How do primary care physicians prioritize preventive services?

Although many clinical preventive services, including childhood immunizations, have unfortunately been deferred during the COVID-19 pandemic, it was difficult to address the lengthy list of screening tests, counseling, and preventive therapies with an "A" or "B" letter grade from the U.S. Preventive Services Task Force (USPSTF) even when most primary care visits were in person. In a previous AFP Community Blog post, I wrote about the National Commission on Preventive Priorities' (NCPP) ranking of preventive services based on population health impact and cost-effectiveness. The NCPP's highest-ranked services were the childhood immunization series; counseling and medications to assist smoking cessation in adults; and counseling to prevent initiation of tobacco use in children and adolescents. However, it isn't known how family physicians and other primary care clinicians actually prioritize the services we provide at health maintenance visits.

In a recent study published in JAMA Network Open, researchers from the Cleveland Clinic and Case Western University surveyed 137 internists and family physicians in their health system about 2 hypothetical adult patients who were each eligible for at least 11 preventive services. Based on the patient profiles and visit lengths (20 or 40 minutes), physicians were asked if they would find it necessary to prioritize preventive services, the factors they considered, and what their top 3 priorities were. The researchers compared physicians' stated priorities with a mathematical model that predicted what preventive services were most likely to improve life expectancy.

Unsurprisingly, physicians were more likely to need to prioritize services during a shorter visit, and they selected services that they thought would improve the patient's quality of life, help the patient live longer, and were strongly recommended by their professional organization or guidelines. Cost and patient adherence were less important in determining the services physicians discussed. Across both hypothetical patients, smoking cessation, hypertension control, glycemic control, and colorectal cancer screening were the most highly prioritized services. Only 35% of physicians included a lifestyle intervention (diet and exercise or weight loss) in their top 3 services, even though the mathematical model ranked both lifestyle interventions among the top 3 improving life expectancy for both patients.

As the researchers acknowledged, the intensive behavioral counseling interventions recommended by the USPSTF for adults with cardiovascular risk factors are not feasible in most primary care settings; lifestyle change presents substantial adherence challenges; and diet and exercise counseling are not generally included in quality of care metrics. However, brief evidence-based strategies to encourage health behavior change, as described in a 2018 FPM article, may be effective to prevent cardiovascular disease in individual patients. A recent post on FPM's Getting Paid Blog suggested three steps for family physicians to improve patients' utilization of preventive services during the pandemic.

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This post first appeared on the AFP Community Blog.

Defining hypertension, personally and professionally

I recently started measuring my blood pressure at home at the recommendation of my new family physician in Salt Lake City, whom at a new patient visit had gotten readings that were somewhat higher than I'd had in the past. This finding was not completely unexpected: I'm in my mid-40s, have a family history of hypertension and cardiovascular disease, and my physical activity and dietary habits frequently fall short of optimal. On the other hand, he and I are well aware that out-of-office blood pressure readings are much better at predicting the risk of future hypertension-related events than those taken in the office; in a recent study of 90 family medicine patients with "uncontrolled" blood pressure in the office, nearly two-thirds had normal (defined as <140/90 mm Hg) readings at home.

Professionally, I struggle with hypertension too. As a former Clinical Practice Guideline subcommittee Chair and current scientific advisor for the American Academy of Family Physicians, I participated in the development of a 2017 guideline that suggested a target systolic blood pressure goal of <150 mm Hg for adults aged 60 years or older, and in the decision to not endorse a guideline from the American College of Cardiology / American Heart Association that set a blood pressure target of <130/80 mm Hg for adults of all ages, effectively redefining hypertension. Several publications have expressed concerns about the ACC/AHA hypertension guideline, including my Medscape commentary, an independent analysis of incremental benefits and harms, and a more recent research letter finding that "the clinical trials underlying new treatment thresholds are representative of less than one-third of the guideline target population."

Is it problematic that inconsistencies across recommendations in hypertension practice guidelines mean that family physicians and general internists may define high blood pressure differently than cardiologists? Yes and no. Although in an ideal world there would be a single (primary care-led, federally funded) hypertension guideline endorsed by all relevant stakeholders, including patient representatives, this is unlikely to be a national priority until the COVID-19 pandemic, which has caused the premature deaths of more than 163,000 Americans, is brought under some semblance of control. And just as emergency medicine physicians are often justified at taking a more aggressive testing and treatment approach to a patient with chest pain than a family physician evaluating a patient in his or her office, it's arguable that the greater long-term risk of cardiovascular events in patients who see cardiologists warrant more intensive treatment of blood pressure than patients in primary care settings.

I acknowledge that my training in family medicine and expertise in guideline development make me an atypical patient, better positioned than most to debate the pros and cons of blood pressure interpretation and treatment. At the same time, I have no interest in receiving "special treatment." I want my primary care physician to choose a hypertension guideline that makes sense given my individual circumstances and recommend a course of action supported by the best available evidence. Ultimately, that's what every patient deserves.

Syphilis and COVID-19: an epidemic within a pandemic

In many communities, the same people who work on preventing the spread of sexually transmitted diseases such as syphilis have been called on to help prevent the spread of COVID-19. Departments are reporting mass interruptions in STD care and prevention services. 

- Kaiser Health News, June 4, 2020

Contact tracing is a public health tool that was developed long before the COVID-19 pandemic. It is an essential element of sexually transmitted disease (STD) prevention and treatment programs that rely on notifying partners of infected persons so that they can be treated with antibiotics in time to stop the chain of transmission. As discussed in the article "Syphilis: Far From Ancient History" and my accompanying editorial in the July 15 issue of American Family Physician, the national increase in the number of primary and secondary syphilis infections since 2000 has fueled increases in the incidence of congenital syphilis, with 1306 cases diagnosed in 2018.

Although the essentially flat (40% decreased in inflation-adjusted dollars) Centers for Disease Control and Prevention (CDC) budget for STD prevention programs since 2003 has likely worsened this problem, a CDC analysis of year 2018 cases identified four types of missed prenatal prevention opportunities that can be addressed by family physicians, obstetricians, and other maternity care providers: 1) lack of timely prenatal care (and consequently no syphilis screening); 2) lack of timely syphilis screening despite timely prenatal care; 3) inadequate maternal syphilis treatment; 4) diagnosing syphilis less than 30 days before delivery. In my editorial, I added that "family physicians can prevent congenital syphilis by following national screening guidelines; taking accurate, detailed sexual histories; providing evidence-based interventions to people who use injection drugs; and advocating to reduce structural barriers to care."

COVID-19 has complicated congenital syphilis prevention by diverting health department personnel who would typically staff STD programs and discouraging expectant mothers from attending in-person prenatal visits due to infection concerns. In a Health Affairs blog post, Dr. Marcus Plescia and Elizabeth Ruebush from the Association of State and Territorial Health Officials affirmed that "there’s nothing non-essential about prenatal care and appropriate testing and treatment for syphilis," and discussed strategies for continuing to provide these critical health care services:

In our current environment, we’re seeing healthcare providers develop creative strategies to limit the number of in-person clinical visits by concentrating care around critical visits (e.g., for tests and ultrasounds) and leveraging the use of telemedicine when appropriate. Telemedicine visits should incorporate a comprehensive sexual history, and timely syphilis testing should be a key consideration when planning for prenatal care visits. ... It's also important to take a closer look at the maternal syphilis treatment regimen, which—depending on how long the mother has had syphilis—can involve three shots of penicillin, each seven days apart. ... Text and email reminders can be used to prompt individuals to return for their complete series of penicillin shots, and partnerships with clinical sites in the community can provide alternative models for delivering injectable therapy.

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This post first appeared on the AFP Community Blog.

A meaningful best hospitals list, and a temporary relocation

This July 4th, as Americans held socially distanced celebrations (or not) of the 244th anniversary of our Declaration of Independence, the Washington Post published a story whose headline just about said it all: "Hospital ratings often depend more on nice rooms than on health care." The story reviewed a 2012 study that found that more satisfied patients were more likely than less satisfied patients to be dead 6 months later, and subsequent research that found little correlation between patient-recommended hospitals and quality of care or patient survival.

In a previous blog post, I criticized the Cleveland Clinic, at the time ranked by U.S. News and World Report as the #2 hospital in America, for providing little tangible benefits to its surrounding community in exchange for its non-profit status. (The Cleveland Clinic is hardly alone in taking advantage of its reputation among patients and tax-exempt status to rack up lucrative profits; a Washington Monthly article exposes the University of Pittsburgh Medical Center's performance in this regard.) The title of my post was a question: How about ranking how well hospitals serve their communities?

The Lown Institute, in partnership with the Washington Monthly, has now done just that. For their "Best Hospitals for America" rankings released earlier this month, Lown created a Hospital Index that incorporated not only patient outcomes (mortality, safety, and satisfaction), but also civic leadership (community benefit, representativeness of patients compared to the surrounding community, and institutional salary distribution) and medical overuse. Unsurprisingly, few of the famous academic hospitals that traditionally dominate rankings (and receive the bulk of philanthropic and Medicare graduate education dollars) performed well on these criteria. Instead, top primary care and community-focused institutions such as JPS Health Network in Fort Worth, TX (#1) and Lancaster General Hospital in PA (#13) - where I completed my family medicine residency - led the way in the composite Lown rankings. Lown and the Washington Monthly hope that other hospitals can become more like JPS and LGH:

Hospitals motivated to rise in our rankings ... would compete to bring in patients from all levels of society, not just the well insured. They would find ways to get their staffs to stop performing unnecessary procedures and tests. They would try to reduce the pay differential between hospital workers and chief executives. (Do we really want our hospital workers earning so little that they feel they can’t afford to stay home when they’re sick, especially during a pandemic?) And they would put more of their earnings into improving the conditions that affect the health of their communities.

On a personal note, after 16 years of living and practicing family medicine in DC, I am relocating with my family to Salt Lake City for the next academic year so that my wife can pursue an training opportunity there. Even though I won't be physically in DC (my colleagues have graciously agreed to take on my patients while I'm away), and plan to continue practicing part-time while in Utah, I have decided not to change the tag line of this blog, "Common sense thoughts on health and conservative medicine from a family doctor in Washington, DC." I'm not sure how my new perspective and new colleagues (I will be a visiting professor in the Department of Family & Preventive Medicine at the University of Utah) will influence my blog posts, but I intend to keep writing regularly while I'm there.

Adverse childhood experiences and their sequelae in primary care

In a recent editorial on the relationship between stress and chronic disease, Dr. Jennifer Middleton mentioned that adverse childhood experiences (ACEs), "such as physical or sexual abuse, witnessed domestic violence, loss or incarceration of a parent, and poverty," are associated with later development of diabetes, cardiovascular disease, asthma, and cancer. A 2019 report from the Centers for Disease Control and Prevention (CDC) found that 60% of U.S. adults surveyed from 2015 to 2017 had experienced at least one ACE, while 1 in 6 adults had experienced four or more. In addition, the CDC identified a dose-response relationship between number of ACEs and prevalence of health risk behaviors, socioeconomic challenges, and chronic health conditions.

In a Curbside Consultation in the July 1 issue of American Family Physician, Drs. Jennifer Hinesley and Alex Krist discussed the primary care approach to a woman who presented with irritability, depression and anxiety and a history of childhood physical and sexual abuse. The U.S. Preventive Services Task Force (USPSTF) does not have a recommendation for screening for ACEs; however, a sample screening tool is available in a recent FPM article. In patients who disclose a history of ACEs, Drs. Hinesley and Krist suggested assessment for mental health conditions such as post-traumatic stress disorder and substance use disorders. For other health care needs, including preventive care, applying principles of trauma-informed care may reduce the risk of re-traumatization and increase patients' comfort.

Can screening for ACEs at well-child visits improve resilience and prevent future ACEs and associated toxic stress? Similarly, what types of interventions might help adults with a history of ACEs but no symptoms of related chronic issues? Dr. Krist previously wrote an AFP editorial about the necessary prerequisites for the USPSTF to recommend 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. We know that having a social need leads to poorer health. In some cases, we even know that screening identifies those with a need, but often we do not know what to do after we have identified the need.

Substituting "ACE" for "social need" highlights some potential problems with systematic identification of ACEs in primary care. As Dr. Thomas Campbell noted in a JAMA Viewpoint, the evidence is lacking that ACE-related clinical interventions in children or adults improve any health outcomes. It is possible that screening for ACEs might inadvertently cause harm by reducing trust between clinicians and patients or parents/guardians, or by erroneously labeling patients as "high risk" for future problems based on a high number of ACEs alone.

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This post first appeared on the AFP Community Blog.

Reopening schools (or anything else) safely depends on first containing the virus

If you have young children, you probably breathed a huge sigh of relief when the school year ended. For my wife and me, working from home while taking turns keeping track of our kids' various Zoom meetings and their teachers' creative class assignments (including science projects involving neighborhood nature walks and open flames in the kitchen) was an exhausting ordeal. Yet in some ways we were lucky; unlike many children who lost educational ground, our kids adapted well to online learning, and the older ones were able to help the younger ones stay on task when their attention spans faltered.

Surely, we expected, by the start of the school year in the fall, the pandemic would be under control.

Unfortunately, with less than two months until Labor Day, COVID-19 still very much has the upper hand in the United States. Although pockets of the nation (including the Washington, DC area) have successfully reduced viral spread, two-thirds of states have seen increasing case numbers over the past two weeks, driving new national record highs each day. Belying President Trump's contention that the rising numbers are solely the result of increased testing, the number of infected patients hospitalized and in intensive care units are rising overall and skyrocketing in several states, and the number of daily deaths, which had been trending down since mid-April, is also on the rise.

If you want to read about how the U.S. became an international outlier in the fight against COVID-19 and who is to blame, check out James Fallows' story in The Atlantic, "The 3 Weeks That Changed Everything," and Jonathan Mahler's profile of Michigan governor Gretchen Whitmer's response to the crisis in The New York Times Magazine. A recent JAMA viewpoint also explored four types of cognitive bias that drove poor policy responses: identifiable victim effect (responding more aggressively to threats to identifiable lives than to projected statistical deaths), optimism bias (assuming that the best case scenario is most likely), present bias (preferring smaller immediate benefits to larger future benefits), and omission bias (preferring that a harm occur by failure to take action than as a direct consequence of actions taken). Regarding the latter, the authors wrote:

Policy makers who do not advocate for increasing the ventilator supply, and clinicians who follow triage guidelines, may perceive that they are responsible for the [COVID-19] deaths. In contrast, responsibility is more effortlessly evaded for causing greater numbers of deaths through failures to enact policies that effectively suppress viral spread.

Omission bias explains why federal and state leaders moved heaven and earth to increase supplies of mechanical ventilators and hospital capacity, but dragged their feet on recruiting public health contact tracers, mandating mask wearing, and keeping businesses and schools closed where community spread of the infection remained high.

The American Academy of Pediatrics (AAP) published guidance for school re-entry that "strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school." On the surface, this guidance seems to support the Florida education commissioner's order that all public and charter schools open in the fall for in-person instruction and President Trump's recent declaration that schools will re-open nationally or forego federal funds. However, the AAP's president clarified that states should not force school districts to re-open where transmission of the virus is clearly out of control.

There is much that we still don't know about the contribution of school-aged children to COVID-19 spread and the potential risks classroom exposures to adult teachers, administrators, cafeteria workers, and janitorial staff (who will likely shoulder the additional burden of frequently sanitizing shared spaces). Guidance from the Centers for Disease Control and Prevention (CDC) and the public health organization Resolve to Save Lives combines the best science and common sense to provide schools with strategies to minimize risk when and if they hold in-person instruction. But as former CDC Director Tom Frieden and the Education Secretaries under Presidents Obama and George W. Bush wrote in an editorial today:

The single most important thing we can do to keep our schools safe has nothing to do with what happens in schools. It’s how well communities control the coronavirus throughout the community. Such control of COVID-19 requires adhering to the three W’s—wear a mask, wash your hands, watch your distance—and boxing in the virus with strategic testing, effective isolation, complete contact tracing, and supportive quarantine—providing services and, if necessary, alternative temporary housing so patients and contacts don’t spread disease to others.

I hope that all of my children can return to school in person in the fall. But if they do, I want it to be because elected representatives and public health leaders have taken appropriate steps to contain COVID-19 and make school environments as safe as humanly possible, not due to political pressure or reckless executive orders.