Tuesday, July 24, 2012

Common Sense Family Doctor turns 3: no more baby (or toddler) steps

"What is a year, after all?" I rhetorically asked an audience of Washington DC-area breast cancer care coordinators yesterday during a talk about the limitations of screening mammography. "It's 365 days. There is nothing magic about a yearly screening interval." So, too, is there nothing magic about a blog enduring for a year, or in the case of Common Sense Family Doctor, three years. But it is a convenient milestone worth celebrating in this, my three hundred and seventeenth post. To date, this blog has been viewed more than 172,000 times. My most popular post, an indictment of the deceptive advertising practices of Life Line Screening, has been viewed nearly seven thousand times.

As a father of three children younger than age 7, I can't help but view the passage of time in child years. A few months after my older son was born, I started working at the Agency for Healthcare Research and Quality. I remember rehearsing my first presentation for the U.S. Preventive Services Task Force (a summary of the evidence on screening for COPD using spirometry) in front of my rapt ten-month old, whom I like to think understood the importance of the occasion. Two months after the birth of my daughter, the USPSTF recommended against screening for prostate cancer in men age 75 and older, which appears to have had a significant effect on clinical practice. (The effect of their new recommendation against PSA screening in all men remains to be seen.) By the time my younger son was born this year, I had long since left AHRQ and was preparing to re-enter the world of academia, where I now direct Georgetown University School of Medicine's Fellowship in Primary Care Health Policy.

By the child year standard, then, Common Sense Family Doctor has passed through infancy and toddlerhood, and is now entering what some child-rearing experts call "the wonder years," that amazing period when children achieve a measure of self-sufficiency but remain comfortingly dependent on mom and dad for most of their daily needs. The blog's growth and visibility has been been helped immensely by regular syndication in KevinMD, The Doctor Weighs In, Prepared Patient Forum, and coming soon, Physician's Weekly. It has also given me the opportunity to write for different audiences in Family Health Guide, U.S. News and World Report, and the AFP Community Blog. Many thanks to all of my readers and fellow health bloggers who have provided validation and encouragement along the way.

What can readers of Common Sense Family Doctor expect in the future? More reflections on the proper role of primary care and prevention, now that the Affordable Care Act appears to be here to stay (and prominent Republicans Bill Frist and Mike Leavitt are publicly supporting state-based health insurance exchanges, which I discussed in a previous series of posts). I also intend to write about innovative ways to improve population health outside of health care - a tricky topic, to be sure, and fraught with ethical/political questions about the appropriate role of governments in improving the heath of their citizens (such as putting restrictions on the size of soda containers). No, I don't believe that any government should have the power to force you to buy a gym membership or eat broccoli, and I've always been a skeptic about the value of dietary guidelines. But I consistently favor happy mediums over hardened ideological positions, and hope that this blog will become wiser as it ages. Of course, you will ultimately be the judge of that.

Tuesday, July 17, 2012

How politically unpopular research from AHRQ helps us make better medical decisions

The health services research world is reeling today from the inclusion of draft language in a House of Representatives appropriations bill that would eliminate the entire budget of the Agency for Healthcare Research and Quality starting on October 1, 2012. Below is a screenshot from page 90 of the bill:

As most readers know, I was employed by AHRQ from 2006 to 2010, as a Medical Officer supporting the work of the U.S. Preventive Services Task Force, which recently recommended against PSA screening for prostate cancer on the grounds that the downstream harms of the service outweigh any potential benefits. As documented in an October 2011 New York Times Magazine story, the USPSTF deliberately withheld its initial conclusions on PSA screening, fearing a politically-driven backlash against it and AHRQ. Despite the long delay, as well as a carefully orchestrated scientific communications campaign that enlisted the support of powerful allies such as the American Cancer Society's chief medical officer, Otis Brawley, the Agency once again finds itself at death's door. (For an in-depth history of AHRQ's first near-death experience in the mid-1990s at the hands of back surgeons and their supporters, read this Health Affairs article.)

For those of you who may be unfamiliar with AHRQ and the benefits of the research it supports, below is a Healthcare Headaches blog post I wrote last year for USNews.com. Its message is even more relevant now than it was then. Please call your Congressmen and women, spread the word to friends and colleagues, and help #SaveAHRQ from a fate that would have devastating effects on the future health of our nation.


When a new drug goes on the market for, say, diabetes, doctors are typically bombarded by advertising messages that promote it. Patients may see television commercials touting the new drug’s advantages over older ones and advising them to "talk to your doctor" about obtaining a prescription. But since the U.S. Food and Drug Administration only requires drug companies to prove that new drugs work better than placebos (sugar pills), there’s often little or no reliable information about whether a new drug is actually an improvement over existing therapies.

How, then, can a doctor like me make good choices about which treatment to give each patient? To provide answers, last year's health reform law devoted billions of dollars over the next decade to "comparative effectiveness" research, or research that directly compares different tests and treatments to determine which are better at improving health in particular groups of patients.

Funding for comparative effectiveness studies was recently targeted for budget cuts by politicians who argue that such research may limit patients' treatment choices and lead to the withdrawal of insurance coverage for drugs that are found to be costly or ineffective. In reality, however, that’s not necessarily the case. For example, when the FDA recently concluded that the cancer drug Avastin does not help patients with breast cancer (and often causes serious side effects such as bleeding, heart attacks, and heart failure), officials were quick to assure the public that the Medicare program will continue to pay for it anyway.

What has been lost in the political debate is the value of comparative effectiveness studies in helping doctors and patients make better treatment decisions. For example, the Effective Health Care Program at the Agency for Healthcare Research and Quality (AHRQ), which sponsors comparative effectiveness research for many conditions that I commonly treat among my patients, recently published a patient-friendly guide to medicines for type 2 (adult-onset) diabetes that clearly spells out the advantages and disadvantages of the many drugs available to lower blood sugar. Patients can read this guide online or print out a copy to take with them to their doctor. (Full disclosure: I am a former employee of AHRQ, but was not involved with this program.)

Also, in a 2009 study published in the Archives of Internal Medicine, Mayo Clinic researchers concluded that a "decision aid" for patients with diabetes based on a previous version of the AHRQ medication guide improved patients' knowledge and involvement in their care. This decision aid consisted of six flash cards containing basic information about the effects of five types of diabetes drugs on weight change, blood sugar levels, side effects, and ease of use (when to take it and how often blood sugar testing is required).

In a highly charged political environment, it’s tempting to score points (and scare patients) by falsely equating comparative effectiveness research with “rationing.” But I believe that the valuable information obtained from this research, rather than restricting patients' treatment options, will instead empower them and their doctors to make better decisions about their health care.

Monday, July 16, 2012

Evidence that EHRs can promote better preventive care

In a previous post, I summarized the mixed evidence that using electronic health records with clinical decision support systems (CDSSs) improves processes and outcomes of preventive care. Most of the literature supporting a positive effect of EHRs with CDSSs is either anecdotal, observational, or limited to specific settings (namely, practices of employed physicians in large, integrated health systems). I concluded that it remained uncertain if these results could be duplicated in randomized trials in typical private practices.

Uncertain, that is, until last week, following a study by Alex Krist and colleagues, "Interactive Preventive Health Record to Enhance Delivery of Recommended Care: A Randomized Trial," in the Annals of Family Medicine. The authors randomized 4500 patients from 8 primary care practices in Virginia to usual care versus an invitation to use MyPreventiveCare, an interactive personal health record (IPHR) that generates a list of screening and counseling recommendations based on guidelines from the U.S. Preventive Services Task Force, as well as links to more detailed explanations of these preventive services and relevant decision aids. When patients used the IPHR, their physicians also received a summary of the recommendations in their EHRs.

Although only about 1 in 6 invited patients had actually used the personal health record 16 months later, it was enough to show a statistically significant difference between the proportion of patients in that group who were up-to-date on all recommended services, compared to the control group. After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users. The authors concluded: "Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefits." A how-to guide on the use of personal health records to promote uptake of recommended preventive services is available on the Agency for Healthcare Research and Quality website.


A modified version of this post first appeared on the AFP Community Blog.

Wednesday, July 11, 2012

The end of the line on PSA screening

In the summer of 2007, then-U.S. Preventive Services Task Force member Russ Harris, MD, MPH approached me about taking on what he suggested would be a fairly quick and straightfoward project: summarizing the small amount of medical literature on the benefits and harms of the prostate-specific antigen (PSA) test that is commonly used to screen asymptomatic men for prostate cancer. Little did I know that this research and its implications would dominate the next five years of my career. There would be some good moments (my published systematic review of the topic was honored as AHRQ's Article of the Year award in 2009) as well as many bad ones (encapsulated in this series of posts that recount the reasons for my subsequent resignation from the Agency in 2010). This year, the USPSTF finally confirmed what had become clear to me and many other scholars of PSA screening: the test's harms outweigh its benefits for the vast majority of men, and therefore it should not be recommended.

Although the Medicare program and private insurance plans continue to pay for the PSA test, there is reason to hope that the new recommendation will eventually change medical practice. Despite the backlash that greeted the USPSTF's 2009 recommendation for individualized decision-making regarding mammography for women in their 40s, recent national data has demonstrated a 6 percent decline in screening rates in this age group - modest but notable evidence that more women are making thoughtful screening decisions that reflect their personal values and preferences. Based on the USPSTF's assessment, I now tell older male patients that the harms of the PSA test's downstream consequences are very likely to outweigh any potential health benefits. Some still request the test, but such requests are becoming less common.

During the past five years, I have given countless lectures and participated in many public debates about PSA screening. I recently agreed to address the subject once more in October at a panel discussion sponsored by the Department of Health Policy and Management of the Johns Hopkins University Bloomberg School of Public Health (where I am an adjunct instructor). And I have decided that for me, that event will be the end of the line for public speaking about PSA screening, at least until there is more evidence to discuss. It's time for me to move on, personally and professionally. Nonetheless, I hope that others will take up the essential task of communicating the flaws of this test to physicians and the public, so that someday we may reach the end of the line on PSA screening itself.

Monday, July 9, 2012

Rhythm or rate control for atrial fibrillation?

For many years, the standard thinking regarding treatment of patients with atrial fibrillation was that drug therapy to restore sinus rhythm (rhythm control) was superior to drug therapy to slow the ventricular response rate (rate control). That all changed in 2002, when a clinical trial found no difference in survival between patients randomized to rhythm or rate control, and a higher incidence of adverse effects in the rhythm control group.

This trial and other evidence led the American Academy of Family Physicians to issue a guideline that recommended rate control with chronic anticoagulation as the preferred strategy for most patients with atrial fibrillation. A recent AFP review article echoed this guidance, assigning an "A" strength of evidence rating to the following statement:  "Rate control is the recommended treatment strategy in most patients with atrial fibrillation. Rhythm control is an option for patients in whom rate control is not achievable or who remain symptomatic despite rate control."

On occasion, however, evidence-based interventions achieve different results in primary care than in clinical trials. A study published earlier this month in the Archives of Internal Medicine used administrative databases in Quebec, Canada to compare mortality between older patients with atrial fibrillation who were initially prescribed rhythm or rate control therapy after their diagnoses. After experiencing similar mortality through 4 years of follow-up, patients in the rhythm control group had a significantly lower risk of death, with 23% lower relative mortality than patients in the rate control group at 8 years. These surprising results beg the question: was this new study somehow flawed? If not, as the subtitle of an accompanying editorial asked, can observational data trump randomized trial results?

Although it is unlikely that treatment guidelines will change any time soon, this study should remind clinicians that management of patients with newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.


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

Thursday, July 5, 2012

Public Speaking Update

Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.comThe Health Care Blog, and Gary Schwitzer's HealthNewsReview, as well as the websites of major national newspapers such as the New York Times, the Wall Street Journal, USA Today, and the Boston Globe. I also wrote the consumer health blog Healthcare Headaches for U.S. News and World Report from August 2010 through September 2011.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.

Upcoming events:

PSA Screening, Science, and Public Policy (panel discussion)
- Johns Hopkins University Bloomberg School of Public Health
- October 25, 2012

Screening for Osteoporosis: Who, When, and How Often?
Spanish Catholic Center of Catholic Charities of Washington DC
- September 2012

Screening Mammography for Women in their 40s: Exploring the Controversy
NCA Breast Healthcare Improvement Initiative
- July 23, 2012

Past events:

Why You Should Stop Screening Patients for Prostate Cancer
- Ephrata Community Hospital (PA)

Identifying and Using Good Practice Guidelines
- Temple University School of Medicine / Lancaster General Hospital

Cancer Screening: A Primer for Journalists
- National Press Foundation's Cancer Issues 2011

What to Do When Screening Guidelines Conflict: HIV and Mammography
- Grand Rounds, Georgetown University Department of Family Medicine

Overdiagnosed: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health

For Geeks and Geezers: With Social Media Skills You Can Change the World
- Family Medicine Education Consortium Northeast Region Meeting

Screening for Diabetes: What Does the Evidence Say?
- Spanish Catholic Center of Catholic Charities of Washington, DC

Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians

Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Library Association Annual Meeting

Medical Blogging and Other Professional Uses of Social Media
- Grand Rounds, Virginia Commonwealth University Internal Medicine

Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine Annual Meeting

Health Promotion and Disease Prevention in Clinical and Community Settings
- Uniformed Services University of the Health Sciences

The Value of Preventive Health Services
- Webinar for Employees of MetLife

COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians

Monday, July 2, 2012

Guest Post: Reports of the ACA's death were greatly exaggerated

Marya Zilberberg, MD, MPH is an independent physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. I recently reviewed her excellent book on evidence-based medicine, Between the Lines. The following post was first published on her blog, Healthcare, etc.


This was a big day for President Obama's signature legislation, the Affordable Care Act. The Supreme Court upheld its constitutionality, and the punditdom thinks that further challenges are unlikely. On the other hand, if Romney takes the White House in the next election... Well, you can guess what will happen then.

It has been interesting to watch the run-up to this decision. Most recently I have been amused by surveys finding that on the one hand, many American people are in favor of the pre-existing condition inclusion (this part of the bill forbids insurance companies to discriminate against people with prior health conditions), as well as the provision that allows young adults to stay on their parents' insurance policies through a certain age. On the other hand, the majority of Americans are against the healthcare law itself, and most also oppose the individual mandate provision (this is the part where everyone has to buy insurance or pay a tax). Given this imbalance in the public opinion, a more pertinent survey should have assessed how well people understand these provisions in the first place. And this would have had to establish how well the public gets our whole healthcare "system."

To start from the beginning, any healthcare system can be judged on three criteria:
1. How accessible is it?
2. Is it of adequate quality?
3. How expensive is it?

The answer to the first question provides one of the rationales for the individual mandate. Currently there are about 50 million people without health insurance in the US, and, hence, without adequate access to the system. Many of these people are the young and the healthy who gamble on staying young and healthy. And many are consigned to relying on expensive emergency care when this gamble fails. Some of them go bankrupt trying to pay for it, while others become "safety net" cases, where the institution that cares for them swallows the costs. These institutions do get some public dollars for providing safety net care, but not nearly enough to break even. Since many of the 50 million don't buy health insurance because they cannot afford it, the healthcare bill provides a way to create more affordable insurance products.

The answer to the second question is not related directly to the individual mandate. Since much of this blog is devoted to the issues of healthcare-associated harm, I do not wish to belabor this point here. Suffice it to say that the bill does try to address this catastrophic situation, though it remains to be seen if it will succeed.

The third question is the crux of the story. Many have said that the escalation of healthcare costs is unsustainable, and I subscribe to this notion: I am not sure how much more than $2.6 trillion/year we want to pay for this insatiable beast. Yet judging by the near-revolt that "death panels" rhetoric caused, the citizenry is not interested in being thoughtful about what services make sense. The vehement knee-jerk to the "R" word shuts down the discussion before it even starts. So, OK, how do we pay this ever-increasing bill? Moreover, since we are all happy with the government mandate for all insurance to pay for pre-existing conditions, how do we propose to pay for this additional coverage? Short of printing money (not generally a good idea) or creating a single-party payer system that regulates these expenditures, the only way is to broaden the pool of revenue. The way the ACA has proposed to broaden this pool is through the very individual mandate that is anathema to our American way of life. But without it, there is no broadening of coverage, and there is no paying for every intervention that we seem to feel entitled to.

I doubt very much that the ACA will substantively contain healthcare costs. I even doubt that it will solve the quality problems, but I am willing to wait and see on that. This bill is but a band-aid on an arterial bleed. However, I do believe that upholding this legislation allows us to take the first steps toward a reasonable national dialog about the kind of healthcare system we need. This dialog will not be helped by stupid surveys that reinforce our willful ignorance. We have the opportunity to move this conversation to a higher level, where people begin to understand the issues we are up against more deeply. Let's take it.