JdBdkNAjt2JCuQpWyaxAGnT889zHCz9OZJrVxdxDuRFnUHF-83im-9N7CrZ7hJth2qO5BvUkNDYG1mFTrqRGHt9j0lNVSNdoRh-hfKpHZa5keRP1gPCLq-cuCK7zf79rEeG5czOIifzV2vSeuyaQPM4aLZZn7s65c2x_MIASsL4Q/w512-h640/Hot%20Topics%20Flyer.jpg" width="512" /></a></p><p></p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-56063424960342872772024-01-28T12:42:00.001-05:002024-01-28T12:42:10.784-05:00Latent Autoimmune Diabetes in Adults (LADA): recognition and managementA recent <a href="https://kffhealthnews.org/news/article/diabetes-misdiagnosis-type-2-lada-black-women/"><i>KFF Health News</i> article</a> highlighted misdiagnoses of <a href="https://www.aafp.org/pubs/afp/topics/by-topic.diabetes--type-2.html">type 2 diabetes</a> in several Black female patients who actually had latent autoimmune diabetes in adults (LADA), a slowly progressive form of type 1 diabetes. Although the article suggested that the patients’ race may have played a role in delaying their LADA diagnoses, this condition commonly goes unrecognized in primary care. According to Dr. Jeff Unger in a 2010 <a href="https://www.aafp.org/pubs/afp/issues/2010/0401/p843.html"><i>American Family Physician</i> editorial</a>, an estimated 10% of patients with a diagnosis of type 2 diabetes actually have LADA. <br /><br />Unlike patients with classic type 1 diabetes, patients with LADA have initially preserved pancreatic beta cell function and thus may have a transient response to noninsulin therapy and lifestyle modifications. However, as the disease progresses, they will require insulin to maintain blood glucose control, generally within one year of diagnosis. <br /><br />A feature that distinguishes LADA from type 2 diabetes is the presence of at least one autoantibody, most commonly islet call antibodies or antibodies to glutamic acid decarboxylase (GAD). While persons with type 2 diabetes have normal to high C-peptide levels, <a href="https://diabetesjournals.org/spectrum/article/29/4/249/32702/Recognizing-and-Appropriately-Treating-Latent">patients with LADA tend to have low levels</a>. Dr. Unger provided other potential clues that should prompt clinicians to reconsider a type 2 diabetes diagnosis: <br /><br /><i>Suspicion of LADA should be heightened in patients with coexisting autoimmune disorders, such as hypothyroidism, who are not excessively overweight and who have deteriorating glycemic control despite intensification of oral therapies and the use of incretin mimetics. Physicians may consider GAD antibody testing to determine whether LADA is present. </i><br /><br />A <a href="https://diabetesjournals.org/diabetes/article/69/10/2037/16062/Management-of-Latent-Autoimmune-Diabetes-in-Adults">2020 consensus statement</a> from an international expert panel made treatment recommendations for patients with LADA. Although insulin is effective and safe, it is unclear if it should be given to patients in the early stages of LADA who may still respond to oral therapies such as metformin. The panel discouraged the use of sulfonylureas, which may accelerate loss of beta cell function. Dipeptidyl peptidase 4 inhibitors, glucagon-like peptide receptor 1 agonists, and sodium-glucose cotransporter 2 inhibitors have shown promise in small studies, but more research is required. The panel recommended that all patients with newly diagnosed type 2 diabetes be screened for LADA with a test for antibodies to GAD, followed by tests for other autoantibodies if clinical suspicion remains high. <br /><br />In patients who have one or more autoantibodies and presumed LADA, the next step is C-peptide measurement. Those with C-peptide levels greater than 0.7 nmol/L can be managed similarly to patients with type 2 diabetes; those with levels lower than 0.3 nmol/L should start insulin. Patients in the “gray area” (with a C-peptide level between 0.3 and 0.7 nmol/L), should start metformin and other noninsulin agents based on blood glucose levels and cardiovascular and kidney disease risk; C-peptide levels should be rechecked every 6 months to monitor for the development of insulin deficiency.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-59249487504287684232024-01-24T08:33:00.003-05:002024-01-24T08:33:40.553-05:00A venerable family medicine journal exits the stage<p>Six years ago, <a href="https://commonsensemd.blogspot.com/2018/02/the-changing-of-guard-at-american.html">I was promoted</a> to the rank of deputy editor at <i>American Family Physician. </i>On the whole, I continue to find translating the latest scientific evidence into continuing medical education for family physicians and trainees to be satisfying and intellectually rewarding. As I pass the likely midpoint of my career, I have achieved all of my editorial goals, save one. In pursuit of that goal, in March 2023 I applied for the position of editor-in-chief at <i><a href="https://www.mdedge.com/familymedicine/archived-issues/jfponline">The Journal of Family Practice</a></i>, a widely respected primary care journal for nearly 50 years (<i>AFP</i> will celebrate its 75th anniversary in 2025) whose editor's chair had been vacated by the<a href="https://www.mdedge.com/familymedicine/article/257315/memoriam-john-hickner-md-msc"> sudden passing of the legendary family physician educator John Hickner, MD</a>. I began reading <i>JFP</i> during my residency 20 years ago, and its editorial board still included the same faculty mentor (now retired) who launched my editing career by urging me to write a <a href="https://www.aafp.org/pubs/afp/issues/2004/0101/p75.html">clinical review article</a> for <i>AFP</i>. The timing seemed favorable for me to climb the last rung of the editorial ladder.</p><p>Alas, not only was another very well-qualified candidate selected instead, but in November, <i>JFP</i> permanently ceased publication for financial reasons. It happened so abruptly that the journal had a backlog of accepted but unpublished articles that would need to find new homes elsewhere; I'm happy to share that a few of them will appear in future issues of <i>AFP</i>. In the January issue of <i>Family Medicine</i>, Dr. John Frey penned an <a href="https://journals.stfm.org/familymedicine/2024/january/janeditorialfrey/">eloquent "curtain call"</a> for <i>JFP</i>:</p><i>A superior group of editorial board members guided publication of research on topics that still are the source of much of the literature in the discipline and philosophical and intellectual articles by some of the most important writers and researchers in the first 20 years of family medicine’s existence. That the journal continued to publish after shifting from a primary research journal to a quality review journal, and managed to survive as long as it did is a tribute to the integrity and hard work of the many distinguished academic editors over its history. ... </i>JFP<i> was one of the principal reasons that family physicians, who were unused to reading primary sources of clinical research, began to change both by reading and contributing to the scholarship of a new field.</i><div><i><br /></i></div><div>Although the past half-century has seen an outpouring of scholarship on clinical questions relevant to family physicians, academic family medicine remains woefully undervalued by research funders such as the National Institutes of Health, which from 2017 to 2021 devoted <a href="https://www.aafp.org/pubs/afp/issues/2023/1200/graham-center-family-medicine-research.html">a paltry 0.2 percent of its budget</a> to grants to family medicine departments. Nonetheless, a 2019 study found that faculty in family medicine departments <a href="https://journals.stfm.org/familymedicine/2019/february/liaw-2018-0273/">publish 84% of the time in non-family medicine journals</a>, paralleling my own publication record. This statistic suggests that the exit of <i>JFP</i> hardly closes the door on the possibility of new family medicine journals being launched to publish a share of the discipline's future scholarly output.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-62925402006247082612024-01-13T13:02:00.001-05:002024-01-13T13:02:03.026-05:00Despite weak evidence, spinal cord stimulators are big businessA <a href="https://www.aafp.org/pubs/afp/issues/2023/1200/cochrane-spinal-cord-stimulation-low-back-pain.html">Cochrane for Clinicians article</a> in the December 2023 issue of <i>American Family Physician</i> reviewed randomized trials assessing the effectiveness of surgically implanted spinal cord stimulation devices for the treatment of <a href="https://www.aafp.org/pubs/afp/issues/2015/0515/p708.html">chronic low back pain</a>. These devices come with a high price tag ($30,000) and <a href="https://link.springer.com/article/10.1007/s11916-023-01190-7">potential complications</a> that include electrode migration, hematoma formation, infection, spinal cord injury, and cerebrospinal fluid leak. Dr. Brian Nelson and colleagues summarized a <a href="https://www.cochrane.org/CD014789/BACK_spinal-cord-stimulation-low-back-pain">Cochrane review</a> of 13 placebo-controlled trials with 699 adult participants (mean age 47 to 59 years) who had low back pain for at least 12 weeks. Primary outcomes included pain intensity, physical function, and quality of life. Most studies reported outcomes at follow-up dates of one month or less; only one study reported outcomes at six months.<br /><br />Overall, the body of evidence was assessed as having significant bias, including selection bias (five studies), performance and detection bias (10 studies), attrition bias, and selective reporting bias. The largest study, with 50 participants, found no statistical benefits. Three smaller trials suggested that “adding spinal cord stimulation to medical management may slightly improve function and slightly reduce opioid use in the medium term (i.e., one to less than 12 months).” Based on these findings, Dr. Nelson concluded:<br /><br /><i>The data do not support the use of spinal cord stimulation to manage low back pain outside of a clinical trial, and it is unclear if spinal cord stimulation has long-term clinical benefits to reasonably outweigh the costs and risks of surgical intervention.</i><br /><br />In a <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2812937">recent commentary</a> in <i>JAMA Internal Medicine</i>, two of the <a href="https://www.cochrane.org/CD014789/BACK_spinal-cord-stimulation-low-back-pain">Cochrane review</a> authors discussed tactics used by the spinal cord stimulator industry to dismiss the findings of their review and other independent reviews and studies that came to similar conclusions. These tactics included publishing lengthy critiques in paywalled industry-affiliated journals rather than the journal where the original study was published. They stated that “the credibility of our review team was attacked because one of the authors … had authored books on harms in health care,” equating this intellectual interest with financial conflicts held by supporters of spinal cord stimulators. Finally, critics conflated approval of spinal cord stimulators by the U.S. Food and Drug Administration (FDA) through the <a href="https://www.fda.gov/medical-devices/premarket-submissions-selecting-and-preparing-correct-submission/premarket-notification-510k">“substantial equivalence” 510(k) pathway</a> with evidence of effectiveness and safety, even though this pathway does not require evidence of that kind.<br /><br />In a 2022 <a href="https://www.aafp.org/pubs/afp/issues/2022/0600/p667.html">Lown Right Care article</a> on interventional procedures for low back pain, Drs. Alan Roth and Andy Lazris noted that “Surgery for low back pain is one of the most overused procedures in the United States, with more than 1.2 million back surgeries performed every year.” At an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391880/">estimated 50,000 procedures annually</a>, spinal cord stimulators make up a relatively small portion of these back surgeries. However, in a 2020 <a href="https://public4.pagefreezer.com/browse/FDA/08-08-2023T13:42/https:/www.fda.gov/medical-devices/letters-health-care-providers/conduct-trial-stimulation-period-implanting-spinal-cord-stimulator-scs-letter-health-care-providers">letter to health care providers</a>, the FDA reported that over the preceding four-year period, it received “a total of 107,728 medical device reports related to spinal cord stimulators intended for pain, including 497 associated with a patient death [representing 428 deaths], 77,937 with patient injury, and 29,294 with device malfunction.” That seems like an unacceptably high rate of unintended effects for a device with modest benefits.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-70515315964024086932023-12-30T14:15:00.002-05:002023-12-30T14:15:26.819-05:00What do the Air Force and family medicine have in common? AI<p>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 <a href="https://journals.lww.com/academicmedicine/fulltext/2023/09000/artificial_intelligence_screening_of_medical.22.aspx">reduce the grunt work of selecting future physicians</a>; become a <a href="https://commonsensemd.blogspot.com/2023/01/integrating-ai-into-family-medicine.html">required competency in medical education</a>; provide <a href="https://link.springer.com/article/10.1007/s11606-023-08271-8">relief from overflowing primary care electronic in-baskets</a>; and provide <a href="https://fmch.bmj.com/content/11/4/e002391">clinical decision support for treating patients with depression</a>. I've read pessimistic commentaries about chatbots and large language models <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2804310">being a "Pandora's box"</a> and more optimistic pieces arguing that generative AI <a href="https://jamanetwork.com/journals/jama/fullarticle/2812615">can overcome the "productivity paradox"</a> 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, <a href="https://www.politico.com/news/2023/10/28/ai-doctors-healthcare-regulation-00124051">regulatory authorities are still struggling to catch up</a> 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.</p><p>"<a href="https://www.nytimes.com/2023/08/27/us/politics/ai-air-force.html?mwgrp=a-dbar&unlocked_article_code=1.J00.req4.6oY2iK8EAnxx&smid=url-share">AI brings the robot wingman to aerial combat</a>," declared the science fiction-sounding headline of this August 2023 <i>New York Times</i> 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?</p><p>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.</p><p>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?</p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-51985695786851142852023-12-22T12:32:00.000-05:002023-12-22T12:32:01.298-05:00My favorite public health and health care books of 2023<p>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 <a href="https://commonsensemd.blogspot.com/2022/12/my-favorite-public-health-and-health.html">2022</a>, <a href="https://commonsensemd.blogspot.com/2021/12/my-favorite-public-health-and-health.html">2021</a>, and <a href="https://commonsensemd.blogspot.com/2020/12/my-favorite-public-health-and-health.html">2015-2020</a>. Other than the occasional free book to review for <i><a href="https://journals.stfm.org/familymedicine/">Family Medicine</a></i>, I don't receive anything for reading or sharing them.</p> **<br /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2E5F6qrunl52DCVqPZH2nHYSx3bbXB6Fi20eZ9h-DWiRNBK-0yxROnbL_zYGNKuO1vSoYS0AOpgsDz5lMFTTZQOYXN1gAiwE0OUjDkli6mocco9VlaKX9QHJZoJKKVCN_at4B-86lOz-iuFjrSxj1zWFZeSW86kE96XrzXUZkfqMgQUVN_64aGOz0iIs/s450/Chasing%20My%20Cure.jpg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="450" data-original-width="288" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2E5F6qrunl52DCVqPZH2nHYSx3bbXB6Fi20eZ9h-DWiRNBK-0yxROnbL_zYGNKuO1vSoYS0AOpgsDz5lMFTTZQOYXN1gAiwE0OUjDkli6mocco9VlaKX9QHJZoJKKVCN_at4B-86lOz-iuFjrSxj1zWFZeSW86kE96XrzXUZkfqMgQUVN_64aGOz0iIs/s320/Chasing%20My%20Cure.jpg" width="205" /></a><br /><br />1. <a href="https://chasingmycure.com/">Chasing My Cure: A Doctor’s Race to Turn Hope into Action</a>, by David Fajgenbaum <br /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRPNy5L1CRYhnFkUDBacUHcmJK8nc809sKQPbWle0RJjzXhrLw4XEJb32uai6p4dQB4DdBf4VQt7nonlnUNgWYEcGah3NaYbxSnmOfcRsOCOrmobPt6JvTB4_BWURwWdeF5ChOOXb-RMGrRHTL0DZN6S0it4cBvv3DY4EP7CiyqR-3VqEigLj8-r7TCIE/s2775/From%20Whispers%20to%20Shouts.jpeg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="2775" data-original-width="1838" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRPNy5L1CRYhnFkUDBacUHcmJK8nc809sKQPbWle0RJjzXhrLw4XEJb32uai6p4dQB4DdBf4VQt7nonlnUNgWYEcGah3NaYbxSnmOfcRsOCOrmobPt6JvTB4_BWURwWdeF5ChOOXb-RMGrRHTL0DZN6S0it4cBvv3DY4EP7CiyqR-3VqEigLj8-r7TCIE/s320/From%20Whispers%20to%20Shouts.jpeg" width="212" /></a><br /><br />2. <a href="https://cup.columbia.edu/book/from-whispers-to-shouts/9780231192262">From Whispers to Shouts: The Ways We Talk About Cancer</a>, by Elaine Schattner<div><div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOzuCXPBLufsbOfIffl25P63I2tbYrtMc7nFffh7rVIdQ1V5_eSmn-jpigv_EXHm1nep-Tt0y6n2Ovn2MVZELJwmHGfOt4jqqmp8RHtX33JveBbfvJwFxLDUSbgJzVlRiHO-4KWYA36T2uNW5tMhyphenhyphenx6waem18_mzJShIjuokUYMkLIdaBPT3YoOuPR6cc/s933/Maladies%20of%20Empire.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="933" data-original-width="600" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOzuCXPBLufsbOfIffl25P63I2tbYrtMc7nFffh7rVIdQ1V5_eSmn-jpigv_EXHm1nep-Tt0y6n2Ovn2MVZELJwmHGfOt4jqqmp8RHtX33JveBbfvJwFxLDUSbgJzVlRiHO-4KWYA36T2uNW5tMhyphenhyphenx6waem18_mzJShIjuokUYMkLIdaBPT3YoOuPR6cc/s320/Maladies%20of%20Empire.jpg" width="206" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div>3. <a href="https://www.hup.harvard.edu/books/9780674971721">Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine</a>, by Jim Downs <br /><br /> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_rEspiX90AJsdGCYsWb3Rb-vugTbVQjIGvQliK3qlgPYxwKzmz_s-xpHRXKy75M0qoBNfvBsNA6o_B0fJSbFCgYYRKbWBZhhHXUnbzlYezhnLkrfqGOdi5iLFWLGTdLIW8NMlLQlPYE9WEhQodXvdlMmaxFLe4wPhlsqBLQrf0EtvqwH6wSlS-4IoBBo/s450/Masters%20of%20Medicine.jpg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="450" data-original-width="300" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_rEspiX90AJsdGCYsWb3Rb-vugTbVQjIGvQliK3qlgPYxwKzmz_s-xpHRXKy75M0qoBNfvBsNA6o_B0fJSbFCgYYRKbWBZhhHXUnbzlYezhnLkrfqGOdi5iLFWLGTdLIW8NMlLQlPYE9WEhQodXvdlMmaxFLe4wPhlsqBLQrf0EtvqwH6wSlS-4IoBBo/s320/Masters%20of%20Medicine.jpg" width="213" /></a><br /><br />4. <a href="https://www.penguinrandomhouse.com/books/718935/the-masters-of-medicine-by-andrew-lam-md/">The Masters of Medicine: Our Greatest Triumphs in the Race to Cure Humanity’s Deadliest Diseases</a>, by Andrew Lam <br /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYA7caoC38B_S2ZtLXhBx4hVsQzSyQ6MH6CAkhBTDVPDj0n4pGd07o-b0gCK1-0BfURquLQ_cie-y9EqtaIarTrmTX7hAdOf2_2wlVkiw1-HfkQ-r8BAhghe2iWKPkRRIFZ8JKGplttSCZM8YCSeZMCZ5TNvVQzmgFqH8FGkm2zeyGyZbAM4IEhKAqb8g/s400/Medicine%20and%20Miracles%20in%20the%20High%20Desert.jpg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="400" data-original-width="270" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYA7caoC38B_S2ZtLXhBx4hVsQzSyQ6MH6CAkhBTDVPDj0n4pGd07o-b0gCK1-0BfURquLQ_cie-y9EqtaIarTrmTX7hAdOf2_2wlVkiw1-HfkQ-r8BAhghe2iWKPkRRIFZ8JKGplttSCZM8YCSeZMCZ5TNvVQzmgFqH8FGkm2zeyGyZbAM4IEhKAqb8g/s320/Medicine%20and%20Miracles%20in%20the%20High%20Desert.jpg" width="216" /></a><br /><br />5. <a href="https://www.simonandschuster.com/books/Medicine-and-Miracles-in-the-High-Desert/Erica-M-Elliott/9781591434191">Medicine and Miracles in the High Desert: My Life Among the Navajo People</a>, by Erica Elliott<br /> <br /> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfOYt6F8_1apX7Q7rKJ6FmD2rUHWJnHeJ21-slbYNZ8gzMuoKjsG7vhN0rFOdQDqK-X1QyOR-puBi0qC2Q0vNcSyg65p2bm41ElqEHW6XEZFIu-9qFyDKW3M-ZDaM0pOCW5aJqIqjc_Qmk2ZC7sh9CKVENbW0FMdtrARag5EknWNK-qfs-dpxQl4NDHrE/s450/The%20Other%20Dr%20Gilmer.jpg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="450" data-original-width="292" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfOYt6F8_1apX7Q7rKJ6FmD2rUHWJnHeJ21-slbYNZ8gzMuoKjsG7vhN0rFOdQDqK-X1QyOR-puBi0qC2Q0vNcSyg65p2bm41ElqEHW6XEZFIu-9qFyDKW3M-ZDaM0pOCW5aJqIqjc_Qmk2ZC7sh9CKVENbW0FMdtrARag5EknWNK-qfs-dpxQl4NDHrE/s320/The%20Other%20Dr%20Gilmer.jpg" width="208" /></a><br /><br />6. <a href="https://benjamingilmer.com/">The Other Dr. Gilmer: Two Men, A Murder, and an Unlikely Fight for Justice</a>, by Benjamin Gilmer <br /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIOhIn3La_x3iapAXTAZNIhW2OHDk08cknmckH6nIHJeE97o1likgg6w09-bISKn6oCncsJ5Abq2EOxl4B9roEKlmzvfD_B3Rn8jkQffV2aSlscfX2SpOjr4A3W6-k4Fsczi3I7ZeP1wS65bscaekuvRBuW08_T2Ny4dx5avWF-X943deyFsnvDE4I3sk/s450/Rough%20Sleepers.jpg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="450" data-original-width="292" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIOhIn3La_x3iapAXTAZNIhW2OHDk08cknmckH6nIHJeE97o1likgg6w09-bISKn6oCncsJ5Abq2EOxl4B9roEKlmzvfD_B3Rn8jkQffV2aSlscfX2SpOjr4A3W6-k4Fsczi3I7ZeP1wS65bscaekuvRBuW08_T2Ny4dx5avWF-X943deyFsnvDE4I3sk/s320/Rough%20Sleepers.jpg" width="208" /></a><br /><br />7. <a href="https://www.penguinrandomhouse.com/books/594500/rough-sleepers-by-tracy-kidder/">Rough Sleepers: Dr. Jim O’Connell’s Urgent Mission to Bring Healing to Homeless People</a>, by Tracy Kidder <br /><br /> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7ZhLG07P36sCBN1yoEPqnDLZYRvdBlzaE31ICIl686o8XBezjcUGNUhNM6vqpnRhKUhmz_oII6uGLEKz0aa5CnuP2_Fpd4pCnfXDGvD1FwyCjPXaZ1BTNvG97sp_r3_SqfnZQW7FawmKbTw0eYGVml-TS6rjQ9SLDezg79K3TLu5piU8yIRlAcMRggEA/s450/Take%20My%20Hand.jpg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="450" data-original-width="292" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7ZhLG07P36sCBN1yoEPqnDLZYRvdBlzaE31ICIl686o8XBezjcUGNUhNM6vqpnRhKUhmz_oII6uGLEKz0aa5CnuP2_Fpd4pCnfXDGvD1FwyCjPXaZ1BTNvG97sp_r3_SqfnZQW7FawmKbTw0eYGVml-TS6rjQ9SLDezg79K3TLu5piU8yIRlAcMRggEA/s320/Take%20My%20Hand.jpg" width="208" /></a><br /><br />8. <a href="https://dolenperkinsvaldez.com/books/take-my-hand/">Take My Hand</a>, by Dolen Perkins-Valdez</div><div> </div><div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTX2E_SFMYa5EN7_MFXADOTKNtg_-iw9vVzOgNZKLKtQKDk5STu8Znu7SgA0Umz5sdDKqrocNE03FURPTG-1jQCM-Sdf5ZdCzf-V5zie3eV3eeml8UQsOLVl-lMPFilJn-dPFm6qJzqVfkGLbvUqa7LuuIwtCvdBWOC6WRbYCEPVAUMPqFyGCx4ei1Y_M/s830/That%20Time%20I%20Got%20Cancer.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="830" data-original-width="550" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTX2E_SFMYa5EN7_MFXADOTKNtg_-iw9vVzOgNZKLKtQKDk5STu8Znu7SgA0Umz5sdDKqrocNE03FURPTG-1jQCM-Sdf5ZdCzf-V5zie3eV3eeml8UQsOLVl-lMPFilJn-dPFm6qJzqVfkGLbvUqa7LuuIwtCvdBWOC6WRbYCEPVAUMPqFyGCx4ei1Y_M/s320/That%20Time%20I%20Got%20Cancer.jpg" width="212" /></a></div><br />9. <a href="https://www.jimzervanos.com/advance-praise">That Time I Got Cancer: A Love Story</a>, by Jim Zervanos</div><div> <br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAlSbAVvcBn75hf1LAWMF9SBS1HgGoklTHdNIUMNwV10KoI7B4LoXtq5yhO4vkoM4sar_vyYmW9_s6NNqMidbEm2mTBV6H61oMv6CqEYPnrw_kn1nSLMCML7tV3nvObGzxXr8yYBs96CELsR2SGYuasH0ZIKS_SN06GyL4HK_rPv7d5qARkh5RH6UJt3g/s595/2060.jpg" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="595" data-original-width="396" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAlSbAVvcBn75hf1LAWMF9SBS1HgGoklTHdNIUMNwV10KoI7B4LoXtq5yhO4vkoM4sar_vyYmW9_s6NNqMidbEm2mTBV6H61oMv6CqEYPnrw_kn1nSLMCML7tV3nvObGzxXr8yYBs96CELsR2SGYuasH0ZIKS_SN06GyL4HK_rPv7d5qARkh5RH6UJt3g/s320/2060.jpg" width="213" /></a><br /><br />10. <a href="https://wildlarkbooks.com/events/2060-novel-richard-young/">2060</a>, by Richard Young<br /></div></div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-27323654254989973132023-12-17T21:37:00.003-05:002023-12-17T21:37:55.689-05:00Will the high price of gene therapy for sickle cell disease put this cure out of reach?On December 8, 2023, the <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-gene-therapies-treat-patients-sickle-cell-disease">U.S. Food and Drug Administration (FDA) approved Casgevy</a>, 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—<a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2031054">initial results were published in 2020</a>—29 out of 31 treated patients had no severe VOC episodes for at least 12 consecutive months during the 24-month follow-up period.<br /><br />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 <a href="https://ashpublications.org/bloodadvances/article/7/3/365/485129/Lifetime-medical-costs-attributable-to-sickle-cell">lifetime medical costs associated with sickle cell disease average $1.7 million</a>, insurance companies may be unwilling to pay the exceptionally high up-front cost of this curative therapy. Compared with standard of care, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10370480/">one analysis found gene therapy to be an equitable strategy for U.S. patients</a> 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.<br /><br />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 <a href="https://www.nejm.org/doi/full/10.1056/NEJMp2201763">recently proposed expanding the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)</a> 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 <a href="https://www.statnews.com/2023/03/07/crispr-sickle-cell-access/">one of the only three centers for bone marrow transplants in Nigeria, Tanzania, and South Africa</a>.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-81146567226088507742023-12-08T14:26:00.002-05:002023-12-08T14:26:39.115-05:00As goes college, so goes health care?<p>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 <a href="https://www.insidehighered.com/news/students/financial-aid/2023/11/01/buyers-market-tuition-increases-havent-outpaced-inflation">actually increased at a lower rate than general inflation</a> from 2022-23, <a href="https://www.usnews.com/education/best-colleges/paying-for-college/articles/see-20-years-of-tuition-growth-at-national-universities">breaking a 20-year trend</a> 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.</p><p>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 <a href="https://www.nytimes.com/2023/09/05/magazine/college-worth-price.html"><i>New York Times Magazine</i> story</a> by Paul Tough (<a href="https://commonsensemd.blogspot.com/2014/07/nurturing-next-generation-of-diverse.html">whom I've quoted previously</a> 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.</p><i>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.</i><br /><br /><div>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, <a href="https://www.nytimes.com/interactive/2023/07/13/opinion/politics/student-loan-payments-resume.html">more than half now owe more than what they originally borrowed.</a>"</div><div><br /></div><div>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 <a href="https://www.statista.com/statistics/184955/us-national-health-expenditures-per-capita-since-1960/">costs and fees have been rising exponentially</a> while the return on investment is middling and the quality of the product remains opaque: health care.</div><div><br /></div><div>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 <a href="https://www.npr.org/sections/health-shots/2023/03/25/1164819944/live-free-and-die-the-sad-state-of-u-s-life-expectancy">stopped rising in 2010 and plummeted during the first two years of the COVID-19 pandemic</a>, 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 <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2811338">recent study</a> in <i>JAMA Internal Medicine</i>. The biggest drivers of this gap were deaths from COVID-19 and drug overdoses, which medicine can prevent with highly effective interventions: vaccines, <a href="https://www.ama-assn.org/topics/medications-treat-opioid-use-disorder-moud">medications to treat opioid use disorder</a>, and the opioid reversal agent <a href="https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/naloxone">naloxone</a>.</div><div><br /></div><div>It's not that patients aren't enthusiastic about prevention. We <a href="https://www.health.harvard.edu/staying-healthy/dont-waste-time-or-money-on-dietary-supplements">spend $35 billion per year</a> on largely worthless over-the-counter dietary supplements. According to a <a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2023.00270">recent analysis</a> 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 - <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2808648">generally don't help people live longer</a> and often <a href="https://www.cfp.ca/content/69/11/767">lead to unintended harms</a>. While discrete medical services don't save lives, we know that <a href="https://www.washingtonpost.com/health/2023/10/17/primary-care-saves-lives/">having a relationship with a primary care physician does</a>. 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 <a href="https://www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard/">the percentage of health care dollars invested in primary care nosedived from 2013 to 2020</a>.</div><div><br /></div><div>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? <a href="https://thepcc.org/sites/default/files/resources/Lessons%20Learned%20from%20Multi-Stakeholder%20Advisory%20Groups.pdf">Some states are starting to recognize the wisdom of increasing primary care spending</a>, 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.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-78911769743978666272023-11-19T19:37:00.000-05:002023-11-19T19:37:54.431-05:00Bariatric surgery and other AAP recommendations for children with obesityA <a href="https://www.nytimes.com/2023/10/31/magazine/teen-bariatric-surgery.html?smid=em-share">recent article</a> in <i>The New York Times Magazine</i> 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 <a href="https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and">clinical practice guideline</a> 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, <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2805358">the number of procedures increased from fewer than 800 in 2016 to 1,349 in 2021</a>. (In comparison, more than 200,000 adults had bariatric surgery in 2021.) <br /><br />In <a href="https://www.aafp.org/pubs/afp/issues/2023/1000/editorial-aap-guideline-childhood-obesity.html">an editorial</a> in the October issue of <i>American Family Physician,</i> 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 <a href="https://www.aafp.org/pubs/afp/issues/2022/0600/p593.html">the most commonly performed metabolic surgery procedures</a> in adolescents, and long-term outcomes are unknown. Similarly, although <a href="https://www.aafp.org/pubs/afp/issues/2023/0100/steps-semaglutide-obesity.html">semaglutide (Wegovy)</a> 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.” <br /><br />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 <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-children-and-adolescents-screening">recommended by the U.S. Preventive Services Task Force</a> have been mostly disappointing. A <a href="https://www.aafp.org/pubs/afp/issues/2018/0801/p151.html">2017 Cochrane review</a> 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 <a href="https://www.aafp.org/pubs/afp/issues/2020/0401/p394.html">more recent Cochrane review</a> confirmed this finding but also found low-quality evidence that these interventions did not change BMI in children 13 years and older. <br /><br />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 <a href="https://www.statnews.com/2023/03/20/childhood-obesity-guidelines-eating-disorders-data-concerns/"><i>STAT News</i> story</a> 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 <a href="https://www.nytimes.com/2023/10/31/magazine/teen-bariatric-surgery.html?smid=em-share"><i>New York Times Magazine</i> article</a> 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 <a href="https://www.endocrinepractice.org/article/S1530-891X(23)00335-X/fulltext">adults with obesity often experience weight stigma and bias</a>.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-5509215115774785492023-11-10T16:04:00.001-05:002023-11-10T16:04:07.134-05:00Medical debt is a moral failure of our health care non-system<p>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 <a href="https://commonsensemd.blogspot.com/2022/08/preventive-services-mandate-can-be.html">preventive services</a>, it doesn't cover any health care expenses incurred during the plan year until (in my case) the insured person(s) meets a <a href="https://www.healthcare.gov/glossary/deductible/">deductible</a> 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 <a href="https://www.kff.org/health-costs/report/2023-employer-health-benefits-survey/">Kaiser Family Foundation's Employer Health Benefits Survey</a>, HDHP/SO type plans now cover 29% of all private sector employees with health insurance. Since <a href="https://www.cnbc.com/2023/08/31/63percent-of-workers-are-unable-to-pay-a-500-emergency-expense-survey.html">63% of workers are unable to pay a $500 emergency expense</a> 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.</p><p>A <a href="https://www.nejm.org/doi/full/10.1056/NEJMms2308571">recent article</a> in the <i>New England Journal of Medicine</i> 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 <a href="https://www.ncbi.nlm.nih.gov/books/NBK539798/">Emergency Medical Treatment and Active Labor Act</a> (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."</p><p>A <a href="https://www.commonwealthfund.org/publications/surveys/2023/oct/paying-for-it-costs-debt-americans-sicker-poorer-2023-affordability-survey">Commonwealth Fund survey</a> 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 <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.00604">study of pre-pandemic data</a> 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.</p><p>In the past, I would have said that having the national uninsured rate <a href="https://www.healthaffairs.org/content/forefront/national-uninsured-rate-record-low-focus-maintaining-gains">fall to a record low of just 7.7% during the first quarter of 2023</a> 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 <a href="https://kffhealthnews.org/news/article/medicaid-unwinding-disenrollment-redetermination-state-delays/">currently being undone</a>, 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.</p><p>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 <a href="https://maysville-online.com/opinion/104327/veterans-service-priceless-to-nation-state">arguably priceless</a>, 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.</p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-37612423383971095682023-11-07T15:35:00.000-05:002023-11-07T15:35:09.429-05:00Health journal editors and the Pope call for action on the climate crisisLast 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, <a href="https://jamanetwork.com/journals/jama/fullarticle/2811131">an editorial</a> 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 <a href="https://www.aafp.org/pubs/afp/afp-community-blog/entry/how-health-care-can-break-the-harm-treat-harm-climate-emissions-cycle.html">previous group editorials</a> 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 <a href="https://www.who.int/emergencies/situations">global health emergency</a>. <br /><br />Three weeks earlier, on October 4, Pope Francis issued an <a href="https://www.vatican.va/content/francesco/en/apost_exhortations/documents/20231004-laudate-deum.html">apostolic exhortation</a> “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 (<a href="https://www.cop28.com/">COP28</a>) 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.” <br /><br />An <a href="https://www.iea.org/reports/net-zero-roadmap-a-global-pathway-to-keep-the-15-0c-goal-in-reach">International Energy Agency report</a> 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 <a href="https://www.nytimes.com/2023/10/24/magazine/canada-wildfires.html">this summer’s Canadian wildfires</a>, 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. <br /><br />The U.S. health care industry remains <a href="https://time.com/6321357/how-us-hospitals-undercut-public-health/">one of the world’s largest climate culprits</a>, 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 <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(18)30147-5/fulltext">an estimated 77,000 excess deaths</a> annually. Overuse of single-use disposable plastic devices is an important part of the problem, a <a href="https://jamanetwork.com/journals/jama/fullarticle/2810394">recent <i>JAMA</i> Viewpoint</a> observed: <br /><br /><i>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. </i><br /><br />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. <br /><br />More broadly, overdiagnosis and unnecessary medical treatment not only waste money and energy and expose patients to harm, but also <a href="https://www.bmj.com/content/375/bmj.n2407">increase the carbon footprint of health care</a>. The scientific committee of this year’s <a href="https://www.bmj.com/content/382/bmj.p1865.long">Preventing Overdiagnosis conference</a> 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.”<br /><br />**<br /><br />This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-64377686707503532322023-10-20T16:24:00.002-04:002023-10-20T16:24:42.549-04:00Task Force to revisit prostate cancer screening recommendationsThe U.S. Preventive Services Task Force (USPSTF) is inviting public comments on a <a href="https://www.uspreventiveservicestaskforce.org/uspstf/document/draft-research-plan/prostate-cancer-screening-adults">draft research plan</a> to update its <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening">2018 recommendation statement</a> on screening for prostate cancer. As I wrote in a <a href="https://commonsensemd.blogspot.com/2018/10/psa-screening-uspstf-recommendations.html">previous blog post</a>, 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 <a href="https://commonsensemd.blogspot.com/2019/01/what-do-recent-publications-mean-for.html">trials of localized prostate cancer treatments</a> has shown no mortality benefits for immediate surgery or radiotherapy compared with active surveillance <a href="https://www.aafp.org/pubs/afp/afp-community-blog/entry/prostate-cancer-newest-study-shows-no-change-in-15-year-mortality-regardless-of-treatment-strategy.html">for 15 years after diagnosis</a>. In the October issue of <i>American Family Physician</i>, a <a href="https://www.aafp.org/pubs/afp/issues/2023/1000/poems-prostate-cancer-surveillance.html">POEM on the UK ProtecT study results</a> 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. <br /><br />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 <a href="https://www.aafp.org/pubs/afp/issues/2022/0600/p665.html">2022 Diagnostic Tests article</a> examined the utility of multiparametric MRI (mpMRI) for the evaluation of prostate cancer. A <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808559">subsequent study</a> 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 href="https://bmjoncology.bmj.com/content/2/1/e000057">a UK study</a> 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. <br /><br />The American Urological Association (AUA) updated its guidelines on <a href="https://www.auajournals.org/doi/10.1097/JU.0000000000003491">prostate cancer screening</a> and <a href="https://www.auajournals.org/doi/10.1097/JU.0000000000003492">considerations for a prostate biopsy</a> 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: <br /><br /><i>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. </i><br /><br />In the meantime, how should primary care physicians approach patients who are potentially eligible for screening? The current issue of the <i>Annals of Family Medicine</i> includes a scoping review on <a href="https://www.annfammed.org/content/21/5/448.long">patient communication preferences for prostate cancer screening discussions</a>. 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.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP </i>Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-64836730378481729512023-10-09T17:56:00.004-04:002023-10-09T17:56:58.666-04:00Coronary artery calcium is a common finding in older adultsThe 2018 American College of Cardiology/American Heart Association <a href="https://www.aafp.org/pubs/afp/issues/2019/0501/p589.html">cholesterol management guidelines</a> 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: <br /><br /><i>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. </i><br /><br />This recommendation to selectively incorporate CAC scoring into ASCVD risk management has been controversial; the U.S. Preventive Services Task Force (USPSTF) <a href="https://www.aafp.org/pubs/afp/issues/2019/0115/od1.html">found insufficient evidence</a> that adding the CAC score to traditional risk assessment improves patient-oriented outcomes. In a <a href="https://www.aafp.org/pubs/afp/issues/2019/1215/p734.html">previous <i>American Family Physician</i> editorial</a>, 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 <a href="https://www.aafp.org/pubs/afp/issues/2022/0700/diagnostic-tests-coronary-artery-calcium-scoring.html">Diagnostic Tests article</a> 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.” <br /><br />Incidental detection of CAC on chest computed tomography (CT) scans performed for other reasons in persons without clinical ASCVD was demonstrated in <a href="https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.062746">a previous study</a> 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 <a href="https://www.mesa-nhlbi.org/">Multi-Ethnic Study of Atherosclerosis</a> in persons aged 45 to 84 years without ASCVD symptoms at baseline, Dr. Matthew Tattersall and colleagues <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2809981">calculated CAC prevalence by age, sex, race, and ethnicity</a>. 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. <br /><br />The study authors concluded the following: <br /><br /><i> [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. </i><br /><br />Further, <br /><br /><i>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. </i><br /><br />Clinical summaries of current USPSTF recommendation statements on <a href="https://www.aafp.org/pubs/afp/issues/2023/0200/uspstf-statin-use-cardiovascular-disease.html">statins</a> and <a href="https://www.aafp.org/pubs/afp/issues/2022/0900/uspstf-aspirin-cvd.html">low-dose aspirin</a> for primary prevention of ASCVD in adults are available on the <i>AFP</i> website.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the<i> <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html">AFP </a></i><a href="https://www.aafp.org/pubs/afp/afp-community-blog.html">Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-16847969326775870472023-09-25T21:06:00.000-04:002023-09-25T21:06:49.481-04:00Prescribing food as medicine lowers weight, blood pressure, and blood sugarAt 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 <a href="https://www.abc27.com/local-news/lancaster/food-farmacy-program-in-lancaster-county-tackles-health-issues-food-insecurity/">“Food Farmacy”</a> to meet with dietitians and receive free produce from local food pantries. Similar “food as medicine” programs have been piloted throughout the United States, <a href="https://www.aafp.org/news/education-professional-development/20190410foodishealth.html">including several led by family medicine residencies</a>. As Dr. Jen Middleton <a href="https://www.aafp.org/pubs/afp/afp-community-blog/entry/Making-nutritious-foods-accessible-to-all-patients.html">wrote on the <i>American Family Physician</i> Community Blog</a>, the 2022 White House Conference on Hunger, Nutrition and Health <a href="https://informingwhc.org/wp-content/uploads/2022/08/Informing_White_House_Conference_Task_Force_Report_Aug22-Executive-Summary.pdf">made a number of policy recommendations</a> 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. <br /><br />In <a href="https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.122.009520">a recent study</a> published in <i>Circulation: Cardiovascular Quality and Outcomes</i>, 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 <a href="https://www.aafp.org/pubs/afp/afp-community-blog/entry/the-evidence-is-in-wic-improves-maternal-and-child-health.html">the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC)</a>. 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. <br /><br />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. <br /><br />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 href="https://www.ahajournals.org/doi/10.1161/JAHA.122.029215">A microsimulation modeling study</a> projected that over a lifetime, <br /><br /><i>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). </i><br /><br />A <a href="https://www.aafp.org/pubs/afp/issues/2018/0801/p143.html">2018 <i>AFP</i> editorial</a> provided other practical information for clinicians to help patients with food insecurity, including a <a href="https://www.aafp.org/pubs/afp/issues/2018/0801/p143.html#afp20180801p143-ta">list of food assistance programs</a> for children and adults.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-49099871527918371012023-09-13T20:16:00.000-04:002023-09-13T20:16:00.701-04:00CMS announces “top 10” costly drugs list selected for price negotiationsTwo weeks ago, the Centers for Medicare & Medicaid Services (CMS) <a href="https://www.hhs.gov/about/news/2023/08/29/hhs-selects-the-first-drugs-for-medicare-drug-price-negotiation.html">announced the first 10 brand name medications</a> 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 <i>American Family Physician</i>’s <a href="https://www.aafp.org/pubs/afp/collections/departments.steps.html">STEPS (Safety, Tolerability, Efficacy, Price, Simplicity) New Drug Reviews</a> 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. <br /><br />Apixaban (<a href="https://www.aafp.org/pubs/afp/issues/2014/0415/p672.html">Eliquis</a>) <br /><br />Empagliflozin (<a href="https://www.aafp.org/pubs/afp/issues/2016/1215/p1014.html">Jardiance</a>) <br /><br />Rivaroxaban (<a href="https://www.aafp.org/pubs/afp/issues/2012/1015/p768.html">Xarelto</a>) <br /><br />Sitagliptin (<a href="https://www.aafp.org/pubs/afp/issues/2007/0915/p861.html">Januvia</a>) <br /><br />Dapagliflozin (<a href="https://www.aafp.org/pubs/afp/issues/2020/0715/p115.html">Farxiga</a>) <br /><br />Sacubitril/valsartan (<a href="https://www.aafp.org/pubs/afp/issues/2016/1015/p611.html">Entresto</a>) <br /><br />Etanercept (Enbrel) <br /><br />Ibrutinib (Imbruvica) <br /><br />Ustekinumab (Stelara) <br /><br />Insulin aspart (Novolog/Fiasp) <br /><br />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 <a href="https://jamanetwork.com/journals/jama/article-abstract/2795651">the passage of the Inflation Reduction Act</a> 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. <br /><br />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, <a href="https://www.kff.org/medicare/issue-brief/a-small-number-of-drugs-account-for-a-large-share-of-medicare-part-d-spending/">with the 10 most expensive drugs accounting for 22 percent of gross Medicare Part D spending in 2021</a>. In addition, <a href="https://www.healthaffairs.org/content/forefront/medicare-drug-price-negotiation-few-drugs-big-impact">there may be “spillover” effects from negotiated lower prices</a> because competitors in the same therapeutic class may decide to lower their prices or risk being left off of Part D drug formularies. <br /><br />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, <a href="https://www.statnews.com/2023/08/29/10-drugs-medicare-price-negotiation/">according to STAT</a>), the pharmaceutical industry has <a href="https://www.nytimes.com/2023/07/23/us/politics/medicare-drug-price-negotiations-lawsuits.html">already filed multiple lawsuits</a> 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 <a href="https://www.cbo.gov/system/files/2022-07/senSubtitle1_Finance.pdf">have a small impact on FDA new drug approvals</a>, with 15 fewer drugs approved over the next 30 years out of about 1300 projected.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-32874906044445405852023-08-27T17:03:00.002-04:002023-08-27T17:03:47.213-04:00For accurate blood pressure measurement, cuff size mattersA <a href="https://www.aafp.org/pubs/afp/issues/2023/0800/editorial-hypertension-treatment.html">thought-provoking editorial</a> in the August issue of <i>American Family Physician</i> discussed the reasons for the divergence in treatment guidelines for mild hypertension that followed the publication of the <a href="https://commonsensemd.blogspot.com/2016/04/walk-dont-run-to-implement-sprint.html">Systolic Blood Pressure Intervention Trial</a> (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 <a href="https://www.aafp.org/pubs/afp/issues/2018/0315/p372.html">2018 editorial</a> about the American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline and reiterated in a <a href="https://www.aafp.org/pubs/afp/issues/2021/0900/p237.html#best-practices-for-home-blood-pressure-monitoring">clinical review article on home BP monitoring</a>, include using an appropriately sized blood pressure cuff:<br /><br /><i>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.</i><br /><br />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.<br /><br />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 <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2807853">randomized crossover trial</a> 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.<br /><br />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 <a href="https://academic.oup.com/ajh/article/35/11/923/6692616">recent analysis</a> 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:<br /><br /><i>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.</i><br /><br />In a table summarizing <a href="https://www.aafp.org/pubs/afp/issues/2023/0800/editorial-hypertension-treatment.html#afp20230800p122-t1">lessons learned and cautions raised by SPRINT</a>, 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 <a href="https://www.aafp.org/pubs/afp/issues/2022/1200/practice-guidelines-aafp-hypertension-full-guideline.html">recommended for most people by the American Academy of Family Physicians</a>, using an appropriately sized cuff is critical to avoid overdiagnosing healthy adults with hypertension.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-34871481452124806342023-08-20T15:00:00.003-04:002023-08-20T15:00:37.263-04:00Preventing Overdiagnosis: do Americans have too many cancer screening choices?<p>At the <a href="https://www.cebm.ox.ac.uk/upcoming-events/preventing-overdiagnosis">Preventing Overdiagnosis Conference</a> 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 <a href="https://www.aafp.org/pubs/afp/issues/2021/0201/p138.html">widening disease definitions</a> and resulting overdiagnosis and <a href="https://www.aafp.org/pubs/afp/issues/2015/0301/p289.html">overtreatment</a>. After the American Board of Internal Medicine Foundation's discontinuation of logistical support for the <a href="https://ebm.bmj.com/content/early/2023/07/20/bmjebm-2023-112266">Choosing Wisely campaign</a> and the retirement of <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2806467"><i>JAMA Internal Medicine</i> editor and "Less Is More" champion</a> Rita Redberg (who also attended the conference), it was reassuring to hear that the vital work of doing less <i>to</i> patients and more <i>for</i> 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.</p>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 <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3569-9">develop a prioritized guideline</a> 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 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5549533/">doesn't occur in Canada or the United Kingdom</a> and may, despite the U.S. Preventive Service's Task Force (USPSTF)'s endorsement, <a href="https://www.bmj.com/content/382/bmj.p1615">lead to more harm (opportunity costs and overdiagnosis) than good</a>.<br /><p>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 <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening">undergo bone measurement testing</a> for osteoporosis (a disease-oriented outcome), the Canadian Task Force on Preventive Health Care recommends <a href="https://www.cmaj.ca/content/195/18/E639">“risk assessment–first” screening</a> 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 <a href="https://www.cfp.ca/content/69/8/537">it requires less clinician time</a>. When there isn't nearly enough time for prevention in primary care, argued Sweden's Minna Johansson and the Mayo Clinic's Victor Montori, <a href="https://www.bmj.com/content/380/bmj-2022-072953">guidelines should consider clinicians' time needed to treat</a>.<br /></p><p>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 <a href="https://www.medscape.com/viewarticle/995196">having an individual shared decision making discussion</a> 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, <a href="https://elifesciences.org/articles/81808">the COVID-19 pandemic had only modest effects</a> 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.</p><p>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: <a href="https://www.aafp.org/family-physician/practice-and-career/administrative-simplification/prior-authorization.html">prior authorization</a>. 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 <a href="https://www.aafp.org/pubs/afp/issues/2023/0300/editorial-multicancer-early-detection.html">multicancer early detection blood tests</a> 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.</p>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-25852320038192680172023-08-14T11:42:00.000-04:002023-08-14T11:42:49.591-04:00Get out the vote: supporting civic health in primary careThe national organization Vot-ER has designated August as <a href="https://vot-er.org/civic-health-month/">Civic Health Month</a>, “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 <a href="https://www.aamchealthjustice.org/news/news/civic-health-month">Association of American Medical Colleges</a>, encourage clinicians and health care organizations to support an inclusive democracy by providing patients with nonpartisan education and voter registration services.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_oBT-xRCgj4l8D8y8_T4z4_mo05ocF-921tLSUsG18d-rNt6GNcSIgZo8D-jcuXfgVINQMZls6myeXqh4L3a2mE3eM3L0s1cy9g97wigKj7hvqvLeioeXlYynUPQH3yjhqpv4udX0oPGL4Wd-lbZeLjlU5xkNDuzA03ilYMaO2Ug7TH37ixXMnR8p6M4/s1080/Civic-Health-Checkup%20graphic.webp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1080" data-original-width="1080" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_oBT-xRCgj4l8D8y8_T4z4_mo05ocF-921tLSUsG18d-rNt6GNcSIgZo8D-jcuXfgVINQMZls6myeXqh4L3a2mE3eM3L0s1cy9g97wigKj7hvqvLeioeXlYynUPQH3yjhqpv4udX0oPGL4Wd-lbZeLjlU5xkNDuzA03ilYMaO2Ug7TH37ixXMnR8p6M4/w400-h400/Civic-Health-Checkup%20graphic.webp" width="400" /></a></div><div><div><br />A <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/1468-0009.12661">recent narrative review</a> in <i>The Milbank Quarterly</i> 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.”<br /><br />Primary care physicians have successfully engaged patients with “civic health check-ups” at federally qualified health centers and other outpatient locations. In a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4157984/">voter registration project</a> 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 <a href="https://pubmed.ncbi.nlm.nih.gov/37075802/">disseminate a REDCap survey</a> containing embedded links to voter resources, including safer alternatives to in-person voting during the 2020 elections.<br /><br />Outside of these and other individual case studies, voter enfranchisement remains, to borrow from the title of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571786/">a 2020 perspective article</a> in the <i>Journal of General Internal Medicine</i>, “an underused treatment strategy." To make voting a “standard of care,” Vot-ER and its partners are hosting <a href="https://vot-er.org/civic-health-month-events-actions/">several online events</a> this month for clinicians who are interested in empowering patients to support their community’s health at the ballot box.</div></div><div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.comtag:blogger.com,1999:blog-1528123283952414948.post-75099609516045333272023-08-01T21:09:00.001-04:002023-08-01T21:09:52.623-04:00Current prescriptions for addressing health-related social needs fall shortAccording to <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2804032">one recent estimate</a>, 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 <a href="https://afpjournal.blogspot.com/2018/05/supporting-our-patients-health-outside.html">organized medicine initiatives aimed at identifying and meeting those needs</a>, such as the American Academy of Family Physicians’ (AAFP) <a href="https://www.aafp.org/family-physician/patient-care/the-everyone-project.html">The EveryONE Project</a>.<br /><br />In a <a href="https://www.aafp.org/pubs/afp/issues/2019/0415/p476.html">2019 editorial</a>, 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 <a href="https://www.aafp.org/family-physician/patient-care/the-everyone-project/neighborhood-navigator.html">AAFP’s Neighborhood Navigator tool</a> (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 <a href="https://www.aafp.org/pubs/afp/issues/2023/0100/graham-center-neighborhood-navigator.html">Graham Center Policy One-Pager</a> found that the most common Neighborhood Navigator searches since 2018 were for food, housing, and health care.<br /><br />Some practices and health care systems have begun screening patients for social needs using print or electronic health record-embedded questionnaires. Two articles in <i>FPM</i> (<a href="https://www.aafp.org/pubs/fpm/issues/2018/0500/p7.html">A Practical Approach</a> by Drs. David O’Gurek and Carla Henke and <a href="https://www.aafp.org/pubs/fpm/issues/2022/0300/p6.html">Screening in Daily Practice</a> 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 <a href="https://jamanetwork.com/journals/jama/fullarticle/2783974">considers social risk in the majority of its recommendation statements</a>, it has not found sufficient evidence to recommend screening for social needs. In a <a href="https://www.aafp.org/pubs/afp/issues/2019/0515/p602.html">2019 editorial</a>, Dr. Alex Krist and colleagues discussed the research that still needs to be performed:<br /><br /><i>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. </i><br /><br />In 2017, the Centers for Medicare and Medicaid Innovation launched the <a href="https://innovation.cms.gov/innovation-models/ahcm">Accountable Health Communities Model</a>, 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, <a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2022.01507">an independent evaluation</a> 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 <a href="https://www.aafp.org/pubs/afp/issues/2018/0801/p143.html">food insecurity</a> despite receiving food assistance). A <a href="https://www.healthaffairs.org/content/forefront/moving-incremental-transformational-strategies-address-health-related-social-needs"><i>Health Affairs Forefront</i> commentary</a> pointed out the need to solve the “last mile problem”:<br /><br /><i>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.</i><br /><br />Equally important, many community organizations have inadequate resources and funding to serve their populations. A <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2805020">microsimulation study</a> in <i>JAMA Internal Medicine</i> 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 <a href="https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html">unwinding of Medicaid’s COVID-19 continuous enrollment condition</a> (which expired on March 31, 2023) proceeds, the <a href="https://jamanetwork.com/journals/jama/article-abstract/2776338">need for social policy as health policy</a> has never been greater.<div><br /></div><div>**</div><div><br /></div><div>This post first appeared on the <a href="https://www.aafp.org/pubs/afp/afp-community-blog.html"><i>AFP</i> Community Blog</a>.</div>kennylinhttp://www.blogger.com/profile/00240060576692353940noreply@blogger.com