Thursday, September 30, 2010

Self-management support doesn't help in heart failure

Heart failure is the most common reason seniors wind up in the hospital, and many patients are hospitalized again and again. They find it's just too difficult to properly manage their condition with its complex drug regimens, dietary restrictions, and frequent monitoring—all of which have been shown in studies to reduce their risk of severe disability and even death. As a family doctor, I've always had a hard time getting my patients to adhere to my advice on managing their heart failure and assumed that any additional one-on-one counseling would be beneficial. Turns out, though, that may not be the case. A study published in a recent issue of JAMA finds that patients with heart failure who receive customized support are no less likely to suffer from disabling symptoms, be hospitalized, or die prematurely than patients receiving standard educational materials.

Self-management support has been shown to improve blood sugar control and quality of life in patients with diabetes. It differs from traditional patient education in that it enables patients to better monitor their own conditions, set personal goals, and overcome any physical or psychological impediments that prevent them from controlling their disease. Rather than, say, simply handing a patient a brochure about the disease and its treatments, a doctor would help patients implement problem-solving strategies and tap into community resources. For example, clinicians might help patients sketch out exercise plans or help them join a local YMCA or neighborhood walking group. They would also check in with patients every week or two to see if those exercise promises were being kept.

The researchers in the JAMA study, which included more than 900 patients with mild to moderate heart failure, randomly assigned participants to either receive face-to-face counseling with educational materials or just the materials without any counseling. Those who received counseling attended two-hour meetings 18 times over the duration of a year to learn skills in monitoring their condition, reducing stress, altering their diets and calling on family and friends for support with their changes. Unfortunately, the study found that these intensive efforts were no better than basic educational materials.

I prefer, though, to look at this from a positive perspective. Those patients in the study who received just the educational materials were actually quite successful at reducing their sodium intake and reported less depression and improved confidence in their ability to manage their disease. These patients had 18 tip sheets mailed to them over a year and received followup phone calls to make sure they'd received each one; the caller also answered any questions patients had about the sheets. This type of support that the control group received, frankly, goes above and beyond the normal standard of care for most heart failure patients. What's more, it was just as good as 36 hours of face-to-face meetings—and far less expensive.

For me, the take-home message of this study is that if you have heart failure, you should learn as much as you can about things you can do to manage your condition, and the way you get that information doesn't seem to matter. Perhaps face-to-face counseling with a doctor or nurse works best for you. Maybe you'd rather take home some handouts to read on your own or look up information online from reputable health sites run by the government or university health centers. Or you may choose to turn to social networking tools such as blogs, Twitter or smart phone apps that have supportive and educational messages. While these technologies weren't included in the JAMA study, I'd be surprised if they don't turn out to be effective too.


The above post is excerpted from "Heart Failure Treatment: Counseling Not Necessary," first published on my Healthcare Headaches blog on (By the way, I don't write the headlines. In this case I would not have chosen those words. Counseling is necessary and good - but more counseling may not be better.)

Monday, September 27, 2010

One month until the FMEC NorthEast Region meeting

For those of you who are family physicians or teach family physicians-in-training, I want to make sure you're aware of the Family Medicine Education Consortium (FMEC) and their upcoming Northeast Region meeting ("Family Medicine Innovations: Blueprints for Redesigning Health Care") in Hershey, PA at the end of October. Along with accepting an award for creative nonfiction, I will also be participating in a panel discussion on the uses of social media for personal and professional purposes. Plenary speakers will include Paul Grundy, President of the Patient-Centered Primary Care Collaborative; and Roland Goertz, President-Elect of the American Academy of Family Physicians. You can learn more about this exciting conference by checking out its unofficial blog or watching the professionally produced YouTube video below.

Saturday, September 25, 2010

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from August and September:

1) Spain: an unlikely primary care model for the U.S. (8/14/10)

2) Air, space, and primary care checklists (8/23/10)

3) Primary care and health disparities (9/16/10)

4) Care management for chronic health conditions (8/28/10)

5) Quality assessment in primary care: an imperfect science (9/6/10)

If you have a personal favorite that isn't on this list, please let me know. As always, thank you for reading!

Wednesday, September 22, 2010

Money-saving medication tips

When you purchase a new item of clothing, television set, or a car, as a general rule you can assume that the higher-quality items are the newest and/or those with the highest price tags, even if you know little about the products themselves. But this approach is often a poor guide to purchasing medications, where the newest and most costly drugs are often no better than, and occasionally inferior to, older and less expensive ones.

Most family practices have a "sample closet" stocked with free samples of brand-name prescription drugs for common conditions. When I was in training, I often gave financially needy patients who were starting a new medication a one month supply of samples instead of a prescription. Although it seemed like a money-saving idea at the time, it wasn't long before the samples ran out, and my patients were left with the choice of paying for an unnecessarily expensive medication or switching to a less expensive drug that they hadn’t tried before. In fact, a 2006 study in the Journal of the American Board of Family Medicine found that practices that distributed free drug samples actually cost their patients an average of $7 more per prescription per month than practices that did not give out samples.

This added cost might have been worth it if patients were paying for higher-quality medications, but most new drugs offer no clinical advantages. The Food and Drug Adminstration requires only that new drugs be superior when compared to a placebo, not to the best drug already on the market. Also, in order to maintain patent protection and prevent competitors from offering cheaper versions, pharmaceutical companies often develop “new” drugs with trivial differences from the originals. For example, prescription Clarinex for seasonal allergies is more expensive, but no more effective than, over-the-counter Claritin, and prescription Nexium for acid reflux is more expensive, but no more effective than, generic omeprazole.

Even worse, a few drugs that are commonly stocked in sample closets turn out to be downright dangerous to your health, since rare and potentially fatal side effects often don't become evident until a drug has been on the market for several years. I remember (and regret) giving out countless samples of Vioxx instead of over-the-counter ibuprofen to patients with arthritis pain; this drug was withdrawn from the market in 2004 after studies showed that it increased the risk of heart attacks and strokes. Avandia, an expensive diabetes drug that has been a fixture in sample closets for years, is the subject of an ongoing FDA safety review about its potential to increase the risk of heart attacks and heart failure.

There are a few easy things that you can do to avoid paying too much for your medications. When your doctor suggests that you need a new medication, ask if it’s possible to prescribe a less costly or generic alternative. Many pharmacies and discount chains offer one month supplies of generic medications for $4 or 90-day supplies for $10. If you are taking more than one medication for a condition (high blood pressure, for example), generic pills may be available that combine two drugs in one. If you don’t have insurance coverage for prescription drugs, some pharmaceutical companies and local and state government agencies often offer sizeable discounts on frequently prescribed drugs for people who meet certain financial requirements. (Here are more details on the Together Rx Access program offered by drug companies.)

Finally, after you have been on a stable dose of a medication for three months or more, consider buying several months’ supply in bulk via mail order. The Pharmacy Checker website provides a useful tool for comparing drug prices among reputable online pharmacies. I have usually advised patients to check with me before doing this, in case I anticipate making a change in their dose or frequency.


The above post is adapted from "Drug Discount: 5 Ways to Save at the Pharmacy," first published on my Healthcare Headaches blog on

Sunday, September 19, 2010

Patient-centered primary care: easier said than done

Two months ago, surgeon and New York Times columnist Pauline Chen observed that primary care demonstration projects have spent most of their efforts building components of the "medical home" - such as proactive, team-based care and health information technology - without necessarily making it "patient-centered":

Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.

It's welcome news, then, that a pair of insightful, accessible analyses of the potential and challenges of the patient-centered medical home model were published last week. The first article, a Health Policy Brief from the Robert Wood Johnson Foundation, succinctly explains the key elements of the medical home, provisions in U.S. health reform legislation designed to spread its adoption in primary care, and remaining questions, including:

1) What does it mean to be a patient-centered medical home?
2) How will we know whether they work?
3) Are patients and physicians ready?
4) Are they for everybody?
5) Do we have the necessary political and financial resources?

The second article on the PCMH, published in the September issue of Family Practice Management, bears the appropriate subtitle "Still a Work in Progress." It describes the variety of pilot projects that are ongoing across the nation, involving "over 14,000 physicians in nearly 5,000 practices caring for nearly 5 million patients."

For these projects to be successful, those 5 million patients need to experience being at the center of their primary care. What does that mean, exactly? In the August issue of Health Affairs, several prominent family medicine researchers defined a patient-centered approach as one that "fosters interactions in which clinicians and patients engage in two-way sharing of information; explore patients' values and preferences; help patients and their families make clinical decisions; facilitate access to appropriate care; and enable patients to follow through with often difficult behavioral changes needed to maintain or improve health."

It's hard for me as a family physician to read those words and not think that patient-centered primary care is stuck in a sort of chicken-and-the egg scenario. In order to "earn" more time per patient visit, we've been asked to prove to insurers, payers, and government officials that the patient-centered medical home provides additional value beyond traditional primary care. But in order to do all of the things that constitute patient-centered care, we first need to be able to spend more time with patients. Therefore the subtitle of this post: easier said than done.

Thursday, September 16, 2010

Primary care and health disparities

One of the ugliest incidents in my career occurred during my faculty development fellowship year, when I spent two days each week seeing patients at several federally qualified community health centers in inner city Washington, DC. Midway through the year, I was transferred from a health center that served an African-American population to one serving a mostly Spanish-speaking clientele. Nearly all of the permanent primary care clinicians at this health center spoke fluent Spanish, and I saw it as a sign of the center's desperate need for clinicians that they willingly accepted a family physician who had never managed to learn enough Spanish to ask any questions more complex than "where does it hurt?"

The plan had been for me to be paired with a Spanish-speaking medical assistant who could also function as an interpreter, but due to staffing changes and the reality that medical assistants have many responsibilities, that never worked out. So I found myself spending hours using awkward telephone translation services, pressing patients' relatives and children into service as translators (a big no-no), or as a last resort, deliberately avoiding picking up the medical charts of patients who knew no English.

None of these actions endeared me to the other clinicians, but one in particular, a short-tempered Latino family doctor who had worked at the health center for many years, seemed offended by my presence from the outset. After weeks of giving me the silent treatment, one day he literally exploded and told me in no uncertain terms that I had absolutely no business seeing patients there (especially "his" patients) when I couldn't speak the language, and that the constant influx of temporary physicians from academic medical centers like me who moved on to other things was what gave health centers for the underserved a reputation for poor quality.

Several years removed from that professionally and personally distressing incident, I came across a study in the Archives of Internal Medicine that examined the relationship between proportions of minority patients served by 96 U.S. primary care clinics and elements of their workplace and organizational environments. Consistent with my experience, clinics that served at least a 30% minority population reported that their patients often spoke little or no English, had lower health literacy, and had more complex and chronic medical problems such as depression, pain syndromes, and substance abuse. To address these challenges, these clinics had access to fewer resources (medical supplies, referral specialists, pharmacy services, and examination rooms) and were more likely to have "chaotic" work environments and low job satisfaction than clinics serving less than 30% minorities. The authors concluded that primary health care for minority populations in this country is both "separate and unequal," and suggested that health disparities may be due as much to disadvantages built into the provision of care as to patient-centered factors.

And last week, JAMA published an important analysis of Health Plan Employer and Data Information Set (HEDIS) performance measures of 162 primary care physicians in a practice-based research network in eastern Massachusetts. The authors concluded: "Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary care physicians."

My hat is off to family physicians and other primary care clinicians who care for underserved patients. Every day, you make do with less, manage more challenging clinical problems, and to add insult to injury, apparently are now getting dinged on the quality of care you provide. There is no excuse for the way I was treated in that clinic many years ago, but I have come to understand my antagonist's "us versus them" mentality as a coping mechanism. Making a real dent in health disparities will require more than expanding Medicaid coverage and building new community health centers. Creative programs are also needed to attract top-flight family physicians to practices for the underserved and keep them there by providing the necessary support for them to thrive, professionally and emotionally.

Tuesday, September 14, 2010

Guest Blog: Prescription report cards

Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog,


Twice a year, each of the major health insurance plans sends me a report card showing how I compare to my peers on prescribing generic medications, formulary medications, and overall cost of medications. For a few years, I always felt good about these reports. I consistently look favorable when compared to my peers. I figured I was doing my part to control the cost of health care. I don’t believe that having good insurance and being able to afford the higher tier co-payments for brand name expensive meds is a good enough reason to skip less expensive generics when I have reason to believe the less expensive meds will be more efficacious. I try to be both informed and conscientious in attempting to manage the costs of prescriptions for my patients. Probably as a result I always look pretty good on the comparison graphs.

Diabetes is one of the conditions where use of only generic medications simply will not get many patients to the goals we are encouraged to pursue. I am proud to be a Diabetes NCQA and Bridges to Excellence Diabetes Recognized Provider, but am certain this would not be the case if I didn’t prescribe the medications I’m encouraged to find alternatives for on these report cards. I’m also encouraged to substitute an ACE inhibitor for any patients I have on an angiotensin receptor blocker (ARB). I know that I rarely prescribe an ARB to patients who have not had unacceptable side effects, usually refractory cough, from an ACE inhibitor. I am reminded of the minority of my patients who are on trade name SSRIs or SNRIs for depression, and non-generic statins. Most of these have been prescribed by their psychiatrists or their cardiologists, and it is difficult for the primary physician to get these substituted if the patient is at goal for their LDL numbers, or is doing well from a mental health standpoint.

Overall, now I look at these reports as what I believe they really are, marketing propaganda insurers use to show prospective large company buyers of their product what they are doing to keep the costs of medical care low. What I’d really like to see is more helpful information from insurers, like which of my consultants spends more money than others in treatment of various conditions. Then I can use the information insurers are the best at collecting to refer patients to specialists whom I believe provide quality care (which I am better positioned to judge than the insurers), and who are cost-conscious as well.

I’d also like to have insurance companies contact my patients directly to get them to have their preventive services done. Rather than scold me for not having all my female patients between the ages of 50 and 65 up-to-date on their mammograms, why not notify them and ask them to see me for an examination and referral? I am already working hard on my patients' health and disease management. Third party payers could make better use of their data than merely sending me report cards on costs of my prescriptions. They could be encouraging patients to get their preventive and disease management care done, too.

Thursday, September 9, 2010

Required reading

"Lessons from the Mammography Wars" is a terrific commentary by physicians Kerianne Quanstrum and Rodney Hayward that appears in today's New England Journal of Medicine. After recapitulating the now-familiar controversy that ensued last November when the U.S. Preventive Services Task Force determined that the decision to begin breast cancer screening for a woman in her 40s should be an individual choice rather than a mandatory requirement, the authors succinctly explore the concept of "gray areas" in the assessment of the net benefit of a health intervention and suggest that a policy of separating self-interest from guideline creation (which does not occur when breast imaging societies make guidelines regarding mammography) would be most likely to benefit patients. Here are two of my favorite passages:

Recent proposals to increase spending on comparative-effectiveness research are certainly laudable, but it is unrealistic to think that an investment in research alone will have a sizable effect on the practice of medicine without a concomitant investment in a credible process for vetting medical evidence and clinical care guidelines.

If there is overutilization in health care, we can be sure that it will continue unabated as long as those with a vested interest are allowed to win the public-relations wars by shouting about "rationing" or "death panels" whenever anyone suggests that more health care, in fact, may not be better.

The entire article, in fact, should be required reading for health policy makers, clinicians, and informed patients.

Monday, September 6, 2010

Quality assessment in primary care: an imperfect science

Several years ago, when I was a very junior faculty member at a well-regarded medical school, I was asked to give a lecture to first-year students about, among other things, medical licensure and specialty board certification. I considered this task to be unenviable because these processes 1) are boring; and 2) don't happen until after medical school graduation, and thus are probably the last things on the minds of first-years who are spending most of their waking hours memorizing anatomical and biochemical trivia.

So, to get them interested, I began the lecture with a question: how does society assure that medical schools like their own produce "good" doctors who are worthy of the trust that patients have traditionally placed in them? More to the point, how do processes such as licensure and board certification assure the quality of practicing physicians? As it turns out, not well at all. Only the worst offenders (doctors who abuse or divert prescription painkillers, for example) are typically disciplined by state medical boards, and there was no publicly available information then or now that would allow an average citizen to determine how his or her doctor measured up against others.

More recently, in an attempt to provide feedback about their performance, some institutions have started giving primary care (and other) physicians "report cards" that summarize their performance on objective measures of care quality; for example, what percentage of patients with a hypertension diagnosis met blood pressure goals at their most recent visits. In theory, this type of reporting should motivate physicians who receive lower scores than their peers to improve their practices, and, therefore, the quality of care they provide their patients.

A few weeks ago, general internist Danielle Ofri, MD, PhD (a frequent guest contributor to Common Sense Family Doctor) wrote a commentary in the New England Journal of Medicine that portrayed current methods for assessing quality in individual primary care physicians as inadequate and potentially misleading. Ofri writes:

Quantitative analysts ... will see it as a sign of medical arrogance that physicians insist that everyone simply trust us to do the right thing because we are such smart and noble people. I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables - experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective - that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care.

Notwithstanding the firestorm of blog responses that Dr. Ofri's editorial provoked (most of whom misunderstood her as arguing for discarding quality measurement in general, rather than the crude tools being used to measure it in primary care), she has a point. Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.

This doesn't mean that we should throw up our hands and stop trying. Not at all - in fact, I think it's critical for family physicians to be open to novel methods of quality measurement to in order to support our role in the changes that will be taking place in the U.S. health system over the coming years and decades. As I've said in this blog again and again, there will be no real health reform without meaningful investment in good primary care. To that statement I now add this corollary: there will be no meaningful investment in good primary care until we develop much better tools to measure what, exactly, good primary care is.

Thursday, September 2, 2010

Writing awards

I've mentioned previously that Common Sense Family Doctor started as the result of a science writing workshop taught by David Taylor at The Writer's Center in Bethesda, Maryland in the summer of 2009.

Earlier in the same year, I took a workshop in prose writing, taught by novelist Nancy Lemann. During this workshop, I wrote a piece titled "Failure to Progress" that chronicled the true story of my son's birth and the somewhat fictionalized impact of that experience on my career as a family physician and writer. I learned today that a revised version of "Failure to Progress" has won 3rd place in the Prose category of the 2010 Family Medicine Education Consortium (FMEC) Creative Writing Awards. Pretty exciting stuff, since the last time I won an award for non-scientific writing was in high school!

After this piece is officially published at the FMEC Northeast Region Meeting at the end of October, I plan to post it on this blog.