Tuesday, May 31, 2011

PPIP: Prevention Politics Injures Patients

PPIP is an acronym that officially stands for "Put Prevention Into Practice," which serves as both the name of the Agency for Healthcare Research and Quality's programs to disseminate the preventive care recommendations of the U.S. Preventive Services Task Force as well as the tagline for a series of case study questions about these recommendations that I wrote for the journal American Family Physician from 2008 to 2010. Given the unfortunate events that have occurred since the USPSTF became inextricably linked to the Obama health care reform bill, however, I now propose a new meaning for PPIP: Prevention Politics Injures Patients.

In a recent New York Times editorial, "Squandering Medicare's Money," Archives of Internal Medicine editor Rita Redberg, MD pointed out that the Medicare program paid physicians more than $40 million in 2009 for screening colonoscopies in patients over age 75, and $50 million in 2008 for PSA screening in men age 75 and older and Pap smears in women age 65 and older. That's nearly $100 million alone for 3 tests that the USPSTF concluded have few or zero health benefits and have a high potential to cause harm, and it doesn't count the additional millions (billions?) of dollars of additional testing and procedures that result from these unnecessary screenings. Dr. Redberg writes:

Our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test. So while Medicare is obligated to follow the [U.S. Preventive Services] task force’s recommendations to cover new preventive services, it has no similar mandate to deny coverage for services for which the task force has found no benefit.

Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view.

Unfortunately, Dr. Redberg is only seeing the tip of the iceberg. Since health reform became law in March 2010, the Task Force has been keeping an unusually low profile. They cancelled their November 2010 meeting (or rather, as I've previously argued, this meeting was a victim of midterm election politics), and when widely respected pediatrician Virginia Moyer was appointed the group's new Chair in March, the only press release came from her academic institution, rather than AHRQ. Even though it's more critical than ever to get the best evidence on preventive care into the hands of primary care clinicians and patients, the USPSTF has only released 6 draft recommendation statements for public comment in the past 14 months, and of those, only two (screening for osteoporosis and screening for testicular cancer) have been published. As a result, its guidelines are aging rapidly; well over half of the group's active recommendations are more than 5 years old and no longer considered up-to-date by the National Guideline Clearinghouse.

Among these outdated recommendations is one on screening for oral cancer, which the USPSTF released in February 2004 and would have likely updated more than a year ago had prevention politics not intervened. In March 2009, I presented a summary of new evidence on oral cancer screening to the USPSTF, which then voted to update its previous recommendation. The new recommendation statement and evidence summary were accepted for publication by the Annals of Internal Medicine that November - in the same week that the Task Force's new position on screening mammography led to a public uproar.

It soon became apparent that any cancer screening statement that was anything less than an unqualified endorsement would not be politically acceptable to the Administration. Not only were we told to withdraw the new recommendation from Annals' publication queue, it wasn't even allowed to be released for public comments until well after the 2010 midterm elections, at which point the evidence was more than 2 years old and I had decided to resign from AHRQ. I've since offered to work for free on updating the evidence manuscript, but have been told that a (political) decision has been made to start from scratch instead, with a new, independently authored evidence update that will presumably require a new USPSTF vote. I'd now be very surprised if the 2004 recommendation is updated before 2013.

These kinds of delays are not just academic; they have real health consequences. If there is strong evidence that screening for oral cancer in primary care settings has no benefits, primary care clinicians need to know that so they can spend their limited time and resources on services more likely to help patients. If there is strong evidence that the PSA test should be abandoned for prostate cancer screening, we need to know that too. Although I've previously stated my belief that prevention politics will hurt the USPSTF's credibility in the long run, the bottom line is that physicians' lack of access to timely, evidence-based information about what works (and doesn't work) in preventive care injures patients, too.

Thursday, May 26, 2011

Checklists and decision support in primary care

Last year, I wrote a blog post on the potential role of checklists, if any, in primary care medicine. Although checklists have recently led to impressive improvements in patient safety in the fields of surgery and critical care, I had doubts that they could be applied to the broader specialties of family medicine, general internal medicine, and general pediatrics:

Primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so?

Although they probably weren't responding directly to me, family physician John Ely and two colleagues published a fascinating article in the March issue of Academic Medicine that explores the use of checklists to reduce diagnostic errors. They suggest that three types of checklists could help physicians "resist the biases and failed heuristics that lead to diagnostic errors": a general diagnostic checklist, a differential diagnosis checklist, and a disease-specific cognitive forcing checklist. Dr. Ely demonstrates the use of a checklist for the diagnosis of a simulated patient with shortness of breath in this 6-minute YouTube video:

Watching the video, I was first struck by the awkwardness of some of the questions, which ran against the grain of my training. In medical school and residency, I learned that a skilled clinician should perform differential diagnosis much as one would a conversation, keeping the diagnostic possibilities in his or her head and shuffling them in order of likelihood in response to new information. In contrast, Dr. Ely's interview sounds more like something a 3rd year medical student might do - for example, considering heart failure as a possibility when nothing else about the history or examination points toward that diagnosis.

But - notice when he gets to anemia: "Hmm. I didn't think of that." I don't like to dwell on it, but the number of times those words have passed through my head, unspoken, while seeing patients must now number in the thousands, if not tens of thousands. Most of the time, it doesn't matter; common problems are common, and the diagnoses that I arrive at using "cognitive shortcuts" are usually the correct ones. Still, I'm all too aware that after seeing several patients in a row with streptoccocal pharyngitis, every sore throat starts to look like strep, and I might easily misdiagnose the patient who suffers from something else.

Dr. Ely cautions that unlike established clinical decision tools, these diagnostic checklists haven't been prospectively tested for usefulness, an essential step before implementing them into practice. Let's hope that this testing is or will soon be underway. While it's heartening to read in this week's issue of JAMA that, once again, places with more primary care physicians have better health outcomes, it is tantalizing to imagine that we could do even better with checklists.

Monday, May 23, 2011

Guest Blog: The Ryan plan for Medicare

Richard Young, MD is a family physician educator and director of research at the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Texas. The following post was originally published on his blog, American Health Scare.


It’s been interesting watching the political maneuvering since Newt Gingrich criticized the plan to reduce the federal budget deficit proposed by the House Budget Committee Chair Paul Ryan of Wisconsin. After receiving push back from fellow Republicans, Gingrich spent the week backpedaling from his earlier remarks.

Many pundits have recognized Ryan for his courage to present his ideas in the first place. I also applaud the fact that he was willing to put the issue of fiscal sanity on the radar screen in a concrete way few other politicians have been willing to. This comes against the backdrop of recent estimates that a 56-year old couple will pay $140,000 in Medicare taxes per person over their work lives, but will receive $430,000 of benefits. This is unsustainable welfare.

I have not read the entire plan myself, but I’ve read enough about it to feel like I understand the basic idea. Ryan proposes to not change Medicare at all for people currently age 55+. People aged less than 55 would be put into a voucher system where they would choose plans by applying the voucher amount to the premium, then pay the difference. As Ryan said recently on "Meet the Press," this would allow seniors to steer away from plans that are inefficient.

There are three big problems with this plan.

First, we have a huge budget deficit NOW, so to kick the problem down the road and not make difficult decisions now means we as a nation still aren’t willing to face facts, hoping that somehow our national character will change at some fuzzy time in the future when we will actually face facts. Highly unlikely.

Second, it puts too much faith in the ability of individual consumers to understand the complexities of the healthcare system. I know how intimidated I am to receive a dentist bill or vet bill. How in the world does anyone expect a person not in healthcare to shop around for medical facilities, physicians, drugs, and the rest? As one doctor writing in Texas Medicine this month put it, “How are they (patients) supposed to value shop for insurance coverage when I have to hire a broker and a couple of financial people to figure out how to get insurance for my own employees?”

Third, the plan calls for choice — which I’m all for — but doesn’t provide any mechanism to allow for meaningful differences in healthcare delivery models that actually break the cost curve. Currently, health plans and facilities try to attract customers with promises of expensive technology. Until some deeper understandings of the role of the healthcare system in our lives start to happen, consumers will continue to be sold on ideas that only raise the cost of healthcare.

Unfortunately, the culture of America must change for us to have significantly more affordable healthcare. The second most budget-busting phrase in America — after entitlements — is medically necessary. We must develop a new set of values and beliefs of what is truly important in healthcare. We can start by challenging the POEM assumptions:

Prevention saves money
Ologist care is best
Early detection prevents all bad outcomes
More treatments equal better care

These should be replaced with new and improved views of what is really important in creating an efficient, but caring healthcare system.

An ounce of prevention costs a ton of money
Family medicine-founded care is best
Early detection doesn’t always change bad outcomes
Aggressive care isn’t always the best care

I give Rep. Ryan credit for his efforts to save our children’s future by putting his political career in jeopardy with his proposals. Unfortunately, a real solution will be even more difficult.

For America to ever have reasonably affordable healthcare, the relationship between doctors and patients must change. The current relationship between doctors and the American public – that all possible healthcare services be provided no matter how rare the benefit or expensive the service – is unsustainable. Until we accept this reality, healthcare costs will continue to rise faster than personal incomes and soon health insurance will be available only to the very wealthy. The great American healthcare irony — we spend the most but get the least — will only get worse.

This reality is what we need to deal with.

- Richard Young, MD

Thursday, May 19, 2011

Genetic guilt and disease susceptibility testing in kids

When my son developed symptoms of asthma at age three, I found it hard to understand why my wife, who also has asthma, expressed a profound sense of responsibility for his illness. Of course, a large component of asthma is inherited, but who was to say that my son's condition wasn't as much or more the result of being raised in a city, or other exposures that we couldn't anticipate or control? (It certainly wasn't from cigarette smoke, which has always been banned in our household.) But a year later, when relatives and teachers began noticing that one of my son's eyes would occasionally slip out of focus, I felt the first twinge of guilt. That sensation only increased after we took him to an ophthalmologist and confirmed his diagnosis of strabismus (the technical term for "lazy eye"). It was the very same condition whose correction had required two eye surgeries when I was eight and twelve years old. And alas, as I suspected, the medical literature indicates that strabismus is inherited, too.

Many parents of young children are fortunate enough not to have any outward signs of inheritable disorders to pass on to their offspring. Common chronic conditions such as diabetes, coronary artery disease, and cancer often don't manifest themselves until middle age or later, by which time the children have become adults themselves. However, genetic testing for these types of conditions is now being marketed directly to consumers, and parents might theoretically order these tests for their children to give both a better idea of what health problems may lie ahead.

The journal Pediatrics recently published an analysis of an online survey of 219 parents enrolled in a separate study of the effect of genomic health risk profiles on health-related behaviors (which I described in a previous blog post). Overall, parents expressed moderate interest in obtaining genetic testing for their children, with the most interested parents being those who would choose testing for themselves; placed a high value on genetic knowledge for its own sake; anticipated feeling good if their children were found to have reassuringly low chronic disease risks; and felt capable of modifying their child's lifestyle if needed.

Putting aside for a moment the limitations of this particular study, which may not be representative of the attitudes of the general population toward genetic tests, it's interesting to consider the larger question of what we gain or lose by predicting our medical futures, and those of our children, with very imperfect tools. It's one thing to detect early signs of incurable diseases, such as Alzheimer's dementia (personally, I'll pass), but learning that one has a higher risk of a future preventable "lifestyle" disease might potentially motivate that person (or his parents) to pay more attention to diet, physical activity, or other behaviors to counteract that risk. I write "potentially" because as far as I know, no one has even come close to proving that the possession of genetic knowledge is self-motivating, rather than self-defeating. (If I'm destined to develop diabetes anyway, why not have that extra slice of cheesecake now?)

Perhaps there will be a day when a detailed map of one's genome will have at least as much predictive value as I.Q., or SAT or MCAT scores - some, but not a great deal. Until then, I will continue to restrict screen time, send my kids outside to play, feed them lots of whole grains, fruits and vegetables, and cross bridges of future health episodes when we come to them.

Tuesday, May 17, 2011

Excessive use of screening colonoscopy

According to guidelines from multiple expert groups, including those of the American College of Gastroenterology and the U.S. Preventive Services Task Force, the appropriate interval between colonoscopies for colorectal cancer screening is 10 years. But a study published last week in the Archives of Internal Medicine found that nearly 1 in 4 Medicare patients who had a normal screening colonoscopy examination from 2001 to 2003 underwent another colonoscopy within 7 years with no other medical indications. This study confirmed previous reports of endoscopists advising patients to return for repeat colonoscopies at substantially shorter intervals than those recommended in current guidelines.

Overuse of screening colonoscopy provides no additional health benefits to patients, but increases the risk of adverse effects, causes unnecessary medical expenses, and diverts resources that might otherwise be available to assist the nearly 40 percent of eligible Americans who are not up-to-date on colorectal cancer screening. Although more adults are being screened today than ever before, much work remains to be done, as family physician Doug Campos-Outcalt wrote in a previous editorial:

Although [colorectal cancer screening] trends show improvement, significant disparities persist. Racial or ethnic minorities and those with no health insurance, low incomes, or less than a high school education have significantly lower rates of use of colorectal cancer testing. There are several hypothesized reasons to explain low adherence to recommendations. These include lack of a medical home, lack of health insurance, lack of awareness of the need, and failure of physicians to recommend screening. Family physicians can address the last two issues; policy makers need to address the first two.

Fecal occult blood testing and flexible sigmoidoscopy are also recommended options for reducing colorectal cancer mortality in adults 50 to 75 years of age. However, evidence suggests that colonoscopy has become the colorectal screening cancer test of choice for many family physicians. What has been your experience with referring patients for screening colonoscopy? Have you observed excessive colonoscopy use for patients without indications other than screening?


The above post was originally published on the AFP Community Blog.

Friday, May 13, 2011

To fix your health habits, do it all at once

As a physician, I have mixed feelings about the popular reality television show "The Biggest Loser." On one hand, some of my patients are surely inspired by seeing severely overweight people, many of them suffering chronic weight-related health problems, make various positive lifestyle changes and rapidly lose weight. Unfortunately, others may assume that eating meals prepared by professional nutritionists and getting one-on-one coaching from a celebrity personal trainer are fundamental to the contestants' successes. Since most people don't have access to such help, they may conclude that it's not worth trying to fix all their unhealthy habits.

That, however, would be the wrong conclusion to draw.

Even off the airwaves, programs designed to change health-related habits are often intensive and expensive. For example, participants in the Diabetes Prevention Program, a classic federal study, received 16 sessions of individual education from master's degree-level lifestyle coaches, followed by meetings at least every two months for the next 3 years. The study paid the coaches' salaries, but if participants had been footing the bill themselves, the cost would have been $2,300 each.

My patients aren't reality show contestants or participants in all-expenses-paid studies. So I have generally advised them to tackle one behavior at a time, rather than trying to do it all at once. Instead of advising a patient to simultaneously try to quit smoking, cut down on calories, and start a daily walking program, for example, I would advise her to focus on the single change that seemed the most doable, and to postpone the others until that first change was well established. For most people, I thought, making many changes at once would be too hard to handle.

But recent studies have challenged my thinking. In a study published in the Journal of Family Practice, Stewart Alexander and colleagues recorded visits that 461 overweight or obese patients made to their primary care physicians. The researchers determined if a physician had provided specific advice regarding weight loss, nutrition, physical activity, or some combination. Patients who received all three types of advice during the same visit were the most likely to decrease their fat intake and lose weight. Surprisingly, patients who received only physical activity advice were more likely to gain weight than patients who received no advice at all.

In another study, published in the Archives of Internal Medicine, researchers examined the effect of an intervention to promote multiple health-related behaviors in black couples aged 35 to 50 years. Participants were randomly assigned either to receive 8 counseling sessions on physical activity, healthy diet, cancer screenings, and alcohol use or to get advice on reducing sexually transmitted disease risk. A year later, those who had received combined lifestyle counseling were 40 percent more likely than those in the other group to report meeting national guidelines for fruit and vegetable consumption and physical activity. Cancer screening rates rose in the first group, too.

How can you make these discoveries work for you? One way is to take advantage of a proven program that will soon be widely available via YMCAs nationwide. A 2008 study found that group classes led by YMCA employees reduced participants' body weight and cholesterol levels at rates comparable to those in the Diabetes Prevention Program—at a cost of only $300 per person. With funding from last year's health reform law, YMCAs have begun offering this program at sizable discounts to members and non-members, and in some cases it may be covered by health insurance.

For me, the take-home message from the recent research is that all of us can change multiple health-related behaviors at once, as long as we receive structured support from health professionals and peers. And although it probably isn't enough for you to spend a few minutes reviewing lifestyle changes with your family doctor, he or she should now be able to refer you to an effective, affordable group program where you can find strength in numbers.


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

Tuesday, May 3, 2011

Partnering with community health workers for better primary care

In developing countries, most primary health care is provided not by doctors or nurses, but by community health workers who have limited or minimal medical training. In the U.S., in contrast, most primary care services are provided by physicians with extensive residency training in family medicine, internal medicine, pediatrics, and obstetrics/gynecology. Even the emerging concept of the primary care team largely remains centered around the physician and his or her office practice.

But when patients with multiple uncontrolled chronic medical conditions need intensive primary care, health services researchers are discovering that the critical role of the community health worker may be just as relevant in the U.S. as it is in the Third World. An Innovation Profile in the March issue of the journal Health Affairs describes a pilot program in Vermont where patient-centered medical homes are supported by community health teams consisting of registered nurses, behavioral counselors, and dietitians, and community health workers. These teams have reduced hospital admissions, emergency department visits, and overall costs. As the profile notes, community health workers play multiple vital roles in helping patients access and navigate the care system:

Community health workers on the team help patients fill out insurance applications, follow treatment plans, manage stress, and work toward their personal wellness or disease management goals. In some cases, community health workers accompany patients to appointments and help them find transportation or child care. ... Providers said that they felt they could respond to a range of patient needs - nonclinical as well as clinical - with the community health team's support. As [one physician] puts it, "Having access to the community health team removes the fear of asking a patient the simple open-ended question, 'So, how are things?' If the patient breaks into tears or admits that things at home are chaotic, I do not feel that I need to solve all of their social woes then and there by myself. I have a whole team to help."

As Vermont moves toward becoming the first state in the nation to enact a single-payer health system for all of its residents, its thus-far successful experiment with community health teams as primary care partners bears watching closely.

Sunday, May 1, 2011

Should pharma have unrestricted access to doctors' prescribing profiles?

For many years, it has been a common practice for pharmaceutical companies to use individual physicians' prescribing profiles to tailor their marketing and sales strategies. For example, if a drug rep had access to data showing that a particular family doctor was prescribing more of a competitor's anti-hypertensive drug, he or she might make a point of dropping off a batch of samples to change that doctor's prescribing practices. As explained in a previous AFP Journal Club, this strategy is often very effective for the drug company, but ends up increasing patients' out-of-pocket expenses in the long run.

Recently, state legislatures in Vermont, Maine, and New Hampshire have passed laws that restrict access to a physician's prescribing profile for marketing purposes. Drug companies and other groups argue that these laws violate the First Amendment, equating a doctor's prescribing data to constitutionally protected "free speech." A news article in the New York Times reported that the Supreme Court will hear arguments in a lawsuit brought against Vermont's confidentiality law by prescribing data collection companies and the industry group Pharmaceutical Research and Manufacturers of America.

In order to balance the sometimes deleterious effects of aggressive drug marketing, AFP provides numerous online resources to support our readers in decision-making about prescriptions. These resources include a systematic eight-step approach to prescribing and individual reviews of new drugs that utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) approach. Are there other ways that we could help you and your patients make informed drug choices?


The above post was originally published on the AFP Community Blog.