The reason citizens most often give for their decision to not vote is that they don't care about who gets elected because the result will not directly affect them. Curtis Gans notes that although in recent years "the United States has made it easier to vote," fewer ordinary Americans actually do vote, "sapping the voluntary spirit of participation" that is essential in any democracy. In contrast, J. Austin Ranney takes the position that "there is no reason to believe that a high level of nonvoting is, by itself, a symptom of sickness in American society." Quite possibly, if those voters who truly "don't care" were forced to vote to avoid nonvoting fines, their random votes could distort the opinions of voters who did care about the issues. Gans's picture of an "interested few" influencing issues is legitimate, but these people should not be regarded as a political elite. His argument can just as easily state, "if the few who do not care do not vote, then each issue will be settled in favor of the many who do care, satisfying the voters and doing no harm to the nonvoters." Although some European nations require all citizens to vote whether they want to or not, American democracy relies on a sacred doctrine called "majority rules," referring not to a majority of the people, but to a majority of those people who care strongly enough to vote.
Saturday, October 12, 2024
Is there a right to not vote?
The reason citizens most often give for their decision to not vote is that they don't care about who gets elected because the result will not directly affect them. Curtis Gans notes that although in recent years "the United States has made it easier to vote," fewer ordinary Americans actually do vote, "sapping the voluntary spirit of participation" that is essential in any democracy. In contrast, J. Austin Ranney takes the position that "there is no reason to believe that a high level of nonvoting is, by itself, a symptom of sickness in American society." Quite possibly, if those voters who truly "don't care" were forced to vote to avoid nonvoting fines, their random votes could distort the opinions of voters who did care about the issues. Gans's picture of an "interested few" influencing issues is legitimate, but these people should not be regarded as a political elite. His argument can just as easily state, "if the few who do not care do not vote, then each issue will be settled in favor of the many who do care, satisfying the voters and doing no harm to the nonvoters." Although some European nations require all citizens to vote whether they want to or not, American democracy relies on a sacred doctrine called "majority rules," referring not to a majority of the people, but to a majority of those people who care strongly enough to vote.
Monday, September 23, 2024
Improving primary care for patients with opioid use disorder
An analysis of 2022 data from the National Survey on Drug Use and Health suggests that 3.7% of U.S. adults meet DSM-5 diagnostic criteria for OUD. Of this group, 55.2% received some form of OUD treatment, and 25.1% received medications for OUD. Another survey study highlighted one significant barrier to care: Most people either do not know that primary care physicians can prescribe medications for OUD or incorrectly believe that they cannot. Although family physicians make up the largest share of buprenorphine prescribers, according to a 2020 Graham Center Policy One-Pager, the vast majority of family physicians are not prescribing. A systematic review found that physicians are reluctant to address substance use and addiction in their practices because of lack of institutional support, knowledge and skills, and cognitive capacity.
Collectively, these health care system limitations create major gaps in the cascade of care for OUD, according to a JAMA commentary:
The care cascade—widespread screening regardless of the point of care; ensuring diagnosed patients receive treatment, including medications; and retaining patients in care—has been part of medical care for many years and most clinicians, regardless of medical specialty or practice setting, have understood its importance. … With 1 in 27 adults needing OUD treatment, most US clinicians are likely to have patients who need treatment in their practices, whether they are aware of it or not.
For patients with OUD who decline treatment with sublingual or long-acting injectable buprenorphine, clinicians can offer harm reduction strategies such as naloxone distribution, needle and syringe programs, and long-acting reversible contraception, if applicable. A previous AFP article on primary care for persons who inject drugs recommends screening for HIV infection, latent tuberculosis, and hepatitis B and C; providing vaccinations for hepatitis A and B, tetanus, and pneumonia if indicated; and offering HIV pre-exposure prophylaxis.
A cluster randomized trial conducted from July 2021 to June 2022 evaluated the effect of a community-level intervention to increase uptake of evidence-based practices to reduce opioid-related overdose deaths: overdose education and naloxone distribution, medications for OUD, and prescription opioid safety. In the United States, 67 communities in Kentucky, Massachusetts, New York, and Ohio were randomized to the intervention or a wait-list control. Unfortunately, opioid overdose death rates were similar in the intervention and control groups. The intervention’s apparent lack of effect may have been due to the short follow-up period, a coincidental spike in fentanyl-related overdoses, challenges in implementing practice changes during the COVID-19 pandemic, and a low (less than 20%) rate of medications for OUD–prescribing in intervention communities.
Sunday, September 15, 2024
Get out the vote: supporting civic health in primary care
A narrative review in The Milbank Quarterly explored the role of primary care in advancing civic engagement and health equity. Research shows that poorer population health is associated with lower voter turnout, with stronger associations occurring in early adulthood rather than in middle age. On the other hand, voting is associated with positive mental health and health behaviors, and higher levels of individual happiness strongly predict future civic engagement. Similarly, volunteers are less likely to be hospitalized and more likely to receive preventive care, even after controlling for age, gender, race, income, education, and insurance status: “In one study of US adults, volunteers spent 38% fewer nights in a hospital and were more likely to receive services such as flu shots, cholesterol screening, mammograms, and prostate exams as compared with nonvolunteers.”
Primary care physicians have successfully engaged patients with “civic health check-ups” at federally qualified health centers and other outpatient locations. In a voter registration project in the waiting areas of two family medicine residency clinics in the Bronx, volunteers registered 114 of 128 eligible patients during a 12-week period, 65% of whom were younger than 40 years. During the COVID-19 pandemic, a general internal medicine clinic in North Carolina used its patient portal to disseminate a REDCap survey containing embedded links to voter resources, including safer alternatives to in-person voting during the 2020 elections.
Outside of these and other individual case studies, voter enfranchisement remains, to borrow from the title of a 2020 perspective article in the Journal of General Internal Medicine, “an underused treatment strategy." To make voting a “standard of care,” Vot-ER is hosting several online events this month for clinicians who are interested in empowering patients to support their community’s health at the ballot box.
Wednesday, September 11, 2024
Assessing new screening strategies: collaboration and persistence pay off
One strategy that I've found ensures a long and productive academic career is collaborating with talented and curious colleagues. I first put it into practice as a medical officer at the Agency for Healthcare Research and Quality, writing evidence summaries and systematic reviews with other staffers and rotating Preventive Medicine residents. At Georgetown, I collaborated with a terrific team of health researchers to write papers on interpreting and managing test results for Zika virus and COVID-19. I've collaborated with members of the AAFP's Commission on Health of the Public and Science on clinical practice guidelines on COPD exacerbations and blood pressure targets in adults with hypertension. I've collaborated on articles on social media for doctors and advocacy curricula in family medicine residency programs. Through the Lown Institute, I have collaborated on original work estimating the U.S. rate of overuse of screening colonoscopy and the associated harms. And most recently, I worked with a longtime mentor and sometime mentee on an analysis piece in BMJ Evidence Based Medicine that assesses evidence thresholds for proposals for updating established screening strategies.
How this paper came about deserves some explanation. In spring 2021, a company interested in developing a new screening test approached me to ask whom they should consult about the type of evidence required for that test to be endorsed by guideline panels and be covered by insurance. I recommended Russ Harris, a former U.S. Preventive Services Task Force (USPSTF) member who had retired from his academic position at UNC-Chapel Hill but was still interested in pursuing new scholarly projects. Russ then reached out to me in an e-mail: "I don’t think the methods are well worked out for replacing an established screening strategy with a new one in the absence of a formal RCT. Do you have any interest in [doing] some scholarly work on making a contribution to this problem?"Saturday, August 24, 2024
Strategies for earlier detection of type 1 diabetes in children
Not only does the presence of islet autoantibodies have prognostic significance, selected patients may be eligible for teplizumab (Tzield), a monoclonal antibody approved by the U.S. Food and Drug Administration in 2022 to delay the onset of type 2 diabetes in high-risk individuals. An international randomized, placebo-controlled trial tested a 14-day intravenous infusion of teplizumab in 76 nondiabetic relatives of patients with type 1 diabetes (including 55 children 8 to 17 years of age) with two or more autoantibodies and impaired glucose tolerance. The intervention group had a median time to diagnosis of type 1 diabetes of 48.4 months, compared with 24.4 months in the placebo group. A subsequent trial showed that teplizumab preserves β-cell function in patients with newly diagnosed type 1 diabetes but does not improve clinical outcomes.
Teplizumab’s exceptionally high price ($13,850 per vial; $194,000 for a 14-day course) and limited benefits—delaying type 1 diabetes onset for an average of 2 years—means that other strategies are needed to improve outcomes in at-risk children. Notably, 80% of patients with type 1 diabetes have no affected relatives. However, it is not known whether screening the general population for type 1 diabetes with genetic or autoantibody tests would lead to more benefits than harms.
One alternative to population-wide screening is using machine learning to predict type 1 diabetes in primary care. A June 2024 study in The Lancet used electronic health records from more than 2 million children in Wales to develop and validate a predictive algorithm for type 1 diabetes based on 26 symptoms, history elements, and timing of primary care visits. When the algorithm was set to generate an electronic alert at 10% of visits, 7 in 10 children with type 1 diabetes would have triggered an alert in the 90 days before diagnosis and been diagnosed an average of 9 days earlier. Fewer alerts (e.g., 5% of visits) reduced the number of early diagnoses. Although the researchers asserted that implementing the algorithm would “substantially reduce the proportion of patients with new-onset type 1 diabetes presenting in [DKA],” they acknowledged that further studies are needed to test the feasibility of this strategy and its relationship to “alert fatigue” and clinician burnout in practice.
Tuesday, August 13, 2024
Vaccines protect patients from complications of measles, RSV, and COVID-19
Recent publications have reinforced the protective effects of vaccines against complications of measles, respiratory syncytial virus (RSV), and COVID-19. In an American Family Physician editorial, Dr. Doug Campos-Outcalt alerted family physicians to this year’s measles resurgence and its association with a small decline (95% to 93%) in the percentage of kindergarten-age children who have received two doses of measles, mumps, and rubella (MMR) vaccine. Measles is a highly contagious illness that is not free from complications, as some people believe:
Before the introduction of the measles vaccine in 1963, there were an estimated 3 million to 4 million cases of measles each year, leading to 48,000 hospitalizations, 1,000 cases of encephalitis, and 400 to 500 deaths.
Although not technically a vaccine, the monoclonal antibody nirsevimab was approved by the U.S. Food and Drug Administration in July 2023 for the prevention of RSV bronchiolitis in infants younger than 12 months. A prospective, matched case-control study examined the real-world effectiveness of nirsevimab in preventing hospitalization for RSV bronchiolitis in France during the 2023-2024 season, before that country’s implementation of maternal RSV vaccination. Nirsevimab was 83% protective against hospitalization for RSV-associated illness and reduced pediatric intensive care unit admissions by 70%.
COVID-19 vaccines have been shown to reduce the risk of infections and hospitalizations; however, there have been conflicting data about whether they are protective against postacute sequelae of SARS-CoV-2 (PASC, also known as long COVID). An analysis of a national primary care registry found that breathing difficulties, fatigue, and sleep disturbances often persist after having COVID-19. A large U.S. Department of Veterans Affairs case-control study showed that the rate of PASC decreased during the pre-Delta, Delta, and Omicron eras of COVID-19 and was significantly lower among vaccinated people after vaccines became available. Of the overall decrease in PASC, researchers estimated that 28% was attributable to viral changes and 72% attributable to vaccines.
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This post first appeared on the AFP Community Blog. Although it's hard to put a price on the suffering and deaths prevented by vaccines, an analysis published last week estimated that during the past 30 years in the U.S., childhood immunizations have produced a net savings of $540 billion in direct costs and $2.7 trillion in societal costs.