How does the model minority myth harm Asian American aspirations and health?

The medical profession, including family medicine, benefits from having a racially and culturally diverse workforce. In my current practice, I care for a disproportionate number of older Chinese American patients even though I was born in the United States and know fewer than a dozen words of Mandarin. Yet my common heritage allows me to relate to these patients in ways that my non-Chinese colleagues cannot and improves their comfort and trust in my clinical recommendations.

In the mid-1990s, I applied for an 8-week summer laboratory research program at an Ivy League university that explicitly recruited college students from minority groups. Although I am a child of Chinese and Taiwanese immigrants, there was then, and is now, no shortage of Americans of east Asian descent in medical and other health care professions, including in my own extended family. I wondered if being a member of an "overrepresented" group would work against my being accepted to the program. As it turned out, it did not. Although the majority of my fellow students were African American or Latino, there were several other Asian Americans and even one white student. Looking back, the program was a great success, as most of us ended up becoming doctors. A few years ago, I began mentoring underrepresented in medicine (URM) college students in a similar program at my own institution.

Asian Americans are often mischaracterized as the "model minority" to contrast us with other non-white groups that have not achieved comparable economic success and health status on a population level. But lumping all Asian Americans together obscures the fact that many subgroups are actually URM. In a Letter to the Editor in Family Medicine, Dr. Oanh Truong highlighted the importance of data disaggregation to reveal these disparities:

When Asian American data are aggregated, the conclusions misleadingly suggest that Asian Americans as a singular population are thriving, perpetuating the harmful myth of Asian Americans being the model minority, where they are assumed to be doing better than other minority groups. ... However, data disaggregation would reveal that while Filipinos make up 18% of the nation’s Asian American population, they made up only 4.3% of the Asian American medical school applicants in 2019. Additionally, Laotians, Indonesians, and Cambodians altogether made up only 0.5% of the Asian American applicants.

The National Institutes of Health (NIH) highlighted "knowledge gaps, challenges, and opportunities in health and prevention research" for Asian Americans, Pacific Islanders (AAPI) and Native Hawaiians in a 2021 workshop whose proceedings were reported in the Annals of Internal Medicine. Although these groups collectively comprise nearly 8% of the U.S. population, the NIH spent just 0.17% of its budget on researching them between 1992 and 2018. The most telling figure in the report was a "heatmap" that illustrated the known prevalence of chronic health conditions in various AAPI subgroups compared to the U.S. white population. Some were lower, the same, or higher, but nearly half of the cells were blank, indicating insufficient data. We can't take action to reduce a health disparity if we don't even know if it exists.

Recent commentaries in Health Affairs and the Milbank Memorial Fund Blog expanded the argument that poor data quality combines with racial stereotypes to "fuel scientific and societal misperceptions that Asian Americans do not experience health disparities, [codifying] racist biases against the Asian American population in a mutually reinforcing cycle." According to the Milbank Fund, "one in four Pacific Islander adults report problems paying medical bills ... and there is wide variation in uninsurance rates across Asian American subgroups."

An article in press in Academic Medicine by a group of medical students and residents traces the history of discrimination and racism that AAPI have experienced from the 1882 Chinese Exclusion Act to the rise in anti-AAPI rhetoric and hate crimes since the start of the COVID-19 pandemic. The authors point out that discrimination is associated with underutilization of health care services and increased risk of chronic illnesses among non-elderly AAPI immigrants. They recommend that U.S. medical schools implement antiracist policies that recognize unconscious biases against AAPI patients, students, and faculty (e.g., the "bamboo ceiling") and "use disaggregated AAPI data so that the designation of [URM] is appropriately used to recruit diverse individuals who are collectively representative of the whole AAPI disapora."

Debating colorectal cancer screening recommendations: too young, too often?

Last year, the U.S. Preventive Services Task Force (USPSTF) updated its colorectal cancer screening recommendations, lowering the starting age for average-risk adults from 50 to 45 years; this change was reflected in the Putting Prevention Into Practice case study in American Family Physician's September 2021 issue. However, after reviewing the USPSTF statement and supporting documents, the American Academy of Family Physicians (AAFP) concluded that the evidence was insufficient to recommend a starting age younger than 50. Two editorials in the February issue of AFP outlined the arguments for and against starting routine screening at 45 years of age.

In the first editorial, Dr. Richard Wender argued that "lowering the starting age is a settled issue," noting that several organizations, including the American Cancer Society, the National Comprehensive Cancer Network, and the American College of Gastroenterology have all independently reviewed the data and come to the same conclusion as the USPSTF. He pointed out that "the incidence of colorectal cancer in 45 year-olds today is ... almost identical to the risk in 50-year-olds in 1979 when colorectal cancer screening was first recommended," and that nearly a quarter of deaths from colorectal cancer in the U.S. occur in individuals diagnosed between 45 and 54 years of age. Four microsimulation models have also concluded that starting screening at 45 years of age is the most efficient strategy to maximize life-years gained per colonoscopy regardless of the initial screening test used.

The second editorial, by Drs. Corey Lyon, Alexis Vosooney, and Melanie Bird, elaborated on the AAFP's position. The authors noted that "many of the trials used in the modeling studies did not include individuals younger than 50 years or did not provide separate data for this younger age group, decreasing confidence in the data inputs." They also expressed concern about costs to patients and the health care system from implementing the USPSTF recommendation as opposed to optimizing screening in patients age 50 years and older: "Expanding screening to up to 80% of eligible patients 50 to 75 years of age would prevent three times as many colon cancer deaths at one-third of the cost [of routinely screening Americans 45 to 49 years of age]." Finally, they argued that persistent disparities in colorectal cancer incidence and mortality in Black patients would be more appropriately addressed by improving insurance coverage and access to care in this population rather than lowering the age to start screening.

While colorectal cancer screening tests remain underused by many patients, studies have also documented that screening colonoscopies are sometimes performed more often than necessary - for example, being repeated 9 or fewer years after an initial high-quality colonoscopy showed no significant pathology, in contrast to the American Gastroenterological Association's Choosing Wisely recommendation. I co-authored a recent systematic review of 6 studies that estimated the rate of overuse of screening colonoscopy in U.S. populations found that it ranged from 17% to 25.7%. Overuse occurs when endoscopists recommend that patients have subsequent colonoscopies at intervals shorter than those supported by their own guidelines, and primary care physicians (PCPs) defer to subspecialists' recommendations. In an editorial, Drs. Archana Radhakrishnan and Craig Pollack acknowledged the obstacles that PCPs face in going against subspecialist advice but argued that they can still "play an important role in preventing overuse of colorectal cancer screening and surveillance colonoscopies" by directing referrals appropriately and communicating with endoscopists about their rationales for deviations from evidence-based practices.

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This post first appeared on the AFP Community Blog.

Benefits of COVID-19 vaccination in persons with past infection

Since the first COVID-19 vaccine received authorization for emergency use in December 2020, physicians and the public have vigorously debated whether infection-acquired ("natural") or vaccine-mediated immunity provides better protection against future infection and severe illness. The answer may never be known for certain, as it's hard to imagine a research ethics committee approving a trial that intentionally exposes immunologically naive people to a potentially lethal infection. A more important clinical question is: does getting vaccinated after recovery from COVID-19 provide additional benefits? Currently, the Centers for Disease Control and Prevention recommends routine vaccination in all persons aged 5 years or older, regardless of their history of past infection.

Two large cohort studies published earlier this month provided the strongest evidence to date that the answer is yes. The first study used electronic medical records from a health care organization covering more than half of the population of Israel to identify 149,000 patients age 16 years or older who had recovered from documented SARS-CoV-2 infection at least 100 days earlier and had not yet received COVID-19 vaccination as of March 1, 2021. 56% of these persons received at least one dose of BNT162b2 (Pfizer-BioNTech) vaccine by November 26, 2021. 2,168 of those who remained unvaccinated (3.3%) were reinfected during the study, compared to 354 of the vaccinated patients (0.4%). After adjustment for sociodemographic factors and coexisting illnesses, the estimated vaccine effectiveness was 82% for patients aged 64 years or younger and 60% for patients aged 65 years or older. A secondary analysis showed no difference in protection between one or two vaccine doses.

A second study in a highly vaccinated cohort of 35,768 health care workers in the United Kingdom tracked primary infections and reinfections between December 7, 2020 and September 21, 2021. Most participants received two doses of BNT162b2 (Pfizer-BioNTech) vaccine; 8% received the single-dose ChAdOx1 nCoV-19 vaccine (AstraZeneca). In previously uninfected participants who received the second dose of BNT162b2 six weeks or more after the first dose, adjusted vaccine effectiveness was 85% up to 73 days after the second dose but declined to 51% after 200 days. In comparison, adjusted effectiveness of the ChAdOx1 nCoV-19 vaccine was only 58% up to 73 days. In 6,169 participants who had COVID-19 prior to the study, long-term (>1 year) protection against re-infection was 69% in unvaccinated persons but remained high at 94% in persons who received one or two doses of BNT162b2.

Acknowledging some differences between the populations and the predominant variants circulating during the respective study periods, the results support the following conclusions. First, re-infection in unvaccinated persons is relatively uncommon during the first 9 months after a primary infection (1 in 30 in the Israeli study) but becomes more likely after 1 year (per the U.K. study). Similarly, the effectiveness of the initial two doses of BNT162b2 vaccine in preventing COVID-19 declines after 6-7 months, supporting booster doses. However, patients with past infections who subsequently receive one or two doses of BNT162b2 have sustained high levels of protection ("hybrid immunity") against re-infection for at least one year. In an editorial in The Guardian, Dr. Eric Topol recently argued that these and other data support re-defining "fully vaccinated" to include recovery from past infection plus a single dose of an mRNA vaccine.

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This post first appeared on the AFP Community Blog.

Screening for atrial fibrillation, revisited

In 2018, the U.S. Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to assess the balance of benefits and harms of screening for atrial fibrillation (AF) with electrocardiography. However, the proliferation of wearable devices capable of detecting brief episodes of cardiac arrhythmias raised the question of whether screening high-risk patients outside of the office, analogous to home blood pressure monitoring, might prove beneficial. In a scientific statement, the American Heart Association discussed the knowledge gaps regarding the risk of stroke and benefits and harms of initiating long-term anticoagulation in persons with subclinical AF.

Two randomized screening trials published in 2021 aimed to fill these gaps, but instead arrived at mixed conclusions. In the LOOP Study, 6004 Danish adults aged 70 to 90 years with stroke risk factors were randomized in a 1:3 ratio to receive an implantable loop recorder (ILR) or routine medical care. ILR participants were contacted if they had atrial fibrillation lasting for at least 6 minutes and recommended to start anticoagulation. Control participants received electrocardiography as needed from their primary care physicians. After a median follow-up of 64.5 months, 32% of patients in the ILR group and 12% of patients in the control group had atrial fibrillation detected, with similar proportions initiating oral anticoagulation. However, there was no significant difference in the primary outcome of stroke or systemic arterial embolism (4.5% of patients in the ILR group vs. 5.6% in the control group). Rates of major bleeding were not statistically different between the groups.

In the STROKESTOP trial, 28,768 Swedish adults aged 75 or 76 years were randomized to receive an invitation to screening with a handheld single-lead electrocardiogram twice daily for 2 weeks or usual care. After nearly 7 years of follow-up, a composite outcome of stroke, systemic embolism, hospitalization for bleeding, or all-cause mortality was slightly less likely to occur in the intervention group (NNT=93), but differences in individual outcomes were not statistically significant.

Reviewing these trial results and additional data, the USPSTF recently updated its 2018 statement and concluded that the evidence remains insufficient to make a recommendation. An accompanying editorial in JAMA Internal Medicine by Drs. John Mandrola and Andrew Foy (who also authored a 2019 editorial on the downsides of detecting asymptomatic atrial fibrillation) noted that the potential benefits of widespread cardiac rhythm monitoring on cardiovascular and stroke risk could be offset by  "misdiagnosis and downstream cascades of care" and that the "work-up of [arrhythmias] can lead to anxiety, iatrogenic harm, and excess health care costs."

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This post first appeared on the AFP Community Blog.

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Update (3/2/22): VITAL-AF, a cluster randomized controlled trial of >30,000 patients aged 65 years or older in Massachusetts General Hospital-affiliated primary care clinics, tested screening for AF with a handheld single-lead ECG (KardiaMobile) during vital sign assessments. Compared to the usual care group, the screened group had a marginally higher incidence of newly diagnosed AF after 1 year, but no difference in the proportion of individuals treated with oral anticoagulants.

How much administration does health care really need?

During my residency in family medicine, one of the faculty was tasked with the challenge of teaching all of us the "practice management" curriculum, trying earnestly to make us understand how much of our time and energy in clinical practice would be consumed by administrative tasks. Even then, it struck me as borderline crazy how non-procedural physicians are paid. At the time I graduated from residency (2004) and for many years afterward, the financial value of an outpatient "evaluation and management" (E/M) visit was determined not only by the complexity, acuity, and number of medical issues addressed, but also by the number of body "systems" discussed and physically examined. Why the latter should have any relationship to how much money a patient and/or her health insurance company pays for an office visit was, and remains, beyond my comprehension.

My colleague and fellow family physician Dr. Ranit Mishori has written for Medscape about why she and many other clinicians have come to hate the review of systems (ROS). Like many others over many years, she pointed out that a comprehensive (rather than focused on the chief complaint or condition being treated) ROS was usually useless and often led to bloated documentation. Nonetheless, each health care organization I've worked for over the years has employed a small army of people whose job it is to make sure that physicians include the ROS and enough physical examination elements to justify coding a higher-level (i.e., higher charge) visit, and to let us know if we're not doing it right.

Last year, the Centers for Medicare & Medicaid Services (CMS) finally simplified their guidelines for E/M visit codes, essentially eliminating the requirement to document more information than clinically useful about the history of present illness, ROS, and physical examination. In FPM, the American Academy of Family Physicians' practice management journal (on whose editorial board I served from 2010-2014), this change was celebrated with articles with titles such as "Outpatient E/M Coding Simplified" and "A Step-by-Step Time-Saving Approach to Coding Office Visits." That a series of several articles was required to explain the simplified guidelines to physicians and common situations such as "Combining A Wellness Visit with a Problem-Oriented Visit" means that practice management curricula aren't going away any time soon, even though the physician who taught me has gone on to a well-deserved retirement. For while some administrative burdens have been lessened, others have been increased, as payment incentives for providing high quality of care require physicians to document other things, such as the reason my 70 year-old patient with end-stage renal disease on dialysis and chronic heart failure doesn't need to have any more screening mammograms. More primary care practices are using medical scribes, in-person or virtual, to document office visits. While that's good to prevent burnout, it remains faintly ridiculous that armies of such people are being employed for a task that adds little actual value to the heath care encounter.

Is there really too much administration in health care? From an objective viewpoint, the answer is absolutely yes, as a recent JAMA commentary observed:

A typical US services industry (for example, legal services, education, and securities and commodities) has approximately 0.85 administrative workers for each person in a specialized role (lawyers, teachers, and financial agents). In US health care, however, there are twice as many administrative staff as physicians and nurses [emphasis mine], with an estimated 5.4 million administrative employees in 2017, including more than 1 million who have been added since 2001.

The commentary went on to discuss the findings of a new report that concluded, amazingly, that "an estimated $265 billion, or approximately 28% of annual administrative spending, could be saved without compromising quality or access by implementing about 30 interventions that could be carried out in the next 3 years." This without any major structural changes in the U.S. health care system - no need to transition to "Medicare for All" or a single-payer model (though either could lead to even greater efficiencies and savings). Companion commentaries explained why U.S. health care administrative expenses are so high (efforts to control care utilization and prices through market-based forces give rise to activities that require the hiring of more administrators) and how administrative simplification can be economically incentivized (because, apparently, wasting $265 billion per year on unnecessary administration isn't incentive enough).

Achieving this logical next step in administrative simplification will, of course, be an uphill battle. To paraphrase Dr. Don Berwick, what some call health care "waste," others call "income." The same certainly goes for those armies of people looking over my E/M coding, the armies of scribes, and the armies of quality of care managers and utilization and cost controllers. The armies of people working in health care today who facilitate transactions and documentation instead of improving the patient's care experience and health outcomes.

Newer glucose-lowering drugs also treat obesity and heart failure

Last June, the U.S. Food and Drug Administration (FDA) approved a weekly semaglutide (Wegovy) subcutaneous injection for chronic weight management in adults with obesity or overweight with at least one weight-related condition, based on randomized controlled trial (RCT) evidence that it produces substantial weight loss in persons with a body mass index of 27 or greater without diabetes. A lower dose of semaglutide (Ozempic), a glucagon-like peptide-1 (GLP-1) receptor agonist, had previously been approved by the FDA as a second-line therapy for patients with type 2 diabetes that reduced risk of major adverse cardiac events (MACE) in patients with established cardiovascular disease (CVD).

A 2021 BMJ clinical practice guideline examined the benefits and harms of GLP-1 receptor agonists and sodium-glucose cotransporter 2 (SGLT-2) inhibitors and made recommendations for use of these two drug classes in persons with type 2 diabetes and different levels of CVD risk with and without chronic kidney disease, summarized in Patient-Oriented Evidence That Matters in the January issue of American Family Physician. A related editorial by Dr. Sandy Robertson discussed how evidence can inform when to recommend starting a diabetes drug from one of these two CVD risk-lowering classes:

Current data strongly support a reduction in MACE and all-cause mortality with SGLT-2 inhibitors and GLP-1 agonists in patients who have diabetes with established CVD or kidney disease. These patients should be offered one of these medications in the absence of contraindications, regardless of glucose control. Because there is no significant reduction in cardiovascular outcomes in patients who have diabetes without established CVD, patient-centered shared decision-making about adding an SGLT-2 inhibitor or a GLP-1 agonist for cardiovascular benefit is important and ... based on other established benefits such as weight control (moderate net weight loss for GLP-1 agonists and small weight loss for SGLT-2 inhibitors) against risks of genital infections (SGLT-2 inhibitors) or gastrointestinal disturbances (GLP-1 agonists).

Although GLP-1 agonists are associated with greater weight loss than SGLT-2 inhibitors, a population-based cohort study using Medicare and two U.S. commercial claims data sets found that starting a SGLT-2 inhibitor, compared to starting a GLP-1 agonist, reduced the relative risk of hospitalization for heart failure by about 30 percent in patients with and without CVD. A recent international RCT (622 centers in 23 countries) found that adding the SGLT-2 inhibitor empagliflozin (Jardiance) to usual therapy for patients with heart failure with preserved ejection fraction improved a composite outcome of CVD mortality and hospitalization, regardless of the presence of diabetes (RRR=19%, NNT=31). Similarly, a systematic review and meta-analysis of 8 earlier RCTs found that in heart failure patients without diabetes, SGLT-2 inhibitor treatment reduced the risk of this composite outcome by 20 percent.

Based on this new data, should family physicians consider adding a SGLT-2 inhibitor to the standard combination of drug therapies for their patients with heart failure? I think the evidence supports doing so, but it may take some time before generalists become comfortable with this practice change, as I explained in a Medscape news story. A qualitative study of Australian general practitioners suggested that knowledge gaps, drug adverse effects, and a preference for subspecialists to initiate SGLT-2 inhibitor therapy may be obstacles to increased prescribing of these drugs, which remain very expensive in the U.S.

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A slightly different version of this post first appeared on the AFP Community Blog.