Wednesday, September 19, 2018

Underperforming big ideas in diabetes and breast cancer

Management of type 2 diabetes and screening for breast cancer make up a large portion of most family physicians' practices, including my own. Care and prevention for these patients is based on straightforward underlying theories of disease causation and behavior. Patients with type 2 diabetes have high blood glucose levels; treatment involves normalizing blood glucose through lifestyle modification and medication. Small, nonpalpable breast cancers eventually become large, symptomatic tumors. Smaller tumors are more likely to be curable, so undergoing regular screening mammography is preferable to not doing so.

But what if these underlying theories are wrong?

In a 2016 editorial in JAMA, Drs. Michael Joyner, Nigel Paneth, and John Ioannidis explored how the "big idea" or narrative that investments in genetics and information technology will lead to a revolution in health care has captured a large share of biomedical research funding and journal publications. They then illustrated how this big idea has "underperformed," as central assumptions of precision/personalized medicine have not been borne out in studies and tens of billions of dollars invested into electronic health records since 2009 have not made patient care measurably better or patient data more accessible to researchers.

Is tight glycemic control for patients with type 2 diabetes mellitus an underperforming clinical big idea? In an analysis in Circulation: Cardiovascular Quality and Outcomes, Drs. Rene Rodriguez-Gutierrez and Victor Montori compared clinical policy statements and practice guidelines for patients with type 2 diabetes between 2006 and 2015 with evidence from randomized controlled trials. Despite little or no evidence that tight glycemic control (hemoglobin A1c less than 6.5 or 7.0%) improves microvascular or macrovascular outcomes compared to less strict hemoglobin A1c goals, the majority of guidelines continued to endorse tight control for one or both of those outcomes. (In contrast, American Family Physician editorials and articles have asserted that "Physicians should not let well-intentioned but misguided concern for glucose levels distract them from attending to other interventions that more profoundly affect mortality [in patients with type 2 diabetes]: smoking cessation, blood pressure control, metformin therapy, and lipid reduction.")

And do small breast tumors detected by mammograms become large, lethal ones? Sometimes, but not as often as most patients and physicians think, according to an observational study in the New England Journal of Medicine that concluded: "Women [with tumors detected on mammography] were more likely to have breast cancer that was overdiagnosed than to have earlier detection of a tumor that was destined to become large." This study also concluded that most of the reduction in breast cancer mortality over the past 40 years could be attributed to improved systemic therapy rather than earlier tumor detection. In an editorial on counseling women about breast cancer screening, Dr. Mark Ebell and I discussed the benefits and harms of mammography in younger women and noted that for every additional breast cancer death prevented by starting at age 40, two women will be overdiagnosed with (and overtreated for) breast tumors that never would have become clinically apparent.

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This post first appeared on Common Sense Family Doctor on October 26, 2016.

Monday, September 3, 2018

Fracture prevention in older adults: what the evidence says

Hip fractures are a significant preventable cause of morbidity and mortality in older adults. Strategies to reduce hip fracture rates include preventing falls, screening for osteoporosis and prescribing bisphosphonate drugs to increase low bone density, and vitamin D supplementation. Recent studies and guidelines have clarified some of the evidence surrounding hip fracture prevention.

In a Putting Prevention Into Practice case study in the August 15 issue of American Family Physician, Drs. Tina Fan and Elizabeth Erickson discussed two updated U.S. Preventive Services Task Force (USPSTF) recommendations on interventions to prevent falls and supplements for primary prevention of fractures. Although the USPSTF continues to recommend exercise interventions to prevent falls in community-dwelling adults 65 years or older at increased risk of falls, it no longer recommends vitamin D supplements to prevent falls, due to evidence of no benefit and potential harms (increased falls and kidney stones). The Task Force found insufficient evidence to assess the balance of benefits and harms of vitamin D and calcium supplements at daily doses greater than 400 IU of vitamin D and 1,000 mg of calcium (lower doses are not effective) in postmenopausal women without a history of osteoporosis, which may come as a surprise, given how many are taking such supplements.

The USPSTF also recently reaffirmed its previous recommendation to screen for osteoporosis with bone measurement testing in women 65 years and older. Earlier this year, The Lancet published the first randomized controlled trial of osteoporosis screening with fracture outcomes. Although screening did not affect the primary outcome of all osteoporosis-related fractures over 5 years (HR 0.94, 95% CI 0.85-1.03), it reduced the incidence of hip fractures (HR 0.72, 95% CI 0.59-0.89). More controversial was the Task Force's recommendation to screen postmenopausal women younger than 65 years at increased risk for osteoporosis. In a JAMA editorial, Dr. Margaret Gourlay argued that the 2-step screening strategy advised by the USPSTF - clinical risk assessment tool followed by bone density testing if indicated - may not produce a net benefit to patients. Although screening women younger than age 65 has potential benefits, it is unclear if these benefits outweigh the opportunity costs:

If complicated risk tools perform no better than age alone to identify screening candidates, women younger than 65 years may be subjected to inefficient screening procedures. … The clinician could spend half of a 15-minute clinical visit accessing a risk tool and asking the patient about unfamiliar risk factors (eg, secondary causes of osteoporosis) to make 1 decision out of the dozen or more compressed into an annual physical examination. … Given the myriad responsibilities of primary care practices caring for patients with high-acuity conditions, implementation of screening programs that are needlessly complex is burdensome and distracts from high-value medical care.

Finally, for patients with osteoporosis who are eligible for treatment, given concerns about long-term adverse effects of bisphosphonates, including rare osteonecrosis of the jaw, for how long should these drugs be prescribed? A FPIN Help Desk Answer found low-quality evidence that for most women, bisphosphonate therapy beyond 5 years does not further reduce clinical vertebral fractures, nonvertebral fractures, or mortality. However, women with persistent femoral neck T-scores lower than -2.5 may benefit from longer treatment durations.

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This post first appeared on the AFP Community Blog.

Thursday, August 30, 2018

Heart disease in the American South: echoes of the Civil War?

He displayed an extraordinary ability to absorb the conflicting wills of a divided people and reflect back to them an unbending faith in a unified future. 

Although historian Doris Kearns Goodwin was describing President Abraham Lincoln when she wrote these words in a recent Harvard Business Review article, they could have been said of a statesman of a later era. The longtime Republican "maverick" Senator John McCain, who passed away on August 25, implored Americans in a farewell letter to "not despair of our present difficulties," but to instead "give each other the benefit of the presumption that we all love our country, we will get through these challenging times. We will come through them stronger than before, we always do."

I had the privilege of meeting Senator McCain in 2014 at a Smithsonian Associates event for Thirteen Soldiers, a book he co-authored with Mark Salter that included the stories of soldiers serving in each of America's thirteen major conflicts, from the Revolutionary War to the current wars in Afghanistan and Iraq. I had seen McCain speak on television countless times, but experiencing his outsized, generous, wisecracking personality in the flesh was something else entirely. And I hope he's right about "our present difficulties."

Outside the John Brown House in Chambersburg, PA

While I have long been fascinated by the American Civil War era, when these United States (as opposed to the United States) were more divided than they have been before or since, I gain no pleasure from watching the ceaseless warring of present-day political factions who have seemingly lost the ability to compromise for the public good.

Mount Hebron Cemetery, Winchester, VA

Along with the end of slavery, another positive outcome of the the Civil War was advances in medicine. In 2004 and 2013, I taught a class at Georgetown University School of Medicine called "Civil War Medicine In the Modern Age," and I have enjoyed attending the National Museum of Civil War Medicine's scholarly Annual Conference, which includes educational talks and entertaining trips to nearby historical sites.

Just north of the Mason-Dixon line

Although the Civil War ended more than 150 years ago, its health effects have echoed through the ages. They echo in the hundreds of thousands of soldiers and civilians who perished prematurely from battles or disease; the hundreds of thousands more who were permanently disabled or disfigured by wounds; and - as reported in the Washington Post in 2016 - in the legacy of increased mortality from heart disease concentrated in the South:

To Richard Steckel, an Ohio State University economist, that striking pattern raises a seemingly outlandish, but utterly serious question: Could the heavy toll of heart disease in the American South today have been triggered, in part, by the region's rapid rise out poverty since the 1950s? In a new paper, Steckel argues that decades of poverty caused by the Civil War shaped people's organs and physiology in a way that left them particularly unsuited for a cushy life. The current health disparities in the South, Steckel says, developed as Southerners encountered more prosperous lifestyle than their bodies were prepared for, including more food and less manual labor.

Monterey Pass Battlefield Park, Franklin County, PA

Steckel's hypothesis is intriguing, but even if correct, it is only part of the story. Surely poor diet, physical inactivity, and unrelieved stress caused by a century of segregation and continuing discrimination against African Americans also had a lot to do with the sky-high heart disease rates. And it doesn't help that most of these states have not expanded their Medicaid programs to extend health insurance coverage to those who are most likely to benefit. But that's something to write about another day.

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I took all of the photos in this blog post on various Civil War-themed summer trips. This is what I do when I'm not seeing patients, editing articles, blogging, or teaching medical students about health policy.

Thursday, August 23, 2018

Overdiagnosis of lung cancer: don't tell, don't ask?

Although the U.S. Preventive Services Task Force recommended in 2013 that current and recent smokers 55 to 80 years of age with at least a 30 pack-year history receive annual low-dose CT screening for lung cancer, family physicians have been slow to implement this recommendation in their practices. Concerns about this screening test include the quality of the supporting evidence (which the American Academy of Family Physicians judged to be insufficient) and potential harms, including overdiagnosis and overtreatment of tumors that, left undetected, would never have caused symptoms during a patient's lifetime. An analysis of the National Lung Cancer Screening Trial (NLST) suggested that one in five lung cancers were overdiagnosed. In recognition of the balance of benefits and harms of lung cancer screening, the Centers for Medicare & Medicaid Services requires that eligible patients first have a "counseling and shared decision making visit" with a clinician that utilizes a patient decision aid prior to undergoing a scan.

A previous study of screening for other cancer types found that clinicians mentioned overdiagnosis as a potential harm less than 10 percent of the time. Are lung cancer screening discussions any different? In a study published this month in JAMA Internal Medicine, researchers evaluated shared decision making (SDM) using the validated Observing Patient Involvement in Decision Making (OPTION) scale in a sample of transcribed physician-patient conversations. Relative to the mean total visit length (just over 13 minutes), physicians spent a mean of 59 seconds discussing lung cancer screening. None of the conversations mentioned decision aids, and the mean total OPTION score was 6 out of 100 (where 0 indicates no evidence of SDM and 100 indicates SDM at the highest skill level), reflecting that physicians rarely informed patients about harms of low-dose CT scans or asked patients how they valued these harms.

This lack of attention to harms of lung cancer screening is concerning because the magnitude of overdiagnosis may be considerably higher than previous estimates. Researchers recently analyzed data from the Danish Lung Cancer Screening Trial, in which participants underwent 5 annual low-dose CT screenings (compared to 3 in the NLST) and concluded that two-thirds of lung cancers were likely overdiagnosed. In an accompanying commentary that compared the methods used to estimate overdiagnosis, AFP Deputy Editor Mark Ebell, MD, MS and I stressed the importance of communicating with patients about this "often underappreciated harm of screening":

Patients can make informed choices about low-dose CT only if practitioners fully disclose all the potential harms of screening, including the risk of overdiagnosis. It will be important to researchers to continue to refine estimates of lung cancer overdiagnosis, allowing physicians to provide more accurate information to our patients.

To best serve patients, primary care physicians and pulmonologists must do better than 59-second conversations about lung cancer screening that only mention potential benefits. We need to take the time to tell patients about harms such as overdiagnosis, and ask them how they value these harms relative to the benefits, before ordering the scan.

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This post first appeared on the AFP Community Blog.

Sunday, August 19, 2018

Will tuition-free NYU produce more primary care physicians?

When I graduated from NYU School of Medicine in 2001, I was one of four in my class to enter a residency program in family medicine. That turned out to be the largest number of family physicians that an NYU class would yield in the 21st century. In several subsequent years there were none at all, and the Class of 2018 produced only two. In one sense, this meager output is unsurprising - NYU, like Harvard, has never had a Department of Family Medicine - but my class also produced only a handful of primary care internists (internal medicine residency-trained physicians who did not subspecialize) and general pediatricians. NYU did not always undervalue primary care. When I attended the annual alumni brunch in Washington, DC, I met many generalist NYU graduates from the 1980s and earlier who asked me when going into primary care specialties started becoming so unfashionable, and who is going to "take care of the folks" when they all start retiring.

Last Thursday, when my best friend from medical school (now an emergency medicine physician in San Francisco) texted me about NYU's stunning announcement that its current and future medical students will no longer pay any tuition, my first reaction was: why didn't they come up with this idea 20 years ago? But when I got over that, I carefully pored over the press release, which implied that the goals of this generous policy are to increase the socioeconomic and racial diversity of their classes, and to encourage more students to choose primary care:

Overwhelming student debt is fundamentally reshaping the medical profession in ways that are adversely affecting healthcare. Saddled with staggering student loans, many medical school graduates choose higher-paying specialties, drawing talent away from less lucrative fields like primary care, pediatrics, and obstetrics and gynecology. Moreover, the financial barriers discourage many promising high school and college students from considering a career in medicine altogether due to fears about the costs associated with medical school.

I am fortunate that student loan debt did not play a role in the type of physician I became. I took out a modest amount of loans during medical school - less than one-third of the average $190,000 debt of 2016 medical school graduates - and knew that I would be able to pay them off regardless of the specialty I chose. In the wake of NYU's announcement, a spirited debate occurred on Twitter about whether the tuition-free school will actually attract more medical students to primary care, or simply vault it past its rivals in the U.S. News rankings and subsidize the education of radiologists, ophthalmologists, anesthesiologists, and dermatologists (the so-called R.O.A.D. specialties, with some of the highest incomes and best lifestyles).

It is hard to imagine that a school with no family medicine department or required clerkship, and few visible outpatient primary care role models, is suddenly going to start churning out family doctors by the dozens. But NYU's decision to go tuition-free may put pressure on other medical schools with similar fundraising prowess and stronger primary care infrastructures to follow its lead. Then the question becomes: will reducing financial obstacles to medical school attract more applicants who are likely to become family physicians?

A recent observational study of the distribution of medical education debt by specialty found that family physicians were the least likely of all the medical specialties to have no student loans at graduation, with 16% and 20% of 2010 and 2016 graduates, respectively, reporting no debt. (Since internists and pediatricians don't decide to subspecialize until well into their residency programs, the researchers could not assess the debts of those who might ultimately choose primary care.) In contrast, in 2016, 40% of future ophthalmologists and 36% of future dermatologists reported no debt. These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

Although making medical school tuition-free for all is an inefficient strategy for producing more family physicians, I predict that increasing the diversity of medical school applicants (and accepted students) will likely have a small, but measurable, positive effect on primary care. To magnify that effect, health care institutions must also invest resources into pipeline programs for underrepresented high school and undergraduate students such as the Comprehensive Medical Mentoring Program and ARCHES, academic family medicine departments (looking at you, Harvard and NYU), and community-based residency training programs such as Teaching Health Centers.

I'm proud to be an NYU School of Medicine graduate, and I'm happy for current and future students who now have one less obstacle to fulfilling their dreams. Perhaps they, too, can aspire to be family physicians someday.

Monday, August 13, 2018

Food insecurity hurts health. Here's what doctors can do.

As screening for social determinants of health in clinical settings "moves from the margins to the mainstream," research has focused on how to efficiently identify and address social needs in practice. An article in the May/June issue of FPM by Drs. David O'Gurek and Carla Henke provided a suite of practical approaches, including tools, workflow, and coding and payment considerations. Dr. Sebastian Tong and colleagues reported the experiences of primary care clinicians screening for social needs in 12 northern Virginia practices in the Journal of the American Board of Family Medicine. Knowledge of a social need changed care delivery in 23% of patients and improved communication in 53%, but clinicians often felt ill-equipped to help patients with identified needs or connect them to appropriate services.

Help is on the way. The American Academy of Family Physicians (AAFP) recently launched an interactive online tool, the Neighborhood Navigator, to make it easier for family physicians to connect patients with community organizations and social services. This tool complements other resources in the AAFP's EveryONE Project to support patients' health outside of the office that Dr. Jennifer Middleton discussed in a previous AFP Community Blog post.

In the August 1 issue of American Family Physician, Dr. Shivajirao Prakash Patil and colleagues reviewed the problem of food insecurity, defined as "limited availability of nutritionally adequate and safe food or the inability to acquire these foods in socially acceptable ways," which affected an estimated 12% of American households in 2016. According to the authors, food insecurity (FI) has a cyclical relationship with chronic disease, constraining dietary options in ways that increase the risk for development and progression of diseases in children and adults. They recommended that family medicine practices follow the SEARCH mnemonic and utilize food security resources and food assistance programs in appropriate patients:

S (Screen) - "An affirmative response to either of the following statements can identify FI with 97% sensitivity and 83% specificity: (1) Within the past 12 months we worried whether our food would run out before we got money to buy more, and (2) Within the past 12 months the food we bought just didn't last, and we didn't have money to get more."

E (Educate) - "Educate patients at risk of FI about appropriate coping strategies. Although some individuals with limited resources manage without major disruptions to food intake, many eat less or eat less healthy foods to get by."

A (Adjust) - "Adjust the patient's medication if it should be taken with food. Prescribe medications that minimize the likelihood of hypoglycemia for patients with FI who have diabetes."

R (Recognize) - "Recognize that FI is typically recurrent but is usually not chronic."

C (Connect) - "Connect patients with assistance programs and encourage patients with FI to use food banks."

H (Help) - "Help other health care professionals recognize that poor health and FI often exacerbate one another."

Family physicians can also choose to advocate to improve the quality and quantity of food resource programs available in their communities and across the nation. A recent episode of the Review of Systems podcast discussed the public health implications of upcoming Farm Bill legislation affecting the Supplemental Nutritional Assistance Program (SNAP).

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This post first appeared on the AFP Community Blog.