Increasing clarity about benefits and harms of screening for diabetes

Affecting about 6 percent of pregnancies in the United States, gestational diabetes increases risks of preeclampsia, shoulder dystocia, and macrosomia, and is associated with a 10-fold greater risk of developing type 2 diabetes mellitus in later life. In a recent draft statement, the U.S. Preventive Services Task Force (USPSTF) affirmed its previous recommendation to screen pregnant persons for gestational diabetes at or after 24 weeks of gestation. Historically, there have been two screening options: a non-fasting 50 gram oral glucose challenge test followed by a fasting 100 gram glucose tolerance test if the first test result exceeds a threshold value (typically 130-140 mg/dL), or a single fasting 75 gram glucose tolerance test. Although two-step screening is more commonly used in the U.S., until recently the comparative outcomes of these approaches were uncertain. This evidence gap is important because the diagnosis is associated with increased psychological and emotional burden; labeling more persons as having gestational diabetes with the one-step screening approach would only be justified if doing so resulted in better pregnancy outcomes than the two-step approach.

A pragmatic, randomized trial recently compared the one-step and two-step approaches in more than 23,000 women who received prenatal care at Kaiser Permanente Northwest and Kaiser Permanente Hawaii. Researchers evaluated five primary outcomes: "diagnosis of gestational diabetes, large-for-gestational-age infants, a perinatal composite outcome (stillbirth, neonatal death, shoulder dystocia, bone fracture, or any arm or hand nerve palsy related to birth injury), gestational hypertension or preeclampsia, and primary cesarean section." As expected, a diagnosis of gestational diabetes was more common in participants who underwent one-step screening (16.5%) compared to the two-step approach (8.5%). However, intention-to-treat analyses found no statistically significant differences in any perinatal or maternal complications. Although the trial was not designed to measure potential long-term benefits of post-pregnancy risk-reduction strategies to prevent type 2 diabetes, the results suggest that the two-step approach produces equivalent benefits, and fewer harms, than the one-step approach.

The USPSTF is also updating its recommendation on screening for prediabetes and type 2 diabetes in nonpregnant adults. Compared to its 2015 statement, which recommends screening overweight or obese adults between the ages of 40 and 70, the updated draft statement lowers the age range to include persons aged 35 to 39 years. Although the focus of the Task Force's old and new diabetes screening guidelines is identifying persons with prediabetes in order to prevent them from developing diabetes and its complications, the utility of the term "prediabetes" is controversial, as Dr. Jennifer Middleton discussed in a previous AFP Community Blog post. In older adults, prediabetes is extremely common. In a prospective cohort study of community-dwelling adults aged 71 to 90 years, 73 percent met one or both of the diagnostic criteria for prediabetes (hemoglobin A1c level of 5.7% to 6.4%, impaired fasting glucose of 100-125 mg/dL). After 6.5 years of follow-up, persons with prediabetes at baseline were substantially more likely to revert to normoglycemia or to die than to progress to diabetes. Based on these findings, stopping diabetes screening after age 70 will avoid overdiagnosis and unnecessary treatment.

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This post first appeared on the AFP Community Blog.

Can Choosing (more) Wisely prevent chronic low back pain?

More than a dozen Choosing Wisely campaign recommendations concern what not to do for patients with acute low back pain. Based on a clinical practice guideline from the American College of Physicians, the American Society of Anesthesiologists and several other groups recommend avoiding imaging studies within the first six weeks in patients without red flags or specific clinical indications. The American Academy of Orthopedic Surgeons and the American Academy of Physical Medicine and Rehabilitation (AAPMR) advise avoiding opioids for these patients unless other alternatives have not provided pain relief. The AAPMR and the North American Spine Society discourage bed rest as treatment for acute low back pain. These recommendations are intended to reduce downstream harms and costs: for example, a spurious finding on MRI could lead to unnecessary surgery; use of opioids could lead to physical dependence and opioid use disorder; bed rest and avoidance of physical activity could increase the risk of long-term disability.

Can guideline-discordant care for patients with acute low back pain increase the risk of progression to chronic low back pain? In an inception cohort study published in JAMA Network Open, researchers enrolled 5233 adults with acute low back pain from 77 U.S. primary care practices, assessed their baseline risk of transition to chronic pain using the Subgroups for Targeted Treatment (STarT) Back prognostic tool, and followed them for 6 months. 32% of participants met clinical criteria for chronic low back pain at the study's end. Characteristics associated with transition to chronic pain included obesity (adjusted odds ratio, 1.52), tobacco use (aOR, 1.56), severe baseline disability (aOR, 1.82), and a depression and/or anxiety diagnosis (aOR, 1.66). Researchers also examined associations between chronic low back pain and inappropriate care processes within 21 days of the initial visit: 1) any opioid prescriptions, or benzodiazepines or systemic steroids prescribed without an NSAID or skeletal muscle relaxant; 2) diagnostic imaging; 3) medical subspecialty referral for back pain. Compared to the 52% of participants who received none of these, patients with 1, 2, or 3 inappropriate care processes were 1.39, 1.88, and 2.16 times more likely to develop chronic low back pain after controlling for clinical characteristics.

Although adherence to Choosing Wisely recommendations was associated with a lower risk of patients developing chronic low back pain in this study, it is disappointing that almost half of them received at least some inappropriate care. Is care for back pain an outlier, or does it reflect national trends? A recent cross-sectional study examined the use of 32 low-value health services in Medicare fee-for-service beneficiaries. The study found modest progress from 2014 to 2018 in the percentage of persons receiving any low-value service (declined from 36.3% to 33.6%), number of low-value services per 1000 persons (declined from 678 to 633), and spending per 1000 persons on low-value care (declined from $52,766 to $46,922). Three services comprised about two-thirds of low-value care: preoperative laboratory testing, opioids for back pain, and antibiotics for upper respiratory infections. While preoperative testing decreased during the study period, opioid and antibiotic prescribing both increased.

Since the campaign's inception in 2012, Choosing Wisely recommendations have been widely disseminated in American Family Physician (AFP), FPM (formerly Family Practice Management), and other family medicine journals. The American Academy of Family Physicians periodically updates and adds new "don't do" recommendations, most recently in 2018. Other studies have recognized that clinicians in underserved or "safety net" practices are as likely to provide low-value care as clinicians in better resourced settings. A 2018 AFP editorial by Dr. Jennifer Middleton recognized that increasing awareness of best practices is necessary but not sufficient to drive implementation: "For meaningful change to occur, the workflows and systems we operate within must change so that new habits become routine." The Medicare study suggests that workflows and systems have not changed enough in the past decade to undo entrenched low-value practices.

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This post first appeared on the AFP Community Blog.

Misinformation can be as contagious and harmful as COVID-19

At the end of August 2020, when around 1,000 Americans were dying from COVID-19 each day, I posted on my personal Facebook account a straightforward translation of the deaths statistic: averaged over 24 hours (86,400 seconds), one U.S. resident was dying every 86 seconds. In another post, I expressed my concern for the mental health and safety of hundreds of public health officials all over the country who were being threatened and harassed for recommending or enforcing measures aimed at stemming these horrifying losses, such as restricting restaurant capacity, banning large gatherings, and mandating mask-wearing when social distancing wasn't possible.

It didn't occur to me that either of these posts would be the least bit controversial among my friends and family. But later that night, a friend from college whom I've known for more than a quarter of a century commented that I was greatly exaggerating the death toll and "fear mongering." Do the math, I responded. He countered by claiming that doctors were inflating COVID-19 death counts for financial benefit and that just because thousands were dying with COVID, they weren't necessarily dying of COVID. The flu kills 100,000 people every year, he wrote, and we don't shut down the country for that. I gently pointed out that according to official CDC statistics, no more than 60,000 people have died in a single influenza season for the past decade, and those numbers are estimates, not actual case counts. We went back and forth like this for a while. Finally, exasperated, I observed that my friend is a lawyer, while I have medical and public health degrees and was probably a little bit more informed than he was. "Elitist," he taunted, your fancy education doesn't mean anything. The great thing about social media is that it's the ultimate equalizer - no one needs to "bow down" to your supposed expertise. By the way, he wrote, right before I wished him well and blocked him from posting more misinformation on my page, those public health officials you support all march in lockstep with the Democratic Party, so as for the harassment, well, they had it coming.

Six months later, more than half a million Americans have died from the pandemic, and though new infections have fallen from their post-holiday peak, we're still losing about 2,000 people every day (or one every 43 seconds). Despite the greatly increased pace of vaccination since President Biden took office, as of today less than 10 percent of the U.S. population is fully vaccinated, and less than 20 percent has received at least one dose of the Pfizer or Moderna two-dose vaccines (the Johnson & Johnson vaccine is a single dose). Nonetheless, the misinformed governors of Texas and Mississippi have declared victory, discarding their mask mandates and restrictions on businesses and sending the message that if COVID-19 was ever a serious public health problem, it isn't any longer.

Of course, online misinformation abounded well before COVID, infamously leading many parents to refuse the measles, mumps, and rubella vaccine for their children because they feared, based on a single fraudulent, discredited and retracted scientific article, that it might cause autism. And I'm deeply concerned that the crazy myths now proliferating online about COVID vaccines - that they make changes to your DNA, they cause infertility, they contain tiny microchips to allow Bill Gates can track your movements, that their side effects are worse than the disease - pose a huge obstacle to achieving herd immunity through vaccinating 70 percent or more of the population. (And don't get me started on the barbaric "let's achieve herd immunity through natural infection." One might as well go back to the days of bloodletting and Hippocrates' four humors, for the immense harms that strategy would cause.) Let me be clear: I don't think that vaccination should be mandatory for every adult (or child, when it is shown to be safe and effective in children), but those who decline it for themselves or on someone else's behalf should do so because they have concerns that medicine can't yet answer (e.g., are there any side effects that don't show up for a year or more?), not because they fall for misinformation or conspiracy theories.

Are physicians overdiagnosing melanoma?

In an editorial in the February 1 issue of American Family Physician, Dr. Jenny Doust and colleagues wrote about the problem of widening disease definitions, a common phenomenon in which the definition of a disease is "broadened over time to include milder and earlier cases," leading to harm "by exposing more patients to the adverse effects of treatments, triggering investigation and prescribing cascades, increasing anxiety, and placing a financial burden on patients and the wider society." Expanding the number of patients diagnosed with disease increases the burden on primary care physicians called on to manage these additional cases, even when it is uncertain if earlier interventions prevent morbidity or mortality. Illustrative examples of wider disease definitions include hypertension, polycystic ovary syndrome, breast cancer, and autism. What can family physicians do about it? The authors responded:

Recognizing the problem is the first step in tackling it. In particular, family physicians should not blindly accept new definitions and testing guidelines without an adequate understanding of the harms and benefits of the changes and the implications for our patients and wider practice.

Along similar lines, a recent analysis in the New England Journal of Medicine by Dr. H. Gilbert Welch and colleagues examined the drivers of the dramatically increased incidence of cutaneous melanoma in the U.S., which today is 6 times as high as in 1975 despite essentially no change in melanoma mortality. They pointed out that exposure to ultraviolent (UV) radiation (including tanning bed use) cannot account for more than a small portion of this increase. Instead, they argued that increased diagnostic scrutiny - "the combined effect of more screening skin examinations, falling clinical thresholds to biopsy pigmented lesions, and falling pathological thresholds to label the morphologic changes as cancer" - is most likely to be responsible for the epidemic of new diagnoses. Not only has the annual percentage of fee-for-service Medicare beneficiaries undergoing skin biopsies nearly doubled since 2004, but pathologists frequently upgraded skin biopsy specimens obtained in the late 1980s from benign to malignant when evaluating the same specimen two decades later. Primary care physicians contribute to widening the definition of cutaneous melanoma by performing or referring for biopsy small (<6 mm), incidentally detected skin lesions and screening patients with dermoscopy, which identifies more melanomas than visual inspection alone but is not well studied in primary care settings.

The U.S. Preventive Services Task Force (USPSTF) has concluded that current evidence is insufficient to assess the balance of benefits and harms of skin cancer screening in asymptomatic adults. Nonetheless, more than half of family physicians and general internists in a 2011 survey reported performing full-body skin examinations for skin cancer screening. In a 2020 AFP editorial, Drs. Michael Pignone and Adewole Adamson (Dr. Adamson also co-authored the NEJM analysis) observed that "compared with usual care, potential effects of screening on morbidity and mortality from keratinocyte carcinoma are at most small, and screening cannot be justified based on the impact on keratinocyte carcinoma alone." Dr. Welch and colleagues went one step further, arguing that the established harms of skin cancer screening already outweigh any potential benefits:

The increase in melanoma diagnoses by a factor of 6, with at least an order of magnitude more persons undergoing a biopsy and no apparent effect on mortality, is more than enough to recommend against population-wide screening. ... It [screening] has been effectively promoted under the guise of public health, with the combination of frightening messages about skin cancer and the premise that screening can only help. However, medical care should be driven by patient needs, not system needs. Now is not the time to add more anxiety and expense to an already anxious and expensive world.

Not surprisingly, dermatologists have a more positive view of skin cancer screening, as reported in a news story about the analysis by Dr. Welch and colleagues that quoted the president of the American Academy of Dermatology as stating that "an aggressive approach to prevention and treatment is entirely appropriate for a disease that kills 20 Americans each day." Of course, no one is urging clinicians to stop counseling patients on minimizing their exposure to UV radiation; indeed, the USPSTF recommends behavioral counseling to prevent skin cancer, particularly for children, their parents, and young adults. But screening for skin cancer, which has effectively widened the definition of cutaneous melanoma and driven widespread overdiagnosis - is a different story. To give Dr. Doust and colleagues the last word: "We [primary care physicians] are not here to passively enact specialist recommendations. Instead, we need to more assertively act as advocates for our patients and our communities."

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This post first appeared on the AFP Community Blog.

Don't put me in a (political) box

On any given day, several hundred people read one or more of my blog posts. I don't have a good sense of who they are or where they stand on the various health and health policy issues that I've been writing about for the past decade. Since I turned off the blog Comments function a few years ago because it was being deluged in spam advertisements for cut-price Viagra and such, the only way I receive feedback about what I've written is when a reader reaches out directly, through an e-mail or private social media message, to let me know what they thought. The exception is my wife, who isn't a regular reader but does me the favor of promoting my blog within her social and professional circles from time to time. That isn't to say that we see eye to eye on all or even most of these topics. In fact, recently she shared, after not reading the blog for quite a while, that she was surprised by how "political" my posts had become. It wasn't only the recent Donald Trump post, which I'll freely admit is out of character for Common Sense Family Doctor and not likely to recur in the post-Trump Presidency era, but also posts about COVID-19 where I've seemed to come down on one partisan side or the other regarding elements of the public health response.

I don't feel that I've become more "political," but rather that public health and scientific evidence have been increasingly politicized. For example, wearing a mask indoors to slow the spread of SARS-CoV-2 wasn't a Republican or Democratic issue until the President declined to wear one and starting mocking rival politicians who did. Closing and re-opening public schools with safety protocols wasn't a liberal or conservative issue until the President, months prior to the results of definitive studies that confirmed that schools can re-open safely, insisted that they all re-open immediately and threatened to withhold federal funding if they didn't. And it became more politicized when teachers' unions, bastions of Democratic support, disregarded the science and insisted on conditions such as having children vaccinated prior to teachers returning, which effectively would keep school online for the remainder of this academic year and likely most of the next one.

I resist being categorized as partisan based on my position on any single issue. I am not currently registered with any political party, and though I voted for Joe Biden for President in 2020, eight years ago I voted for Mitt Romney and would probably vote for Romney again if he chose to run in 2024, based not only on his principled opposition to Trump's unchecked lawbreaking but his role as one of the original architects of Obamacare when he was the governor of Massachusetts. I am as vocal about my support of mask mandates as I am about opening schools. I criticized President Obama's health policy team for suppressing the U.S. Preventive Services Task Force's politically inconvenient statement on prostate cancer screening, and I criticized President Trump's first Secretary of Health and Human Services, Tom Price, for trying to do the same thing when he was a member of Congress. I praised Obama's health officials for aiming to de-stigmatize substance use disorders and later bemoaned the Biden administration's recent decision to block implementation of a proposal to expand access to medication-assisted treatment for opioid use disorder by no longer requiring clinicians to hold a special waiver to prescribe buprenorphine.

In short, I've been on both sides of the partisan divide. My health policy views hew not to any political identity or ideology, but have always been guided by my interpretation of what the evidence says or doesn't say. So when you read something I write, here or anywhere else, please don't automatically put me into a political box and assume that because I'm for this, I must be for or against that. I'm a family doctor, and my goal is to take a commonsense, less-is-more approach to health care.

How state policies influence how long you live

Last summer, I temporarily moved from one of the most politically liberal places in America to one of the most conservative. In the 2020 Presidential election, Joe Biden carried DC's 3 electoral votes with more than 92% of ballots cast, while Donald Trump carried Utah's 6 electoral votes over Biden by a comfortable 58% to 38% margin. As the COVID-19 pandemic became increasingly politicized, the orientations of DC and Utah predicted their public health responses. Although nearly all public and private schools in both places initially switched to online learning, most Utah schools re-opened for in-person learning last fall, while DC public schools stayed closed and are only beginning to re-open this month. DC's mayor instituted a mask-wearing mandate on July 22, while Utah's governor did not do so until November 9, when its hospitals were nearly full and the per capita incidence of COVID-19 was among the top 5 states in the nation. DC has also kept in place more restrictive rules on operating restaurants (including closing indoor dining entirely from Dec. 18 to Jan. 22) and other "non-essential" businesses than most parts of Utah.

A research study in Science Advances examined the relationship between social mobility, community COVID-19 incidence, and partisan differences. Logically, people should be more likely to stay at home when viral spread is higher, and more likely to go out when viral spread is lower. Instead, the researchers found that there was only a weak association of mobility with COVID-19 activity over time; a far stronger predictor of people's willingness to leave home to socialize with others outside of their immediate family was party affiliation:

Using daily data on the reported activities of 1,135,638 U.S. adults collected starting on 4 April 2020, we show that partisanship is 27 times more important than the local incidence of COVID-19 in explaining mobility. Moreover, all else equal, Democrats are 13.1% less likely to be socially mobile over time compared to independents, while Republicans are 27.8% more likely to be mobile.

This study's findings correlate with my own experience. I can't remember seeing anyone indoors in DC who wasn't wearing a mask after mid-March, but outside of Salt Lake City (which leans liberal and has a Democratic mayor) it was common to see unapologetically maskless people shopping in stores where mask-wearing was required by law. In a recent article in The New Yorker, Dr. Atul Gawande reported on the debate surrounding mask mandates in Minot, North Dakota, which in mid-October 2020 held the unenviable distinction of being the county seat of "the worst-hit county in the worst-hit state in the worst-hit country" in the world in new COVID-19 cases and deaths per capita. From a public health perspective, a mask mandate ought to have been a no-brainer. Instead, as the city council debated a mask mandate motion for an hour, a YouTube chat of residents watching the proceedings online erupted with angry comments such as "unconstitutional," "tyrannical," and threats of "mass protests." (The council ultimately adopted a mask mandate with no penalties or other means of enforcement.) A few weeks later, Donald Trump easily carried Ward County over Joe Biden, 65% to 32%.

The influence of partisanship on states' public health approaches to the coronavirus is just the tip of the health policy iceberg, though. A study in Pediatrics showed that higher state and local expenditures on non-health care services such as social services, environment and housing were associated with lower infant mortality from 2000 to 2016. Another, more ambitious study graded state policies on a conservative to liberal continuum from 1970 to 2014 ("liberal was defined as expanding state power for economic regulation and redistribution or for protecting marginalized groups, or restricting state power for punishing deviant social behavior, conservative was defined as the opposite") and found that people consistently live longer in states with more liberal policies than in those with conservative ones. The authors estimated that overall U.S. life expectancy (which since the 1990s has been at or near the bottom of the world compared to other high-income countries) would be nearly 3 years longer among women and 2 years longer among men "if all states enjoyed the health advantages of states with more liberal policies," and would mostly erase the current U.S. life expectancy disadvantage. A few years may not seem like that much, but consider this: the 350,000 excess deaths that the U.S. experienced in 2020 due to COVID-19 reduced life expectancy at birth by just over a year, enough to lower U.S. life expectancy to its lowest level since 2003.

In a recent perspective in The Milbank Quarterly, Dr. Jennifer Karas Montez observed that as states became increasingly polarized to the right or the left in their politics, the range of state life expectancies widened from 5.4 to 7 years between 1980 and 2017. She hypothesized that two major factors have driven the widening disparities between liberal and conservative states: devolution (transferring federal oversight and fiscal responsibilities to the state level) and state preemption laws, which "prohibit or severely restrict local governments from legislating on certain issues," such as social distancing and mask regulations in Florida, Mississippi, and Georgia in 2020. Of course, millions of people immigrate from outside of the U.S. and move from one state to another every year, which complicates the picture: it's possible that healthier people move to certain states in order to enjoy the benefits of more livable environments or liberal policies, rather than those environments or policies creating better health. But all things considered, it's important to recognize that what my Georgetown family physician colleague Ranit Mishori calls "the political determinants of health" act powerfully at the state level, not only through national legislation and executive actions.