Tuesday, November 30, 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 October and November:

1) Family medicine leadership (10/19/10)

2) Direct primary care: health reform's missing piece? (11/18/10)

3) A different perspective on screening for breast cancer (10/5/10)

4) Telemedicine: more than what the doctor ordered (11/3/10)

5) Complexities of cardiac risk assessment (10/2/10)

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

Saturday, November 27, 2010

Your primary care team will see you now

In a previous post about how health reform will change your doctor's visits, I mentioned that you're likely to see your future primary care delivered by a "team" of health professionals rather than your doctor. You might be surprised to hear that "team" is a relatively new concept in family medicine. I once had a colleague who told me, only half in jest, "My definition of good teamwork is that when I tell my office nurse to do something, he or she does it." Personally, I've always favored nurses or medical assistants who excelled at anticipating my needs: those who would prepare a suture tray when a patient showed up with a laceration, for example, or open a urine specimen container for a patient complaining of flank pain and chills.

In contrast, a high-functioning health team doesn't require doctors to issue orders all the time—or expect nurses to read their boss's mind. These medical assistants can read charts and test results to determine if a patient, say, needs a referral or isn't up to date on an immunization. Medical degrees aren't required for these things, according to a 2004 commentary on health care teams that was published in the Journal of the American Medical Association. Medical teams could allow doctors to expand their practices, and also solve the time-crunch problem where appointment slots in some offices have been reduced to 12 minutes per patient. Nurse practitioners and physician assistants can set aside far more time to discuss lifestyle changes and the side effects of various medications than doctors rushing from room to room.

Effective primary care teams delegate responsibilities so that each staff member does only what he or she is trained to do, rather than wasting time and energy on tasks that can be performed with less training. I recently introduced a group of clinicians and staff to an electronic tool that uses a patient's age, gender, smoking status, and sexual activity to determine what screening tests and lifestyle counseling needs should be addressed at a preventive health visit. Under the traditional primary care model, only the doctor would use the tool, advise patients, and order tests and immunizations. Only when the doctor emerged from the examining room would other staff members—who did little more than place patients in rooms and take weight, temperature and blood pressure—have any idea what the patient needed to have done.

In the primary care team model, the receptionist or a medical assistant could ask each patient to fill out a form with the necessary information. The medical assistant could then input this information into the tool and create a customized list of preventive recommendations. A medical assistant or nurse could then counsel patients about exercise habits, dietary practices, and smoking cessation before they even saw the doctor. They could also provide basic information about screening tests and immunizations, leaving the doctor to answer any remaining questions. If a referral was needed to obtain, say, a mammogram or a colonoscopy, the assistant could start the necessary paperwork while the doctor performed the examination.

Primary care teams are already being implemented in some practices throughout the country, and they've been shown to improve patient satisfaction levels as well as a practice's efficiency and finances, according to some recently published case studies. Efforts are now underway to teach teamwork skills in medical school and residency training programs. So what does this mean for your next visit to the doctor's office? Practices will vary, of course, but as more medical groups reorganize themselves into primary care teams, you may start to have more meaningful interactions with nurses and other office staff instead of sitting alone in an exam room waiting for your doctor to arrive. And since staff will relay your specific needs and concerns to your doctor before he or she walks into the room, you may find your concerns addressed more to your satisfaction.


The above post is an excerpt from a piece first published on my Healthcare Headaches blog on USNews.com.

Tuesday, November 23, 2010

The "R" word

There is a terrific two-page commentary titled "The Real Meaning of Rationing" in this week's issue of the Journal of the American Medical Association by Drs. David Meltzer and Allan Detsky. They point out that the price disconnect caused by health insurance leads insurers to attempt to allocate health "goods and services" based on actual need or effectiveness rather than the patient's desires. Of course, in contrast to the example of wartime rationing, any person who is able and willing to pay full price for an uncovered health service can typically receive it - be it a full-body CT scan, an "executive" physical, or an anti-cancer drug.

Because many Americans are deeply suspicious of the motives of government and health insurance companies, they tend to react negatively to perceived actions by "bureaucrats" to limit coverage for services, whatever the reason. "For example," the authors write, "the challenges of rational discussion of health care reform in the United States can be illustrated by typing the words 'mammography' and 'rationing' into a Google search." Noting that "deeply vested interests" often act to inflame the debate, they add:

What is needed is intelligent discourse on what approaches to rationing work best and what values Americans most wish to express as a nation to address this problem. ... Concerns about "death panels" and debates about rationing make better press than balanced discussions of who should or should not receive a mammogram, or the effects of co-payments on appropriate and inappropriate emergency department use. It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.

I agree completely, though I wonder who will be the ones to teach ordinary citizens not to be afraid of the "R" word. Certainly not politicians, or disease advocacy groups, or for the most part, our most respected physicians and scientists. After all, as Josh Freeman noted today on his Medicine and Social Justice blog, the $250 million price tag for the National Cancer Institute's recently concluded lung cancer screening study would have paid for the entire 2008 budget of the Agency for Healthcare Research and Quality or the 2010 primary care workforce programs of the Health Resources and Services Administration. Instead, a year or two from now, when the U.S. Preventive Services Task Force examines the evidence on lung cancer screening, there will probably be lots of powerful, politically-connected groups urging them to give an "A" or "B" level recommendation to CT scans for smokers so that this service will automatically receive first-dollar coverage under the prevention provisions of the Affordable Care Act. And the "R" word will once again rear its ugly head.

Monday, November 22, 2010

Guest Blog: Home glucose testing in type 2 diabetes

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, DrPullen.com.


Home glucose monitoring in non-insulin treated type 2 diabetes has not been shown in controlled studies to improve either blood sugar control or prevent complications of diabetes. Still, it is commonly used by diabetics and commonly recommended by physicians to diabetics as an important aspect of their care. What is the right thing to do? The answer is not simple.

As a pretty valid rule of thumb, we should only do a test in medicine if the results are going to be used to make a decision of some sort. In diabetics who use insulin before each meal, and vary the dose of insulin based on their blood sugar prior to the meal, measuring their blood sugar before each meal is done to obtain information on which to base a decision of how much insulin to inject. This is a classic case of using diagnostic information to make a therapeutic decision. On the other extreme, a person with type 2 diabetes who is either not on medication at all, or who is on a stable dose of oral medication, and has been well controlled over the last few doctor visits, is not going to alter his or her diabetes treatment in any way based on home blood sugar monitoring, and a good argument can be made that there is no need to be measuring home blood sugars.

In my practice I find many diabetic patients who find a good deal of comfort in checking their blood sugars more often than is needed to control their blood sugars. Some patients find daily, or even several times daily, blood sugar monitoring to be strong positive feedback that reinforces their good behavior regarding diet and exercise. Is this a good reason to do home blood sugar testing? More to the point, should third party payers, including Medicare, pay for this testing even though there is little or no evidence that it leads to better health outcomes?

I commonly am faced with non-insulin using diabetic patients who test several times daily, whose insurance companies decline to pay for this frequent testing based on lack of evidence that it is beneficial. Patients then ask me as their physician to explain to the insurer why they need to test several times a day. The reasons acceptable to the insurer usually include: insulin treatment, frequent hypoglycemia, and uncontrolled hyperglycemia. Most of these patients have none of these reasons. They just feel more confident when they know their blood sugars frequently. This can lead to patient dissatisfaction, and puts me in the awkward position of being perceived as not advocating for a patient. This issue has been a hot topic in the UK recently.

We are facing major issues regarding health care spending in America. There is great evidence that control of blood pressure, cholesterol and blood sugars in diabetes can lead to reduced health care costs. Still, with the cost of a single home blood sugar test running about $1, the cost of even once daily home blood sugar testing for a diabetic is $300 to $400 per year. There are approximately 25 million type 2 diabetics in the US. Many do not need to be testing home blood sugars. We need to do a better job of giving patients permission to test less or not at all, and yet encourage them to do the other things that do make a difference. Diabetic eye exams, blood pressure control, and lipid control all have much better evidence for morbidity and mortality prevention than does home blood sugar testing.

Thursday, November 18, 2010

Direct primary care: health reform's missing piece?

Last year, in a blog post titled "the 'single payer' should be you," I profiled the innovative Seattle-based practice Qliance Primary Care, which, rather than billing private or public health insurers, charges patients a flat monthly fee for unlimited access to a broad range of primary care services:

Previous medical groups that utilized this business model often charged exorbitant fees, leading critics to label them "boutique" or "concierge" medicine, available only to the wealthy. In contrast, Qliance's fees are quite affordable: from $49 to $79 per month. This fee, combined with a catastrophic health insurance policy to protect against unexpected ER visits or hospitalizations, is significantly less expensive than traditional insurance policies - which makes sense, since 100 percent of payments go directly to the practice rather than being filtered through insurance bureaucrats. So why aren't there more advocates for a "single payer" health system in which the single payer is you?

The October 15th issue of Family Practice News featured a front-page article about Qliance and its practice model, termed "direct primary care." Although this model was absent from the "Affordable Care Act" law (which instead emphasized accountable care organizations and multi-disciplinary patient-centered medical homes), it provides benefits above and beyond simple cost savings: all in-person appointments are scheduled for at least 30 minutes.

One obvious objection to implementing the direct primary care model nationally is that there are certainly a few people for whom spending even $50 a month out of pocket for basic medical care is a hardship. But consider the comparison: at my wife's nonprofit medical clinic for uninsured patients, the monthly payroll deduction for no-frills, employer-subsidized health insurance in 2011 starts at $281.50 per month, not counting a $350 annual deductible and 20 percent co-insurance for most services. These charges amount to more than 10 percent of many employees' salaries, and has actually led some of them to seriously consider declining health insurance benefits so that they will be eligible to be seen at their own clinic.

Making more low- and middle-income people eligible for government subsidies and tax breaks so that they can afford the skyrocketing cost of traditional health insurance isn't the long-term answer to this problem. By cutting insurers out of the equation, and lowering the cost of basic health care for individuals, direct primary care models offer a real, affordable health reform solution.

Monday, November 15, 2010

VBAC redux

Several months ago, I wrote in this blog about the precipitous decline of vaginal births after Cesarean (VBAC) in the U.S., which I attributed in part to the the internalization by obstetric specialists of the medical maxim "hearing hoofbeats, thinking zebras":

Objective data support the notion that labor managed by family physicians and professional midwives is considerably more likely to result in a vaginal birth than labor managed by an Ob/Gyn, even controlling for factors such as maternal age and risk status. It isn't difficult to understand why. If an Ob/Gyn is feeling uncertain about how well a patient's labor is progressing and has an inflated estimate of the probability that something might go wrong (the zebra), it's very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically, then and there. On the other hand, if the surgeon is at least a phone call away, the family physician or nurse midwife might be more patient with the hoofbeats, betting they're hearing a horse.

In preparation for a consensus development conference on VBAC held in March at the National Institutes of Health, a team of evidence reviewers from Oregon Health and Science University prepared a comprehensive report on the factors associated with successful VBAC delivery and the benefits and harms to the mother and infant from a trial of labor. I summarize this report in the Nov. 15th issue of American Family Physician. Here are the main results:

The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). Most studies found no differences in neonatal intensive care unit admission rates.

Bottom line: "most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant." In July, the American College of Obstetricians and Gynecologists slightly relaxed their previous restrictions on access to VBAC by issuing an updated guideline. Will this guideline change and fresh re-examination of the evidence supporting a trial of labor in patients with a previous Cesarean be enough for VBAC to make a comeback in the U.S.?

Saturday, November 13, 2010

Moneyball and health care quality statistics - Part 2 of 2

The Society of Thoracic Surgeons recently allowed Consumer Reports to use its national database of information about heart bypass surgeries to rate surgical groups on patient survival rates, surgical complications, and medication management. But this ranking, too, has its limitations: While about 90 percent of the approximately 1,100 cardiac surgical groups in the U.S. participate in the society's database, just 22 percent of these groups opted to include themselves in the Consumer Reports rankings. That's because they didn't want their performance data to become public. And none would allow individual surgeons to be named.

Many health insurers have begun sending confidential "report cards" to family doctors that give them feedback on their performance in managing chronic conditions such as heart failure and diabetes. These evaluations, too, have been criticized for ignoring differences in patient populations; younger patients with high-paying jobs, for example, are less likely to stop taking medications for financial reasons than older patients on fixed incomes. So a doctor with a poorer patient population might get poorer grades than one with a richer population. Still, the evaluations might be helpful in comparing two doctors who practice in the same neighborhood, if practices eventually make this information public to prospective and current patients.

In the next few years, more information should become available on the quality of care provided to patients. The government is working to compile national numbers on hospital complication rates, which would add to patient safety data already being collected such as how often incisions reopen after surgery. The new data that will soon be offered on the Hospital Compare tool will, in my opinion, be a game changer. First and foremost, it will include information on infection rates. Nearly 90,000 U.S. patients die every year from hospital-acquired infections, and about a third of those deaths are due to preventable bloodstream infections caused by the insertion of a catheter, according to the Centers for Disease Control and Prevention.

It would be nice to know how often the hospital you pick for surgery takes precautions proven to prevent these infections, like covering patients with sterile drapes and swabbing their skin with an antiseptic before a catheter is inserted and making sure doctors who do the insertion wash their hands and wear a sterile mask, hat, gown and gloves. Hospital Compare will also provide data on surgical mistakes due to foreign objects left in the body; severe pressure ulcers from not turning bed-ridden patients, falls and other accidents that occur in the hospital; blood transfusions with the wrong blood type; and signs of diabetes mismanagement.

As more reliable statistics about the quality of care provided by doctors and hospitals become available, it's important to consider what factors matter most to you as a patient. For example, clean bathrooms are nice, but most people would place a higher value on surviving the hospitalization and not needing to return after being discharged. A heart surgeon's brusque bedside manner may not matter nearly as much to you as the percentage of her patients who develop postoperative infections. And family doctors who are willing to share their numbers—and work to improve them—are likely to go the extra mile to manage your chronic condition appropriately.


The above post (continued from a previous post) first appeared on my Healthcare Headaches blog at USNews.com.

Thursday, November 11, 2010

Moneyball and health care quality statistics - Part 1 of 2

At a recent conference, Harvard surgeon and best-selling author Atul Gawande told the audience of health professionals and policy makers that he always assigns his medical students a book about baseball called Moneyball: The Art of Winning an Unfair Game. It's the story of how the 2002 Oakland Athletics, which had one of the lowest payrolls in professional baseball, were able to consistently out-compete better financed teams due to their general manager's unrivaled ability to evaluate and appropriately value players. Oakland took advantage of the tendency of other teams to overvalue players based on word-of-mouth assessments of talent or commonly measured statistics—such as batting averages and number of stolen bases—that had little relationship to winning games.

Gawande's point was that many of the Moneyball lessons can be applied to medical care when it comes to evaluating the performance of doctors and hospitals. Since I have a policy of not accepting close friends and family members as patients, I refer them to doctors with whom I've worked in the past or have met through medical conferences. My loved ones may be reassured by my recommendation, and I assume I'm pointing them to a good doctor.

But I also have a nagging worry that my gut instincts about a doctor I'm acquainted with may not correlate with the quality of care that doctor provides. I have no way of knowing if my friends and family members will get better or worse care from my referral than if they had randomly selected a name from a list. In fact, a recent study published in the journal Archives of Internal Medicine found that publicly available data on physicians such as medical school attended, malpractice lawsuit history, and specialty board certification are poor predictors of their adherence to accepted standards of medical care such as checking cholesterol levels in patients with diabetes and performing Pap smears in adult women at least every 3 years.

Take the well-known U.S. News & World Report "Best Hospital" Rankings. Whether a hospital is ranked in a particular specialty depends on its score, almost a third of which comes from its reputation with specialists. There may be a good argument for doing that, but to me it's too much like my physician recommendations. The website of the federal Centers for Medicare and Medicaid Services features a Hospital Compare tool that allows patients to search for and compare up to three hospitals at a time based on statistics such as the percentage of patients with heart failure who receive appropriate discharge instructions, medications, and smoking cessation counseling. It tells you if readmission and death rates for patients with heart attacks, heart failure, or pneumonia are better, the same as, or worse than the national average. (Higher rates of readmission could indicate that the hospital didn't do a good job of treating the patient in the first place or provided inadequate instructions for follow-up care.) It also provides subjective measures like patient surveys about the responsiveness of nurses and doctors, the cleanliness of rooms and bathrooms, and how well pain was controlled.


The above post (to be continued in a few days) originally appeared on my Healthcare Headaches blog at USNews.com.

Saturday, November 6, 2010

Guest Blog: The IOM report on the future of nursing

Stephen Ferrara, NP is a family nurse practitioner at Montefiore Medical Center in New York City. The following post originally appeared in his blog, A Nurse Practitioner's View.


The big news this week in the world of nurse practitioners and health care was the release of the Institute of Medicine's (IOM) Report, "The Future of Nursing: Leading Change, Advancing Health." It's a logical read and echoes what NPs, patients, and some other professions have been saying for years: let NPs do the work they are already educated and trained to do without arbitrary and archaic state and/or federal barriers. This is not a "scope of practice" issue; it is allowing us to practice to the full extent of our educations.

For example, when I reflect back on my NP education, there was no course entitled, "How to sort of take care of chronic conditions but when you get in over your head, make sure you have your collaborating physician's number on speed dial." We were taught to function as primary care providers that included acquiring the knowledge base to evaluate, diagnose and treat our patients and their conditions using the skill sets and tools needed to care for our patients. NPs don't practice witchcraft or voodoo - we are providing high-quality, cost-effective and culturally congruent care.

Predictably, organized medicine is playing the "patient safety" and "quality of care" card. Bad outcomes occur when there are breakdowns in communication and from care that is uncoordinated - not usually because the clinician is incompetent.

The bottom line is (at least in New York where I practice), without a collaborating physician on record, the 14,000 or so NPs are unemployed and can't legally do anything that we were trained or educated to do. It is time to remove these non-evidence based barriers and retrospective reviews and allow us to function as true partners on the health care team. Collaboration among providers would still continue to happen, and I promise pigs wouldn't start to fly. Fourteen states have already transitioned to to an autonomous model of practice model for NPs. Lawmakers must not cave to special interests and, instead, make the tough decisions that will enable greater access to care.

Wednesday, November 3, 2010

Telemedicine: more than what the doctor ordered

Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure had risen dangerously. I'd adjust blood pressure medications only to find her short of breath with swollen legs—a sign of worsening heart failure—at her follow-up appointment. The trouble was, I had no idea how well she followed my instructions in between visits which occurred every month or two. Had her blood pressure been soaring at home for the past few weeks or only during the hour she was in my office? I had no way of knowing.

Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.

Given this unacceptable situation, family doctors need to adopt a new model of care that includes more frequent contacts with patients and adjustment of medications based on blood pressure monitoring at home, stress the authors of the AJMC paper who are affiliated with the University of California at San Francisco. They suggest that hypertensive patients receive home monitors to check their blood pressure on a daily basis and record the readings in a paper or electronic log. Nurses, medical assistants, or other "health coaches" should call patients every two weeks in between office visits to check on their blood pressure readings and provide counseling on lifestyle changes, such as starting an exercise program or reducing dietary sodium. If a patient's home blood pressure readings are too high, a medication dose can be increased using standard protocols that are pre-approved by the doctor. This model is supported by research: A 2008 study published in the Journal of the American Medical Association found that patients who received home blood pressure monitors and regular contacts from a pharmacist through a secure Web site were significantly more likely to achieve blood pressure control after one year compared to patients who weren't monitoring themselves.

Of course, remote monitoring or telemedicine for chronic health conditions has applications beyond blood pressure management. Remote devices can send the results of blood sugar readings or body weight measurements, in addition to blood pressure readings, from your home directly to your doctor's office. Studies conducted by the Veterans Health Administration have demonstrated that daily body weight measurements on scales remotely linked to doctor's offices can help reduce re-admission rates for heart failure patients, a major factor in reducing ballooning health care costs. In fact, 12 states now require that health insurance plans cover telemedicine services, and 25 states reimburse doctors for telemedicine services through their Medicaid programs.

Even in states that don't mandate coverage for home health monitoring, many health insurers are introducing pilot programs that provide free equipment to selected patients, provided that their doctors show they're utilizing the data to improve care. If you have high blood pressure or another chronic health condition that might benefit from monitoring in between office visits, it's worth checking with your doctor and insurance provider about options that could be available to you at little or no cost.


The above post was first published on my Healthcare Headaches blog at USNews.com.

Monday, November 1, 2010

The meeting that wasn't, and a surprise announcement

Although I normally arrive at work around 9 AM on Mondays, today would have been an important exception. This was to be the first day of the third U.S. Preventive Services Task Force meeting of 2010, and about now, outgoing Task Force Chairman Ned Calonge would be calling the meeting to order and asking every person in the room, including staff, observers, and the medical transcriptionist, to introduce themselves by name, position, and one interesting personal fact that changed from meeting to meeting. One meeting it was birthplaces; another meeting it was our favorite vacation spots; another, our favorite quotations. Even though this process often consumed half an hour or more, Dr. Calonge believed that getting to know each other a little bit better was crucial to the success of dissecting volumes of scientific evidence and making recommendations that would affect primary care clinicians and patients throughout the United States, if not the world.

As reported in this article in the Wall Street Journal's Health Blog, however, there is no USPSTF meeting today. And while the question of why the meeting was cancelled is perhaps easily answered by looking at the calendar, in my mind it is much less apparent how to repair the damage that this setback did to the Task Force, medicine, and the fragile public trust.

This leads me to an announcement that may come as a surprise to some: in less than three weeks, I will be leaving the support team of the USPSTF and resigning from the Agency for Healthcare Research and Quality. I am looking forward to having more time to spend writing this blog and Healthcare Headaches, as well as expanding my medical editing roles at American Family Physician and returning to patient care. But I will miss my colleagues at AHRQ and the Task Force very much. To borrow a line from a farewell message I sent to many of them last week, they deserve all our thanks for everything they do (and will continue to do) to make the U.S. health care "system" a little bit more rational, despite the many obstacles and challenges. Politics trumped science this time, as it has in the past, and may at times in the future. On the bright side, though, in a few more weeks the growing force of private sector allies of the USPSTF and evidence-based medicine will have one more member, and I'm ready and willing to speak my mind.