Tuesday, January 31, 2012

How often should women be screened for osteoporosis?

Last year, the U.S. Preventive Services Task Force updated their recommendation statement on screening for osteoporosis, which advised dual-energy x-ray absorptiometry (DEXA) in "women 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors." However, the USPSTF statement left one important question unanswered: when should a woman be re-screened if her first test shows normal or slightly decreased bone mineral density (BMD)? Put another way, what are the chances that a woman without osteoporosis today will develop it in the future?

A team led by University of North Carolina family physician-researcher Margaret Gourlay, MD, MPH recently shed light on this question by following nearly 5000 U.S. women age 67 years or older with normal BMD or osteopenia for up to 15 years. They defined the BMD re-testing interval as the estimated time it took for 10% of women to develop osteoporosis before having a hip or clinical vertebral fracture. According to their report in the January 19th issue of the New England Journal of Medicine, more than 90% of women with initially normal BMD or mild osteopenia did not develop osteoporosis after 15 years. As might be expected, women with moderate and advanced osteopenia progressed faster, with 10% of each group developing osteoporosis after 5 years and 1 year, respectively.

This study's results have substantial implications for family physicians and their patients. In the absence of new risk factors for osteoporosis (e.g., significant weight loss, corticosteroid use), a woman with normal BMD at age 65 may not need to be re-tested until age 80, an interval that is substantially longer than current clinical practice. That's good news, since as Dr. Gourlay pointed out in a previous editorial, many U.S. women who are at risk for osteoporosis have yet to receive any screening at all. Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.


A slightly different version of the above post was first published on the AFP Community Blog.

Friday, January 27, 2012

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 some favorites from the past few months:

1) The vital role of guideline narratives (12/1/11)

2) Strengthening the primary care pipeline (1/11/12)

3) "Pure Custer": our obsession with a flawed screening test (11/18/11)

4) Striking back at the true rationers of health care (12/8/11)

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

Friday, January 20, 2012

How much does it cost to have a baby?

When my wife delivered our second child in 2008, the hospital sent our health insurance company a bill for $8569. The insurance company then wrote off $4117 of that bill, paid $4352, asked us for a copayment of $100. When we found out last year that we were expecting again, we noted that my wife's new insurance plan requires us to pay 20% coinsurance for all non-preventive care. That would have amounted to several hundred dollars of our 2008 bill, and knowing the rapid rate of health care inflation, we thought it would be good to find out how much it would cost this time around. So we went back to the same hospital, where we expect our third child to be born in a few weeks, and asked if they could give us an estimate of the charges. It seemed like a reasonable enough request, especially since the pre-admission consent form we signed specifically said that patients had a right to know what the hospital charged for its services.

We're just looking for a ballpark number for our flexible savings account, we said. The charge for an uneventful labor, vaginal delivery and single overnight stay. We understand that unexpected things can happen in childbirth, and we won't hold you to it.

The hospital representative we spoke with clearly wanted to be helpful. She called the billing office, the labor and delivery floor, every place in the hospital she could think of that might have that information. But in the end, no one could give us an answer to a seemingly simple question: how much does it cost to have a baby at your hospital?

And the truth is, even if they had, we would have had no way of knowing how much our insurance company would have actually paid. Hospitals routinely inflate their listed charges, knowing full well that insurers will want to negotiate deep discounts. The only people who actually pay the listed hospital charges - analogous to the sticker price on a new car - are uninsured patients who aren't poor enough to qualify for free or discounted care.

The whole idea of "consumer directed health care" is that patients who anticipate medical expenses in advance  can shop around to get the best prices. We had nearly nine months to get ready for having a baby, and that should have been plenty of time. But consumer directed health care doesn't work when no one can tell you the price. A federal report issued last October confirmed what most doctors have known all along: most medical practices and hospitals either can't, or won't, provide estimates about the costs of commonly provided services such as diabetes screenings and knee replacements. Several years ago, health economist and Princeton professor Uwe Reinhardt called the pricing of hospital services in the U.S. "chaos behind a veil of secrecy," and things haven't gotten any better since the passage of health reform.

In the end, my wife and I were forced to make an educated guess about how much money to put away for her labor and delivery. We're both family doctors, by the way, and between the two of us have personally delivered hundreds of babies. And if we can't figure out how much it costs to have a baby, good luck to all of the other women who will be giving birth in the U.S. this year.

Wednesday, January 18, 2012

Curbing overuse of CT scans - and other interventions

The urban public hospital where I completed most of my training as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present the patient's case to the on-call Radiology fellow and explain how the result of the scan would potentially change management. Since my attending surgeons were usually too busy to trudge down to the Radiology suite, they deputized their residents to do so, and most of the time my residents passed this thankless task down to the students. Thus, my classmates and I learned early on the difference between appropriate and inappropriate reasons for ordering CT scans.

Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, an editorial published last year in American Family Physician reviewed the accumulating evidence that CT scans are highly overused in current medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.

Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published recently in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.

In their editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommended that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:

1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.

These general points can and should be applied to many other medical interventions, including screening tests and treatments. To paraphrase: Never do anything to a  patient unless you think it may help. When an intervention is necessary, intervene as little as possible. Always inform patients of the risks of any intervention, and monitor their exposure to its harmful effects over time so that they can choose to opt out later, if desired.


A slightly different version of the above post was first published on the AFP Community Blog.

Wednesday, January 11, 2012

Strengthening the primary care pipeline

Recently, I had a vivid dream in which I and several family physician colleagues had gathered in a lecture hall to watch the results of the National Residency Match on a huge real-time video screen. On the right side of the screen were the names of all the graduating medical students; on the left was a smaller list of those matching to residency programs in Family Medicine. A bar graph positioned in between showed the overall percentage of our graduates matching into Family Medicine programs, which in previous years had been around 5 percent.

As the results began to trickle in, it looked like that pattern would continue. Then, an astounding thing happened. Student after student began appearing on the left side of the screen, and the percentage bar climbed higher and higher - to 10%, then 15%, then 20%. Everyone began cheering and clapping wildly, as if we were watching the election returns for a victorious Presidential candidate. When the last student's name finally appeared on the screen, the bar stood at just short of 50 percent, a higher Family Medicine match rate than any school in the nation!

Alas, I soon woke to realize that it was only a dream. But this dream got me thinking about what it would take to increase the percentage of primary care physicians to 50 percent, which is the typical ratio in most high-functioning national health systems. The obstacles are formidable, with financial considerations being perhaps the greatest challenge. Consider these figures from a solicitation letter for scholarship donations to my medical school alma mater: "Among the 155 members of the Class of 2008, 78 percent graduated with an average debt load of nearly $143,000. 18 percent graduated with a debt load that exceeded $200,000." These figures are hardly atypical for most private (and some public) medical schools. Given these grim numbers, it's a wonder that any medical students choose careers in primary care, with the lowest-paid specialties being general pediatrics, family medicine, and general internal medicine.

In a 2008 letter published in the Journal of the American Medical Association, family physician-educator Mark Ebell, MD, MS demonstrated a near-linear association between median income and the percentage of U.S. senior medical students who entered a medical speciality - put simply, students go where the money is. And given their increasingly staggering debt loads, who can really blame them?

A few years ago, a group of family physicians and health policy analysts at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care did an exhaustive study of the factors that affect medical students' selection of careers. In their exceptional report, subtitled "What Influences Medical Student and Resident Choices?" Dr. Robert L. Phillips, Jr. and colleagues made several evidence-based recommendations for policymakers that bear repeating loudly in the White House and halls of Congress as the date approaches when 32 million additional Americans will be newly covered by health insurance and seeking primary care doctors.

1. Create more opportunities for students and young physicians to trade debt for service.
2. Reduce or resolve disparities in physician income.
3. Admit a greater proportion of students to medical school who are more likely to choose primary care, rural practice, and care of the underserved.
4. Study the degree to which educational debt prevents middle class and poor students from applying to medical school and potential policies to reduce such barriers.
5. Shift substantially more training of medical students and residents to community, rural, and underserved settings.
6. Support primary care departments and residency programs and their roles in teaching and mentoring trainees.
7. Reauthorize and revitalize funding through Title VII, Section 747 of the Public Health Service Act. (Title VII is a small, little known federal program that supports primary care residency training, but has been severely shrunk by budget cuts during the past decade.)
8. Study how to make rural areas more likely practice options, especially for women physicians. (The report found that "female physicians are twice as likely as men to choose primary care but half as likely to practice in rural areas.")
9. New medical schools should be public with preference for rural locations. (One recently established medical school, The Commonwealth Medical College in Scranton, PA, exemplifies how this recommendation will encourage students to pursue primary care careers.)

The 2010 Affordable Care Act contained some provisions that will modestly benefit primary care physicians, but much more work and legislation is needed if my dream of a robust primary care pipeline is to become reality at medical schools throughout the U.S.

Tuesday, January 3, 2012

First, do no harm: preventing elective inductions before 39 weeks

recent article published in the Journal of the American Board of Family Medicine reported that fewer than 1 in 5 board-certified family physicians provide routine prenatal care, and just over 13 percent perform deliveries. Therefore, more family physicians are referring patients for maternity care and have less influence over troubling national trends, such as declining rates of vaginal births after previous Cesarean delivery (VBAC) and increasing rates of "late" premature delivery (between 34 and 38 6/7ths weeks gestation) due for the most part to elective inductions.

In an editorial in the December 15th issue of American Family Physician, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:

The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.

If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.


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