Monday, July 17, 2017

Self-monitoring doesn't improve control of type 2 diabetes

"Have you been checking your sugars?" I routinely ask this question at office visits involving a patient with type 2 diabetes, whether the patient is recently diagnosed or has been living with the disease for many years. However, the necessity of blood glucose self-monitoring in patients with type 2 diabetes not using insulin has been in doubt for several years.

A 2012 Cochrane for Clinicians published in American Family Physician concluded that "self-monitoring of blood glucose does not improve health-related quality of life, general well-being, or patient satisfaction" (patient-oriented outcomes) and did not even result in lower hemoglobin A1C levels (a disease-oriented outcome) after 12 months. In their article "Top 20 Research Studies of 2012 for Primary Care Physicians," Drs. Mark Ebell and Roland Grad discussed a meta-analysis of individual patient data from 6 randomized trials that found self-monitoring improved A1C levels by a modest 0.25 percentage points after 6 and 12 months of use, with no differences observed in subgroups. Based on these findings, the Society of General Internal Medicine recommended against daily home glucose testing in patients not using insulin as part of the Choosing Wisely campaign.

Still, the relatively small number of participants in trials of glucose self-monitoring, and the persistent belief that it could be useful for some patients (e.g., recent type 2 diabetes diagnosis, medication nonadherence, changes in diet or exercise regimen), meant that many physicians have continued to encourage self-monitoring in clinical practice. In a 2016 consensus statement, the American College of Endocrinology stated that in patients with type 2 diabetes and low risk of hypoglycemia, "initial periodic structured glucose monitoring (e.g., at meals and bedtime) may be useful in helping patients understand effectiveness of medical nutrition therapy / lifestyle therapy."

In a recently published pragmatic trial conducted in 15 primary care practices in North Carolina, Dr. Laura Young and colleagues enrolled 450 patients with type 2 non-insulin-treated diabetes with A1C levels between 6.5% and 9.5% and randomized them to no self-monitoring, once-daily self-monitoring, or once-daily self-monitoring with automated, tailored patient feedback delivered via the glucose meter. Notably, about one-third of participants were using sulfonylureas at baseline. After 12 months, there were no significant differences in A1C levels, health-related quality of life, hypoglycemia frequency, health care utilization, or insulin initiation. This study provided further evidence that although glucose self-monitoring may make intuitive sense, it improves neither disease-oriented nor patient-oriented health outcomes in patients with type 2 diabetes not using insulin. So why are so many clinicians still encouraging patients to do it?

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This post first appeared on the AFP Community Blog.

Sunday, July 9, 2017

Does health insurance save lives? No: primary care does.

Two recent review articles in the New England Journal of Medicine and the Annals of Internal Medicine discussed the relationship between having health insurance and improving health outcomes (including mortality, i.e., "saving lives"). In my latest Medscape commentary, I analyzed these two articles in the context of the debate over the U.S. Senate's Better Care Reconciliation Act (BCRA), which the Congressional Budget Office has estimated would lead to 22 million more uninsured persons if passed, compared to current law. I concluded that arguments about the effects of gaining or losing health insurance largely miss the point, since any positive effects of insurance are most likely mediated through providing primary care:

It is plausible that the positive effect of insurance on health is real. The next question is, why? It's not because insured people receive more or better care for acute, life-threatening illnesses. Instead, people who gain insurance generally increase their use of preventive services and are more likely to report having a usual source of primary care, which other studies have found is strongly associated with lower mortality. In fact, I would argue that health insurance's positive effects on health are mediated largely through prepaid primary care services.

The American Academy of Family Physicians has joined several other major physician groups in opposing BCRA because absent modifications, it will certainly decrease access to primary care by making insurance unaffordable for low-income and other vulnerable populations who don't qualify for Medicaid or Medicare. But paying for a barely affordable bronze marketplace plan with a $6000 deductible hardly makes primary care affordable, either, outside of a limited list of preventive services. The solution? Make it possible for more people to buy inexpensive primary care without having to go through expensive health insurance.

Health reform proposals should build on the knowledge that primary care saves lives for a fraction of the cost of a health insurance premium. In the long run, Democrats and Republicans could find common ground between their "Medicare for all" and "covering everyone costs too much" positions by removing primary care from the inefficient insurance system entirely. Instead, Congress should guarantee everyone a family doctor through a community health center or direct-pay primary care, as physician and financial planner Carolyn McClanahan has proposed.

Wednesday, July 5, 2017

Strategies to limit antibiotic resistance and overuse

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more. Antibiotic resistance occurs in the community, in long-term care facilities, and in hospital settings. Another CDC report on preventing healthcare-associated infections (also discussed in this American Family Physician article) identified six high-priority antibiotic resistance threats: carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enteroccocus, multidrug-resistant Pseudomonas, and multidrug-resistant Acinetobacter.

In a 2014 editorial, "Antibiotic resistance threats in the United States: stepping back from the brink," Dr. Steven Solomon and Kristen Oliver from the CDC identified three strategies that family physicians can use to limit antibiotic resistance: 1) Preventing infections through immunizations, standard infection control practices, and patient counseling; 2) Reporting unexpected antibiotic treatment failures and suspected resistance to local or state health departments; and 3) Prescribing antibiotics more carefully. Unfortunately, inappropriate antibiotic prescribing (also known as antibiotic overuse) is common in primary care, particularly for patients with acute viral respiratory tract infections.


Antibiotic overuse is a multifaceted problem with many potential solutions. On Sunday, July 9th at 7 PM Eastern, Dr. Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will be taking a deep dive into the evidence on the most effective strategies to curb prescribing of unnecessary antibiotics. American Academy of Family Physicians members and paid AFP subscribers can earn 4 free continuing medical education credits by registering for the #afpcme Twitter Chat, reading three short AFP articles, and completing a post-activity assessment. We hope you can join us!

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This post first appeared on the AFP Community Blog.

Thursday, June 29, 2017

Innovations in primary care for underserved populations

Lately, “innovation” is the buzz word that I am hearing most often at conferences and briefings and reading in medical journals. But what counts as innovation in primary care, and how can physicians and patients quickly distinguish true practice-changers from temporary fads? At a conference I attended last year, Ray Rosin, Chief Innovation Officer at Penn Medicine, described three techniques that can be used to rapidly test promising innovations:

Vapor tests, which help innovators determine the demand for a service or program without needing to build the service or program first.

Fake front ends, which "make ideas tangible to help answer the question 'What will people do with it?'"

Fake back ends, which allow "teams to quickly answer the question 'What happens if people actually use it?'"

Even though these techniques require relatively small investments in time and effort, primary care clinicians still need to know about promising innovations in order to test them. One good source for innovations to improve quality and reduce disparities is the Agency for Healthcare Research and Quality's Health Care Innovations Exchange, a searchable database of case studies ("innovation profiles") submitted by health organizations across the nation. Over the past few months, I've also collected several primary care innovations for underserved populations from the new Annals of Family Medicine feature and various other sources.

1) Using QR codes to connect patients to health information - a rural family medicine clinic in Iowa displays QR codes in its waiting room and other areas that, when scanned by a reader on a smartphone or tablet, load general patient education resources or materials related to the specific reason for the patient's visit.

2) Engaging complex patients with drop-in group medical appointments - a stabilizing program for uninsured, low-income patients with complex mental and physical health needs in North Carolina that over the past 6 years has reduced enrollees' hospital utilization by 50% at the cost of $100 per patient per month.

3) Fresh food by prescription - Central Pennsylvania's Geisinger Health system piloted a free, healthy "food pharmacy" for low-income patients with type 2 diabetes and their families on the grounds of one of its hospitals.

4) Telemedicine screening for diabetic retinopathy - Los Angeles County successfully implemented telemedicine screening in its safety net clinics, reducing the wait time for screening from 158 to 17 days and increasing the percentage of all eligible patients screened by more than 40%.

These innovations probably won't work in every underserved setting, but one or more could be worth a try in your clinic or health system, using one of Rosin's rapid-cycle techniques.

Sunday, June 18, 2017

Start collecting community vital signs in your practice

Primary care physicians and educators are increasingly recognizing the usefulness of assessing social determinants of health (defined by the Centers for Disease Control and Prevention as conditions in the places where people live, learn, work, and play) during health care encounters. A recent National Academy of Medicine discussion paper described the Accountable Health Communities Screening Tool, developed by the Center for Medicare and Medicaid Innovation to identify and address five domains of health-related social needs: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. Since 2011, students at Morehouse School of Medicine and Georgia State University College of Law have participated in an interprofessional medical-legal curriculum; surveys suggested that medical students who completed the curriculum were more likely to screen for social determinants of health and refer patients to legal resources. In March, the American Academy of Family Physicians (AAFP) launched its Center for Diversity and Health Equity, whose planned activities will include

- evaluating current research on the social determinants of health and health equity;
- promoting evidence-based community and policy changes that address the social determinants of health and health equity; and
- developing practical tools and resources to equip family physicians and their teams to help patients, families, and communities.

In an editorial in the June 1 issue of American Family Physician, Drs. Lauren Hughes and Sonja Likumahuwa-Ackman add another potential dimension for action on social determinants of health by introducing the concept of "community vital signs." In contrast to data collected directly from patients, the authors write,

Community-level data are acquired from public data sources such as census reports, disease surveillance, and vital statistics records. When geocoded and linked to individual data, community-level data are called community vital signs. Community vital signs convey patients' neighborhood health risks, such as crime rates, lack of walkability, and presence of environmental toxins. ... This enhanced knowledge about where patients live, learn, work, and play can help physicians tailor recommendations and target clinical services to maximize their impact. Rather than simply recommending that a patient eat better and exercise more, care teams can connect patients to a local community garden, low-cost exercise resources (e.g., YMCA), or neighborhood walking groups.

To get started using community-level data to improve patient care and population health, family physicians can consult The Practical Playbook and the AAFP's Community Health Resource Navigator. The editorial also provides a suggested five-step process for incorporating community vital signs into clinical practice.

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This post first appeared on the AFP Community Blog.

Wednesday, June 14, 2017

We shouldn't expect anyone to die in childbirth

Comparing the performance of health systems around the world is difficult to do in a straightforward way. Should one look at differences in life expectancy? Disability-adjusted life years? The percentage of the population that perceives themselves to be in "good health"? We know that poverty, low education, segregation, and other social disadvantages do more to determine health outcomes than does health care. Since newborns presumably haven't had time to become unhealthy from these social factors, the infant mortality rate is commonly cited to illustrate the failure of the U.S. health care system, which has the highest spending per person in the world, but outcomes worse than those in 27 other high income nations.

But it's not only in infant deaths that the U.S. lags behind the rest of the developed world. Last year, the Institute for Health Metrics and Evaluation reported that the maternal mortality rate (the number of deaths per 100,000 births due to complications from pregnancy or childbirth) was higher in 2013 than in 2005, and more than 50 percent higher than the rate in 1990. Even though maternal deaths remain rare (occurring about once every 3600 births in the U.S., 3 or 4 times as often as in Canada and Western European countries), they should be treated like catheter-related bloodstream infections, where the goal is zero. My wife has had four children, at at no point during any of her pregnancies, labors or deliveries did I have the slightest concern that her life was in danger. That's how it should be for moms in the twenty-first century.

And that's also why I, and doubtless many others, found the recent NPR / ProPublica article "The Last Person You'd Expect to Die in Childbirth" so heartbreaking and disturbing. The article recounts the tragic story of Lauren Bloomstein, a 33 year-old neonatal nurse in good health who died of a hemorrhagic stroke in her own New Jersey hospital, 20 hours after delivering her first child. According to the authors, Bloomstein developed preeclampsia with HELLP syndrome, and her physician did not recognize the early symptoms (high blood pressure and abdominal pain) for what they were until it was too late to stop the catastrophe.

It's possible that her death may have been prevented if the hospital had implemented standardized birth safety practices described in an Atlantic article about Dr. Steve Clark, an obstetrician who previously led obstetric safety for 115 programs in the Hospital Corporation of America. But it would be a mistake to conclude from Bloomstein's tragedy that the rising U.S. maternal mortality rate is due primarily to medical errors, when it is in fact a complex public health problem. Dr. Aaron Carroll reviewed some possible causes in a JAMA Forum, including unplanned pregnancies; poor access to preventive care; the opioid epidemic; and the increased prevalence in pregnant women of obesity, hypertension, and diabetes.

Also, the rising overall rate masks persistent disparities. According to a 2010 report on maternal mortality from the Health Resources and Services Administration, non-Hispanic Black women have 3 times the risk of maternal death than White and Hispanic women; counties where 15% or more of the population lives in poverty have twice the risk as counties with a poverty rate of less than 5%; and women in New England have one-half to one-third the risk of women in the Mid- and South Atlantic states. Maternal mortality in the U.S. is largely a problem of social, economic, and geographic inequality rather than differences in health care, and we must look beyond hospitals for solutions. In the short term, it is important to prevent the U.S. Senate from passing its version of the American Health Care Act, which takes $800 billion from Medicaid, the program that pays for 31 to 72 percent of all births depending on the state, like a thief in the night. The last person you'd expect to die in childbirth? We shouldn't expect anyone to die in childbirth, and we certainly shouldn't be hastening their deaths.

Monday, June 5, 2017

The places in America where doctors won't go

This spring, I attended the annual Teaching Prevention conference in Savannah, Georgia sponsored by the Association for Prevention Teaching and Research. Since I haven't spent much time in Georgia outside of Savannah and Atlanta, the welcoming plenary on improving health outcomes for the state's rural and underserved populations was eye-opening. According to Dr. Keisha Callins, Chair of the Department of Community Medicine at Mercer University, Georgia ranked 39th out of 50 states in primary care physician supply in 2013 and is projected to be last by 2020. 90% of Georgia's counties are medically underserved. Mercer supports several pipeline programs that actively recruit students from rural areas, expose all students early to rural practice and community health, and provide financial incentives for graduates who choose to work in underserved areas of the state. But it's an uphill battle. Even replicated in many medical schools across the country, these kinds of programs likely won't attract enough doctors to rural areas where they are most needed.

When people talk about places where doctors won't go, they tend to focus on international destinations, such as war zones in Syria or sparsely populated areas of sub-Saharan Africa. It's hard to believe that many places in America are essentially devoid of doctors, and access to medical care is as limited as in countries where average income is a tiny fraction of that in the U.S. Providing health care coverage for everyone, while important, won't automatically ensure the availability of health professionals and resources in rural communities. In a recent JAMA Forum piece, Diana Mason discussed the financial struggles of rural hospitals that support community health alongside primary care clinicians, which may become more acute if budget cuts to rural health programs and grants occur as proposed in President Trump's budget.

Georgia is hardly the only state struggling to attract doctors to rural communities. In the Harper's Magazine story "Where Health Care Won't Go," Dr. Helen Ouyang chronicles the evolving tuberculosis (!) crisis in the Black Belt, a swath of 17 historically impoverished, predominantly African American counties in rural Alabama and Mississippi. In Marion, Alabama, a single family doctor in his mid-fifties and an overwhelmed county health department grapple daily with the lack of resources to contain the spread of the disease:

There is no hospital in town. The nearest one, twenty minutes away in Greensboro, has minimal resources. The road to get there is narrow, unlit at night, and littered with roadkill. Perry County has only two ambulances, one of which is on standby for the local nursing home. Life expectancy here is seven years lower than the U.S. average, and the percentage of obese adults is almost a third higher; by the latest count, more than a quarter of births take place without adequate prenatal care. [Dr. Shane] Lee’s clinic is Marion’s only place for X-rays.

Ouyang goes on to describe the University of Alabama's Rural Health Leaders Pipeline, a program that recruits and trains medical students from rural communities to eventually become primary care physicians for those communities. Although the program has been modestly successful (since 2004, "more than half have gone on to work in rural areas, compared with only 7 percent of their classmates"), many Black Belt counties have yet to benefit from it. Many medical schools use a minimum score cutoff on the Medical College Admission Test (MCAT) that tends to penalize applicants from rural and minority communities, even though those students are more likely to become primary care physicians for underserved populations:

The purpose of doctors, after all, is to tend to patients’ ultimate needs. Increasing the supply of primary care physicians is linked to lower mortality rates; after compiling data from studies across different parts of the country, a group of public health researchers found that by adding one more doctor for every 10,000 people, as many as 160,000 deaths per year could be averted. When the same researchers considered race as a factor, this benefit was found to be four times greater in the African-American population than among white people. Studies have also observed that the availability of primary care significantly reduces health disparities that result from income inequality.


The problem of too few primary care clinicians is not limited to rural America, but those communities are where the need is greatest, since a town without a family doctor is unlikely to have any other types of physicians. Medical schools can't easily change social determinants of health on their own, but they can rewrite their mission statements to emphasize providing health care to everyone regardless of geography, and implement recruitment and admissions policies that actually support that goal.

Thursday, June 1, 2017

Selected publications list, updated June 2017

I periodically write guidelines, research articles, editorials, and letters in the medical literature about some of the topics that I write about on this blog. Below is an updated list of selected publications, with links to abstracts or full articles if available:

1. Frost JL, Campos-Outcalt D, Hoelting D, LeFevre M, Lin KW, Vaughan W, Bird MD. Pharmacologic management of newly detected atrial fibrillation: updated American Academy of Family Physicians clinical practice guideline, June 2017.

2. Bird MD, Gersch D, Hoelting D, Lin KW, Mishori R. Incarceration and health: a family medicine perspective. American Academy of Family Physicians position paper, May 2017.

3. Lin KW, Frost JL. Should screening tests for colorectal cancer all have an “A” recommendation? No: when it comes to colorectal cancer screening, test choice matters. Am Fam Physician 2017;95:618-620.

4. Lin KW. Is genetic testing sophisticated enough to make PSA screening viable for mainstream use? No. HemeOnc Today, March 25, 2017.

5. Llano J, Lin KW. Management of binge-eating disorder in adults. Am Fam Physician 2017;95:324-326.

6. Petersen J, Lin KW. Radioiodine therapy versus antithyroid medications for Graves disease. Am Fam Physician 2017;95:292-293.

7. Barreto T, Lin KW. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory tract infections in primary care. Am Fam Physician 2017;95:11-12.

8. Schwartz SR, Magit AE, Rosenfeld RM, Ballachanda BB, Hackell JM, Krouse HJ, Lawlor CM, Lin K, et al. Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg 2017;156(1S):S1-S29.

9. Lin KW, Ebell MH. How to counsel men about PSA screening. Am Fam Physician 2016;94:782-784.

10. Lin KW. Increased alignment in preventive services recommendations for children. Am Fam Physician 2016;94:272-274.

11. Lin KW, Yancey JR. Evaluating the evidence for Choosing Wisely in primary care using the Strength of Recommendation Taxonomy (SORT). J Am Board Fam Med 2016;29:512-515.

12. Ebell M, Lin KW. Counseling women about breast cancer screening. Am Fam Physician 2016;93:652-653.

13. Lin KW, Gostin LO. A public health framework for screening mammography: evidence-based vs politically mandated care. JAMA 2016; 315:977-978.

14. Lin KW. Should family physicians routinely screen patients for hepatitis C? No: one-time screening still has too many unanswered questions. Am Fam Physician 2016;93:17-18.

15. Lin K, O'Gurek D, Rich R, Savoy M. How to help your patients Choose Wisely. Fam Pract Manag 2015;22:28-34.

16. Raffoul M, Lin KW. Cultural competence education for health care professionals. Am Fam Physician 2015;91:523-524.

17. Koretz RL, Lin KW, Ioannidis JP, Lenzer J. Is widespread screening for hepatitis C justified? BMJ 2015;350;g7809.

18. Lin KW. What to do at well-child visits: the AAFP’s perspective. Am Fam Physician 2015;91:362-364.

19. Siwek J, Lin KW. Choosing Wisely: more good clinical recommendations to improve health care quality and reduce harm. Am Fam Physician 2013;88:164-168.

20. Lin KW, Sieber PR, Oyer RA. The controversial prostate-specific antigen (PSA) test: a roundtable discussion of its indications and uses. J Lancaster Gen Hosp 2012;7(4):101-110.

21. Lin KW. Practice guidelines produced by subspecialists must meet higher standards. [Letter] Ann Fam Med published online November 15, 2012.

22. Lin KW. Do electronic health records improve processes and outcomes of preventive care? Am Fam Physician 2012;85:956-957.

23. Lin K, Croswell JM, Koenig H, Lam C, Maltz A. Prostate-specific antigen-based screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 90. AHRQ Publication No. 12-05160-EF-1. Rockville, MD: Agency for Healthcare Research and Quality, October 2011.

24. Lin KW. Challenging the conventional wisdom on colorectal and prostate cancer screening. J Lanc Gen Hosp 2010;5(3):74-77.

25. Lin K, Sharangpani R. Screening for testicular cancer: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2010;153:396-99.

26. Lin K. Adverse effects. Pulse: voices from the heart of medicine. May 21, 2010.

27. Lin KW, Slawson DC. Identifying and using good practice guidelines. Am Fam Physician 2009;80:67-69

28. Lin K, Lipsitz R, Miller T, Janakiraman S. Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149:192-99.

29. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2008;148:535-43.

Monday, May 29, 2017

Should we look for pulmonary emboli in patients with syncope?

The standard evaluation of patients with syncope has changed little over the years, with considerable continuity between American Family Physician reviews published in 2005, 2011, and this March. But the field received an unexpected jolt last October, when Dr. Paolo Prandoni and colleagues published a cross-sectional study in the New England Journal of Medicine that calculated a surprisingly high prevalence of pulmonary embolism (PE) of 17.3% in patients hospitalized for a first episode of syncope. In this study, 230 of 560 patients at 11 Italian hospitals who did not have a low pretest probability of PE by the Wells rule and negative D-dimer assay underwent computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion lung scans. 97 of these patients had evidence of PE. Overall, the investigators identified PE in 25% of patients with no alternative explanation for syncope and 13% of patients with an alternative explanation.

Algorithms for syncope evaluation focus on identifying cardiac and neurally mediated causes and do not include routine testing for PE. The question raised by the Italian study is if all inpatients with syncope need evaluation, since nearly 1 in 6 patients may have PE. There are good reasons not to jump to this conclusion. First, we don't know if the prevalence of PE in this study was representative of the general population of adults hospitalized for syncope, as it only included patients admitted from emergency departments (and not patients initially evaluated in primary care settings). Second, the study did not determine if PE was the etiology of syncope, as opposed to an incidental finding. This is important because evidence suggests that the enhanced sensitivity of CTPA for detecting small, subsegmental PE is increasing overdiagnosis and overtreatment of clinically insignificant clots. Finally, the absence of a comparison group means that it is not known if the systematic workup for PE improved the patients' prognoses or just added additional cost and risk to the evaluation.

A retrospective cross-sectional study in JAMA Internal Medicine recently used clinical and administrative data from 4 hospitals in Toronto to estimate the prevalence of PE in 1305 patients with a first episode of syncope who were not receiving anticoagulation at the time of admission. 120 of these patients received CTPA, ventilation-perfusion scan, and/or compression ultrasonography, leading to the diagnosis of PE in 18 patients. As opposed to the Italian study, where all persons received at least a D-dimer test, the decision to evaluate for PE was driven by clinical judgment. Nonetheless, of 146 patients in the Toronto study who received any test for PE (presumably those who were most likely to have one), only 12% were positive, and the overall prevalence of PE was a mere 1.4%. The authors concluded that "there is little, if any, justification for routine testing for [venous thromboembolism] in all patients hospitalized for a first episode of syncope."

Based on both studies, I agree that evidence does not support routinely looking for PEs in patients with syncope. In patients with possible signs or symptoms, another clinical decision rule may be used to confidently rule out the diagnosis without resorting to the less sensitive Wells rule or less specific D-dimer test, where a positive result often leads to unnecessary CTPA.

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

Monday, May 22, 2017

Colorectal cancer and falls: too much and too little prevention

One of the paradoxes of the U.S. health care system is that excess and waste often exist side by side with insufficiently provided services. Colorectal cancer screening is a prime example. Previous studies showed that 25% of Medicare recipients undergo repeat screening colonoscopies sooner than necessary, but the Centers of Disease Control and Prevention recently reported that nearly 4 in 10 adults between ages 50 and 75 are not up-to-date on colorectal cancer screening. Last year, I argued that the U.S. Preventive Services Task Force's decision to expand the number of recommended screening options based on inadequate evidence was unlikely to improve this situation.

In an editorial in the May 15th issue of American Family Physician, I and Dr. Jennifer Frost explained why the American Academy of Family Physicians disagreed with the new recommendations, and instead chose not to recommend CT colonography or fecal DNA testing and to also reaffirm its previous stance against screening adults older than 85 years. BMJ journalist Jeanne Lenzer's question about whether the USPSTF remains a voice of caution remains relevant in an era of increasingly elastic evidence letter grades (see "C" for prostate cancer screening).

Another area where there may be too much prevention occurring for too little benefit is screening and treatment for osteoporosis, which Ray Moynihan and colleagues reported that in contrast to the medical literature, community-dwelling older women would prefer to describe as a "risk factor" rather than a "disease." I couldn't agree more; we physicians focus too much on prescribing drugs to treat low bone density and too little on interventions to address the other critical risk factor for hip fractures: falling.

So I hope that many patients will read and heed Paula Span's recent New York Times column advising older adults to invest in home modifications that will allow them to move safely around their living spaces as they age. Unfortunately, there aren't nearly enough Certified Aging in Place Specialist (CAPS) contractors to meet national needs. Also, many health insurers that would have no issues paying for a PSA test or screening colonoscopy in a 90 year-old would balk at reimbursing home renovations, even though the latter is much more likely to prevent (rather than cause) a hospitalization.

Tuesday, May 16, 2017

Fear-mongering in thyroid and breast cancer screening

A large part of practicing primary care consists of providing reassurance to healthy persons. The patient who asks me to look at the mole on her back to make sure it isn't melanoma. The patient who recently recovered from a cold but is still coughing and wants to know that it isn't a sign of something more serious. The patient whose friend's doctor found a lump on his thyroid gland and wants to have his neck checked too.

The last time the U.S. Preventive Services Task Force recommended against screening for thyroid cancer was in 1996. That it took more than 20 years to release an updated recommendation statement (still a "D," or don't do) speaks to how non-controversial the Task Force judged this topic to be. Unfortunately, in the interim many clinicians and patients ignored this advice. In South Korea, a national cancer screening program that began in 1999 encouraged general practitioners to routinely perform thyroid ultrasound scans, resulting in an "epidemic" of new thyroid cancers but no change in thyroid cancer deaths. In the United States, papillary thyroid cancer diagnoses have quadrupled since 1995, again with no change in mortality. In both countries and around the world, physicians are finding and treating thousands of pseudo-cancers that would not have otherwise been found and don't need to be treated. Overdiagnosis begets more overdiagnosis: patients who are "successfully" diagnosed and treated tell friends and relatives to have their necks palpated or scanned for thyroid tumors. And if that feedback cycle wasn't enough, advocacy groups such as the Light of Life Foundation initiated fear-mongering awareness campaigns, as Dr. Gilbert Welch described in an editorial accompanying the USPSTF recommendation:

About a decade ago, public service announcements began to appear encouraging people to have their physicians “check your neck.” The Light of Life Foundation campaign featured actual testimonials of patients describing their positive health behaviors on the day before they were diagnosed with thyroid cancer. The ads used compelling language: “Thyroid cancer doesn’t care how healthy you are. It can happen to anyone. Including you. That’s why it is the fastest growing cancer in the US. Ask your doctor to check your neck. It could save your life.” The campaign’s title—and its main slogan—was “Confidence Kills.” That’s a great public health message: if you feel good, you are about to die.


Fear-mongering isn't limited to thyroid cancer, of course. From the 1980s-era American Cancer Society print advertisement that lectured women, "If you haven't had a mammogram, you need more than your breasts examined," promoters of breast cancer screening long used fear to motivate women to undergo screening mammography. In 2015, several advocacy organizations successfully persuaded the U.S. Congress to override the U.S. Preventive Services Task Force's "C" grade (small net benefit) on screening mammography for women aged 40-49 with a "Stop the Guidelines" campaign that included full-page advertisements in major newspapers asking the rhetorical question "Which of our wives, mothers, daughters, and sisters would be be OK to lose?"

The major difference between screening for thyroid and breast cancer is that the latter actually reduces cancer deaths. But women under 50 are less likely to benefit because there is less lethal breast cancer to be found in younger women, and consequently much higher false positive rates that affect more than half of all women receiving annual mammograms from age 40 to 50. And the USPSTF didn't tell clinicians don't screen - more accurately, they said don't screen reflexively, and the message to younger women is not to avoid mammograms, but to talk about the pros and cons with your doctor.

That hasn't stopped a new alliance of radiologists and breast cancer surgeons from targeting the Task Force with a 40not50 campaign which encourages women in their 40s to turn off their brains, eschew shared decision-making, and demand that their doctors start screening them at age 40 because mammograms save lives, and a government-appointed panel (whose 16 members include 7 women) wants to prevent women from seeing their 50th birthdays. Notwithstanding the ulterior motives behind this absurd campaign, it is insulting to women. It says that they can't be trusted to consider the medical evidence, have conversations with their primary care physicians, and make decisions about their healthcare that are right for them.

Sunday, May 7, 2017

American Family Physician translates research for practice

Over the next few months, I'll have more to say about the recent announcement that my longtime mentor Jay Siwek, MD, editor of American Family Physician since 1988 and the only family physician in the journal's 67-year history to hold that position, will be stepping down in January after 30 years at the helm. In the meantime, this post highlights three ways AFP currently translates research for primary care practice: the Top 20 research studies articles, Pro-Con editorials, and Journal Club.

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The May 1 issue of American Family Physician features the latest installment of the "Top 20 Research Studies" series of articles that Drs. Mark Ebell and Roland Grad have been writing annually since 2012. What sets this particular set of study summaries apart from other journals' "best of the year" studies lists? Dr. Jay Siwek explains in his editor's note:

Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.

The research studies from 2016 rated most primary care relevant, valid, patient-oriented, and practice changing include patient-oriented evidence that matters (POEMs) on hypertension; respiratory conditions; musculoskeletal conditions; diabetes mellitus and obesity; and miscellaneous items. The complete POEMs are available in AFP's Evidence-Based Medicine toolkit. Also, Canadian Medical Association members identified four important guidelines published in 2016: the U.S. Preventive Services Task Force (USPSTF) on screening for colorectal cancer and interventions for tobacco cessation in adults; the American College of Physicians on management of chronic insomnia; and the Centers for Disease Control and Prevention on opioid prescribing for chronic pain.

During Dr. Ebell's past membership on the USPSTF, the panel voted to recommend one-time screening for hepatitis C virus (HCV) in every adult born between 1945 and 1965 (also known as birth cohort screening). On the other hand, as a member of the Canadian Task Force on Preventive Health Care, Dr. Grad recently developed a recommendation against screening for HCV in asymptomatic adults without risk factors, including baby boomers. AFP previously presented both sides of this complicated debate in a pair of editorials that outlined the case for birth cohort screening and the case against it (which I wrote). You can find other Pro-Con editorials on controversial family medicine topics in this online collection.

Finally, readers should be aware that essential concepts from AFP Journal Club, a popular journal feature that analyzed key research studies from 2007 to 2015, have been incorporated into our EBM toolkit. This annotated collection of evidence-based medicine pointers provides useful information for clinicians, teachers, and learners at all levels.

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This post originally appeared on the AFP Community Blog.

Monday, May 1, 2017

Every screening test is a calculated gamble

When I was last in Las Vegas to attend the International Consumer Electronics Show, I stayed at one of the city's many combination hotel and casinos, with a layout designed to funnel guests and other visitors through the gaming floor to get practically anywhere. While walking past a row of pulsating slot machines in the lobby one morning, I remembered the title of a terrific New York Times editorial I read a few years ago, "You Have to Gamble On Your Health."

Courtesy of www.lasvegas.com

In this editorial, Dr. H. Gilbert Welch (whom I've lauded before for his work on the subject of overdiagnosis) explained why even though most people who receive screening tests for cancer think that they are playing it safe, every test has tradeoffs. Just as a gambler rarely hits the jackpot in Vegas, a patient who undergoes cancer screening is rarely the lucky one whose life is extended from the test, and much more likely to figuratively lose his or her shirt. Common harms of screening include false positive results, risks associated with subsequent diagnostic procedures, and possible unnecessary treatment (and associated side effects) for "cancer" that looks dangerous under the microscope but is actually destined to never cause health problems.

Courtesy of www.lasvegas.com

The good news is that for a few very well-studied screening tests such as mammography, an informed patient can assess the odds of all of these outcomes based on scientific data and decide whether screening is a better choice for her than no screening. A mammography screening decision aid by Dr. Jill Jin that appeared in JAMA did a great job of illustrating these tradeoffs, and may help to explain why one prominent health journalist announced that she had decided to forego mammography because she believed that "the numbers are in my favor."

Yes, every screening test is a gamble, but I give credit to my fellow physicians for providing increasingly sophisticated support for these tough decisions that you'd never get in Vegas.

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This post first appeared on Common Sense Family Doctor on January 6, 2015.

Monday, April 24, 2017

Safety net doesn't protect patients from low-value care

During my residency training and for parts of my career, I practiced in several "safety net" clinics, defined as clinics that serve a patient population where at least 25% have no health insurance or are insured with Medicaid. As family physicians who work in these settings well know, resources are often limited, and arranging for patients to receive necessary care at an affordable price can be a major challenge.

While on telephone hold one day for the umpteenth prior authorization request for a medication my patient had been taking for years, I remember consoling myself that at least these maddening financial constraints provided protection against low-value care. Unlike the concierge practice on the other side of town, I couldn't get patients with acute low back pain into a magnetic resonance imaging (MRI) scanner the next day or order huge panels of unnecessary laboratory tests at health maintenance exams.

As it turned out, my perception was more myth than reality. In a recent cross-sectional analysis of national survey data on nearly 200,000 office visits from 2005 to 2013, Dr. Michael Barnett and colleagues examined performance on quality measures for low- and high-value care among uninsured patients, patients with Medicaid, and privately insured patients. Sample low-value care measures included computed tomography (CT) for sinusitis, screening electrocardiogram during a general medical examination, and CT or MRI for headache. High-value care measures included aspirin, statin, and beta-blocker use in patients with coronary artery disease and tobacco cessation and weight reduction counseling in eligible patients. The authors analyzed the data by insurance type and by physicians classified as practicing in a safety net population. They found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.

This study's findings underline the importance of involving clinicians and patients in underserved practices in the Choosing Wisely campaign against medical overuse. For example, the Connecticut Choosing Wisely Collaborative used a foundation grant to study patient-clinician communication about care experiences and incorporate the Choosing Wisely "5 Questions" at two federally qualified health centers. Lessons learned from these pilot projects included providing patients with context for the "5 Questions" materials and offering ongoing role-specific training and support for everyone on the care team.


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This post first appeared on the AFP Community Blog.

Tuesday, April 11, 2017

The USPSTF takes a step backward on PSA screening

I don't agree with all of the statistics cited in this infographic, particularly the optimistic estimate that 1-2 men out of every 1000 screened with the PSA test avoid death from prostate cancer. I believe that the USPSTF's 2012 estimate of 0-1 men remains more accurate, but even if the new figure is true, I don't think that changing the PSA recommendation from a "D" (benefits no greater than harms, don't do) to a "C" (small net benefit, do selectively) is warranted, given the collateral damage to men's health that screening produces. In an editorial in JAMA, the USPSTF Chair and Vice-Chairs have invited the public to comment on the draft recommendations, which are more consistent with those from the American Cancer Society and American Urological Association than the American Academy of Family Physicians and the American College of Preventive Medicine (which both recommend against PSA-based screening). They will hear from me, and I hope that they will hear from others in primary care about the physical, psychological, and opportunity costs of taking a step backward on PSA screening.

Friday, April 7, 2017

Primary care confronts the opioid epidemic

Although I rarely initiate opioid therapy, my practice has inherited an increasing number of patients for whom previous physicians have prescribed potentially dangerous doses of opioids for chronic musculoskeletal or neuropathic pain. What is the best approach to take to this situation? As Dr. Jennifer Middleton discussed in an earlier American Family Physician blog post, I could follow the Centers for Disease Control and Prevention guideline and try to reduce their pain prescriptions to safer levels by substituting alternative treatments, such as cognitive behavioral and physical therapy. I could choose to stop prescribing opioids for chronic pain, as one federally qualified health center did with notable success. I could also seek out additional training to become certified to treat opioid addiction with buprenorphine.

Last year, Surgeon General Vivek Murthy called on every physician in the U.S. to pledge to work with him to "turn the tide" on the opioid epidemic. Writing in New York Magazine, columnist Andrew Sullivan recently called it "this generation's AIDS crisis" - an epidemic that, by being highly concentrated in one demographic (AIDS in urban gay men, opioids in rural, white working-class persons), was invisible to most Americans:

For many of us, ... it’s quite possible to live our daily lives and have no connection to this devastation. And yet its ever-increasing scope, as you travel a few hours into rural America, is jaw-dropping: 52,000 people died of drug overdoses in 2015. That’s more deaths than the peak year for AIDS, which was 51,000 in 1995, before it fell in the next two years. The bulk of today’s human toll is related to opioid, heroin, and fentanyl abuse. And unlike AIDS in 1995, there’s no reason to think the worst is now over.

The April 1 issue of AFP featured a Practice Guidelines summary of the American Academy of Family Physicians' position paper on management of chronic pain and opioid misuse, which noted that "in addition to physicians, there are opportunities to help at the practice, community, education, and advocacy levels." In an accompanying editorial, two family physician authors of the position paper argued that family physicians should take a leading role in responding to the opioid crisis:

Family physicians are committed to advancing population and community health, and we must take the lead in reducing opioid misuse and overdose before outside entities mandate practice strategies that may not be patient-centered. Substance abuse disorders remain a stigma, and physician offices must be safe places for nonjudgmental diagnosis and treatment. Although we certainly cannot tackle this challenge alone, we have a clear opportunity to combat the problem of opioid misuse.


Similarly, the American College of Physicians recently published a position paper on prevention and treatment of substance use disorders that observed that only 18% of people in the U.S. with a substance use disorder are receiving treatment, far short of treatment rates for other chronic conditions in primary care: hypertension (77%), diabetes (73%), or major depression (71%). The authors concurred with the AAFP that multi-pronged efforts will be required to reduce the rising toll of opioid misuse:

Multiple stakeholders should cooperate to address the epidemic of prescription drug misuse, including the following strategies: implementation of evidence-based guidelines for pain management; expansion of access to naloxone to opioid users, law enforcement, and emergency medical personnel; expansion of access to medication-assisted treatment of opioid use disorders; improved training in the treatment of substance use disorders, including buprenorphine-based treatment; establishment of a national prescription drug monitoring program (PDMP); and improvement of existing monitoring programs.

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This post originally appeared on the AFP Community Blog.

Thursday, March 30, 2017

Is it low T? Maybe not, but pharma advertising pays off

Men's health can be a minefield, and I recently learned that applies to more than screening for prostate cancer.

A few weeks ago, I taped a Medscape commentary about the recent results of the Testosterone Trials, the largest and most rigorous randomized trials to evaluate the effects of testosterone supplements for the pharmaceutical industry-invented condition known as "low T" in older men. I was careful to distinguish low T from hypogonadism, a disease that is also characterized by low testosterone levels but stems from causes other than aging. I began by noting that President Donald Trump had his testosterone level measured last year for no apparent reason, and after analyzing the trial results, I concluded:

Although the Testosterone Trials did not completely rule out benefits of screening for or treating low T, in my view these findings should discourage family physicians from intervening in the vast majority of older men. Most men with low T have no symptoms that will respond to supplements, and for those who do, there are safer and more effective drugs for erectile dysfunction, low bone density, and depression. ... I believe that the story of testosterone supplementation in older men may end up being similar to that of estrogen supplements in postmenopausal women: lots of early hype, but ultimately limited benefits and significant potential harms.


Most of my Medscape pieces receive between 20 to 30 comments; the most I had ever received prior to this was 67 for my analysis of the CDC's opioid prescribing guidelines. I was surprised by the fast and (mostly) furious responses that came in, eventually well over 100. Several suggested that I was "cherry picking" or taking a selective approach to the evidence, even though I placed the new trials in the context of a recent, meticulous systematic review of previous RCTs. A medical student (!) and an endocrinologist questioned my breadth of clinical experience. One physician (not knowing my age) opined that I was obviously too young to have any sympathy for men suffering from the indignities of older age. Another physician (not knowing my testosterone level, which has never been measured) accused me of having a "normal testosterone bias" against low T sufferers. A registered nurse felt that I was motivated by an anti-Trump bias - which I freely admit, but I was not making fun of the President, whose testosterone level was normal. Finally, many disagreed with my contention that testosterone supplements are currently overprescribed, in large part due to aggressive direct-to-consumer (DTC) advertising.

It was a fair point of disagreement. Although testosterone prescribing has skyrocketed (to the tune of $4 billion per year) since televised DTC advertising for prescription medications became legal in 1997, that is an association, not necessarily cause-and-effect, and implies nothing about the appropriateness of such prescribing.

Just in time, a March 21 study in JAMA provided stronger evidence to support my assumptions. Dr. J. Bradley Layton and colleagues linked Nielsen ratings for television programs during which DTC ads for "low T awareness" and specific supplements appeared to a population-level database of testosterone testing and prescriptions from 2009-2013. They found that "each exposure to a testosterone advertisement was associated with monthly relative increases in rates of new testosterone testing of 0.6%, new initiation of 0.7%, and initiation without a recent baseline test of 0.8%." In other words, not only did testosterone-related DTC advertising pay off in thousands of new prescriptions, but many of them occurred without prior testing, despite the Endocrine Society's Choosing Wisely recommendation against doing so.

Monday, March 27, 2017

Does family medicine training lead to high-value care?

The American Academy of Family Physicians this month celebrated the results of the 2017 Match, which saw a record 3,237 medical students and graduates fill first-year positions in family medicine residency programs. Although there is ample evidence that providing primary care improves population health, it is less clear how residency training specialty or location influences future health care quality and spending.

As Dr. Jennifer Middleton and I mentioned in prior posts, the AAFP was an early adopter of the American Board of Internal Medicine Foundation's Choosing Wisely campaign against questionable or unnecessary medical interventions, but so far, studies have shown limited effects of the campaign in primary care. Since an estimated 30 percent of health care spending is wasted on unnecessary services, and a recent case study in JAMA suggested that "excessive resource utilization" may be considered an adverse event, it is worth studying if residency training spending patterns persist in clinical practice.

In a research paper in the Annals of Family Medicine, Dr. Robert L. Phillips, Jr. and colleagues at the American Board of Family Medicine and the Robert Graham Center analyzed spending patterns of a nationally representative sample of 3,075 family physicians and general internists who graduated from residency between 1992 and 2010 and who cared for a total of more than 500,000 Medicare patients. The physicians' residency program locations were matched with Hospital Service Areas (HSAs) and categorized by spending per patient into low-, average-, and high-cost groups. The researchers found that the "imprint" of residency training spending patterns persisted regardless of where physicians ended up providing primary care:

Physicians trained in high-cost HSAs spent significantly more per patient than those trained in low-cost HSAs, no matter what the spending category of the practice HSA. Averaged across all practice HSAs, this difference was $1,644. ... This relationship held true for family physicians and general internists in our multivariable analysis; general internists, however, made up two-thirds of sample physicians trained in high-cost HSAs, and family physicians made up two-thirds of those trained in low-cost HSAs. [Residency] graduates were significantly more likely to be low-cost physicians if their sponsoring institution produced fewer total physicians, more rural physicians, or more primary care physicians.


The researchers found no relationship between spending patterns and diabetes quality measures, suggesting that lower spending did not lead to worse health outcomes. And it is important to note that family physicians who trained in high-cost HSAs were as likely to be big health care spenders as general internists from high-cost programs; in other words, there did not appear to be anything inherent in family medicine training that caused graduates to spend less. However, more general internists provided costlier care by virtue of having trained in high-cost areas - most likely, those with tertiary academic medical centers. I agree with Dr. Phillips and colleagues' conclusion that their study "supports efforts to test interventions in residency training that may bend imprinting toward teaching and modeling behaviors that improve value in health care." One intervention has borne fruit for the past 8 years in a row: attracting more medical students to the specialty of family medicine.

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This post originally appeared on the AFP Community Blog.

Thursday, March 23, 2017

#No2AHCA and positive trends in prostate cancer screening

Without a doubt, today's biggest health policy story is the anticipated House of Representatives' vote on the American Health Care Act, the first step toward fulfilling President Trump's campaign promise to "repeal and replace" the Affordable Care Act. I outlined my position on the AHCA in detail in my latest Medscape commentary; for those of you who are not health professionals, suffice to say that I don't think it will do anything to improve the lives of patients, caregivers, or primary care physicians. Even the AHCA's strongest selling point - billions of dollars saved for the federal government over the Congressional Budget Office's 10-year time horizon - is achieved by shrinking premium tax credits relative to costs to make insurance policies unaffordable for more people (meaning that they will not be able to actually use the tax credits) and forcing states to carry more of the financial burden of Medicaid or (more likely) drop people from their programs. The result is that the AHCA, if passed, could actually result in one million fewer people having health insurance than if the ACA was simply repealed.

The bottom line is that the AHCA doesn't reduce the cost of health care; it just shifts more of those costs on to the backs of people who are least able to afford them.

If we want to actually reduce costs, we can start by not providing health care services that are unnecessary, ineffective, or potentially harmful, which is the premise of the Choosing Wisely campaign, the Right Care Alliance, and the Too Much Medicine initiative. There is some good news on this front: a research letter published this week in the Annals of Internal Medicine reported that among men aged 40 to 64 years who received health insurance from Aetna between 2009 and 2015, substantially fewer are receiving PSA screening, prostate biopsies, and prostate cancer treatments. This finding suggests that U.S. physicians are screening more selectively, raising the threshold for biopsy, and for men with a prostate cancer diagnosis, choosing watchful waiting or active surveillance more often than aggressive therapy with its associated side effects. Thank you, U.S. Preventive Services Task Force.

In my practice, after I counsel older men about projected benefits and harms of PSA screening, some will still choose to have the test, but more will decline. Many men in the latter group ask me if there are any better tests in development, and my answer is yes, but they aren't yet ready for routine use. HemeOnc Today recently invited me to respond the question: "Is genetic testing sophisticated enough to make PSA screening viable for mainstream use?" Below is an excerpt from my "No" response:

The search is on to identify more specific biomarkers that can either replace PSA as a screening test, or augment PSA by predicting which men with elevated levels are at the greatest risk for harboring clinically important — and potentially curable — cancers. However, utilizing genetic tests for this purpose outside of clinical trials is premature. The only genetic test for prostate cancer approved by the FDA is the PCA3 urine assay. In 2014, the Evaluation of Genomic Applications in Practice and Prevention Working Group concluded that PCA3 has insufficient supporting evidence to inform decisions to conduct initial or repeat biopsies for prostate cancer in at-risk men. ...

A 2016 systematic review commissioned by Agency for Healthcare Research and Quality found insufficient evidence to assess analytic validity of 18 commercially — or close to — available multigene panels for prostate cancer risk assessment, evidence of modest clinical validity beyond patient age and family history, and no studies of clinical utility (eg, effects on process of care, health outcomes, harms and economic outcomes).

It is understandable that physicians and patients who are concerned about prostate cancer are impatient for new tests that promise to maximize the benefits and minimize the harms of PSA testing. But we should have learned our lesson from the PSA experience. Now is not the time to perform more uncontrolled experiments on older men by incorporating unproven genetic tests into clinical practice.

Wednesday, March 15, 2017

Is screening African American men for prostate cancer warranted?

Regular readers of my blog know that I believe that the harms of prostate-specific antigen (PSA) screening for prostate cancer outweigh the benefits, if benefits exist at all. That isn't to say that I will not order the test in a man who understands the risks and expresses a clear preference to be screened. In a recent editorial in American Family Physician, I explained my approach to counseling patients about potential screening harms:

Many older men, especially those who have received PSA tests in the past, may be surprised to learn that screening is no longer routine. Primary care physicians should anticipate this possibility and be prepared to explain that more is now known about the outcomes of testing. Phrases that may be helpful to communicate changes in our understanding of the evidence include “the PSA test is now optional,” “this test has limitations and may not be for everyone,” and “there are some important downsides to being tested.” These strategies, combined with decision aids, should help our patients make informed choices that are consistent with their personal preferences on PSA screening.

One question that arises frequently at the hospital and clinic where I precept family medicine residents is: what about African-American men? Should we advise that they be screened because they have a higher prostate cancer incidence and mortality than other racial or ethnic groups? This question came up during the development of the U.S. Preventive Services Task Force's 2008 recommendations, which included this statement:

Older men, African-American men, and men with a family history of prostate cancer are at increased risk for diagnosis of and death from prostate cancer. Unfortunately, the previously described gaps in the evidence regarding potential benefits of screening also apply to these men.

The publication of the U.S. and European randomized trials of PSA-based screening, which ultimately caused the USPSTF to change its "I" (insufficient evidence) statement to a "D" (recommend against) in 2012, unfortunately did not do much to clarify benefits and harms of screening in men of African descent, who comprised only 4% of participants in the U.S. trial and an unknown (but probably low) percentage of those in the European trial. And even the subsequent negative findings of the Prostate Cancer Intervention Versus Observation Trial (PIVOT), whose participants were more than 30% African-American, didn't discourage authors in academic journals and prominent medical blogs from arguing that Black men need separate prostate cancer screening guidelines.

What troubles me about this position is that race is as much a social construct as it is a biological one. Much of the disparity in prostate-cancer mortality between African-American and Caucasians can be explained by lower access to and quality of care, rather than a genetic predisposition for more aggressive and/or lethal cancers. In contrast to national data, studies of equal-access healthcare systems in the U.S. such as the Veterans Health Administration and the Department of Defense found no differences in prostate cancer mortality between Black and White men.

In this context, the USPSTF recently published a thoughtful methods paper explaining their approach to developing recommendations for diverse populations. The research plan for their updated systematic review on prostate cancer screening included explicit questions about whether the effectiveness or harms of PSA-based screening or treatment approaches varied by subpopulations, including race. Such data may or may not be sufficient to permit the Task Force to assign a separate recommendation letter grade to screening in African-American men this time around (I suspect it will not), but it will hopefully result in more helpful guidance for primary care clinicians.

Here is what I currently tell African-American men over 50 who are considering the PSA test: "In general, this test is more likely to harm than to help. Your personal risk of having prostate cancer is higher than other men, which may make it more likely that you benefit from testing, but also increases the potential harms. So while the general statistics on PSA screening might not apply to you specifically, the decision to be screened still comes down to your personal preference."

Thursday, March 9, 2017

Prioritizing effective clinical preventive services: an update

In a widely cited 2003 study, Dr. Kimberly Yarnall and colleagues estimated that in order for a family physician to provide all U.S. Preventive Services Task Force-recommended services to a patient panel of 2500 with an age and sex distribution similar to that of the U.S. population, he or she would need to spend 7.4 hours per working day, leaving little time to address acute or chronic medical problems. Although the subsequent rise of the patient-centered medical home model has allowed physicians to share this work load with other primary care team members, it remains difficult to meet all preventive care needs. In 2006, the National Commission on Prevention Priorities (NCPP) ranked 25 preventive health services recommended by the USPSTF and the Advisory Commission on Immunization Practices (ACIP) based on clinically preventable burden (health impact) and cost-effectiveness. The three services that received the highest score were aspirin use to prevent cardiovascular disease (CVD), the childhood immunization series, and tobacco use screening and brief interventions in adults.

In the January/February Annals of Family Medicine, the NCPP published an updated ranking of effective clinical preventive services, using similar methods as in their 2006 study. The childhood immunization series and adult tobacco use screening and counseling remained the most highly prioritized services, joined by counseling to prevent initiation of tobacco use in children and adolescents, first recommended by the USPSTF in 2013. Although low-dose aspirin for primary prevention remained important, the more targeted 2016 USPSTF recommendation to discuss use with high-risk adults lowered the estimated population health impact of this service. In a recent editorial in American Family Physician, former USPSTF member Douglas Owens explained the rationale for focusing on persons 50 to 59 years of age with a 10% or greater 10-year CVD risk:

The decision to initiate aspirin should be based on a discussion of potential benefits and harms. ... Persons who value avoiding long-term medication use may benefit less from taking aspirin. Cardiovascular risk is also important: the higher a person's risk of CVD, the more potential benefit aspirin provides. The most favorable balance of benefits and harms occurs in persons who are at substantially elevated CVD risk but are not predisposed to bleeding complications. Finally, although older age increases the risk of cardiovascular events, it also increases the risk of bleeding complications.

Dr. Jennifer Middleton discussed the nuances of this recommendation statement, including aspirin's benefits for reducing colorectal cancer risk, in a previous post on the AFP Community Blog.

Finally, clinicians and patients should be aware that the Affordable Care Act (ACA) mandated that in addition to the USPSTF and ACIP, preventive services recommended by the Bright Futures guidelines and the Women's Preventive Services Initiative be fully covered by private insurance plans without cost-sharing. The methods of these groups differ significantly, and unlike the NCPP, none of them review cost-effectiveness. Although political uncertainty surrounding possible repeal of the ACA makes it unlikely that this process will change in the near future, a 2016 editorial in JAMA Internal Medicine proposed improving the consistency of the groups' evidence review methodologies and forming a separate advisory committee "to integrate economic considerations into the final selection of free preventive services." Or, perhaps the NCPP itself could take on that role?

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This post first appeared on the AFP Community Blog. Be sure to also check out the Feb. 15 AFP Podcast, which includes "The Prevention Priorities Game" (starting at 16:10).

Wednesday, March 1, 2017

Patients: steer clear of these six orthopedic procedures

After the American Academy of Orthopaedic Surgeons (AAOS) released its Choosing Wisely list, it was criticized for selecting items that are uncommonly used or have little effect on the income of its members. In an editorial in the New England Journal of Medicine, Dr. Nancy Morden and colleagues pointed out that the five services listed by this specialty group were particularly "low impact":

The American Academy of Orthopaedic Surgeons named use of an over-the-counter supplement [glucosamine and chondroitin] as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.

At the Lown Institute's 2015 Road to RightCare Conference, a group of maverick orthopedic surgeons identified five other procedures that, in contrast to the AAOS list, are frequently performed at great expense in the U.S. but provide little or no benefit to patients.

1) Vertebroplasty for spinal compression fractures - in two randomized controlled trials comparing vertebroplasty to a sham procedure, there were no differences in pain or quality of life between the intervention and control groups. Risks of vertebroplasty include causing compression fractures in adjacent vertebrae, dural tears, osteomyelitis, cement migration, and radiculopathies requiring subsequent surgery.

2) Rotator cuff repair for non-traumatic tears in older adults - A randomized trial comparing physical therapy, physical therapy plus acromioplasty, and physical therapy plus acromioplasty and rotator cuff repair found no differences between the control and surgery groups after one year. About 600,000 Americans undergo rotator cuff surgery every year.

3) Clavicle fracture plating in adolescents - In adolescents with clavicle fractures that were displaced and shortened, there were no differences between nonoperative management (a sling for the affected arm) and surgery in appearance, range of motion, or participation in sports activity two years after the injury. However, 1 in 4 adolescents who underwent surgery required re-operation for surgical complications.

4) Anterior cruciate ligament (ACL) reconstruction - In young, active adults with acute ACL tears, a randomized trial comparing early (within 10 weeks of the injury) ACL reconstructive surgery plus physical rehabilitation to rehabilitation plus optional delayed reconstruction up to 2 years after the injury found similar outcomes between the groups. 61 percent of the optional reconstruction group did not require surgery. More than 100,000 ACL reconstructions are performed in the U.S. each year.

5) Partial medial meniscectomy for adults with knee osteoarthritis and no mechanical symptoms - A randomized trial found no benefit of partial meniscectomy compared to sham surgery in adults with degenerative meniscal tears and no osteoarthritis. A systematic review of 7 trials came to the same conclusion. In adults with osteoarthritis, surgery plus physical therapy was not more effective than physical therapy alone. Arthroscopic partial meniscectomy is the most commonly performed orthopedic procedure in the U.S., with 700,000 operations annually.

Finally, a 2015 randomized trial in JAMA suggested that another procedure whose use is increasing worldwide provides no benefits.

6) Surgery for adults with displaced proximal humerus fractures - Patients who underwent fracture fixation or humeral head replacement within 3 weeks of sustaining a displaced fracture of the proximal humerus had no better outcomes than patients assigned to nonoperative management (sling immobilization) after 2 years.

What accounts for the continued popularity of ineffective orthopedic procedures? Excessive magnetic resonance imaging (MRI) plays a role; immediate MRI is rarely indicated for common musculoskeletal conditions, and may often provide deceptive or confusing results, such as identifying meniscal tears that are unlikely to be the cause of patients' chronic knee pain. Some primary care clinicians' lack of comfort with the orthopedic examination may lead to unnecessary referrals. Patients who perceive surgery to be a "quick fix" may not have the patience to stick with physical therapy and rehabilitation. And there is the inescapable reality that, necessary or not, these procedures pay well.

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This post initially appeared on Common Sense Family Doctor on March 20, 2015.

Wednesday, February 22, 2017

Advanced primary care vs (or is?) direct primary care

One of my most popular Twitter retweets this month highlighted a graphic from the Wall Street Journal showing that in 2014, middle-income households spent 25 percent more on health care than they did in 2007, but 6 to 18 percent less on other basic needs such as housing, transportation, food, and clothing. I commented: Too much of HC debate about "who pays"; not enough questioning "why does HC cost so much?"

One good answer is that lots of health "care" is worthless or harmful, but incentives baked into the U.S. health system push doctors to provide (and be paid handsomely for) it anyway. Shannon Brownlee first told this story in her book Overtreated (and revisited it in this recent review for The Lancet); Atul Gawande described unnecessary medical care as an "avalanche" in his New Yorker profile "Overkill"; and David Epstein called it an "epidemic" in his Atlantic article "When Evidence Says No, but Doctors Say Yes." The bottom line: instead of improving health, many medical interactions are merely opportunities for something bad to happen. (For a timely example, see this NPR article about the harms of screening for cardiac disease in teenage athletes.)

Doctors generally aren't paid to provide quality health care rather than more health care (quantity). A more catchy phrase for this idea among health policy wonks is "moving from volume to value." After more than a decade of trying, mostly unsuccessfully, to cut doctors' fees to compensate for steady increases in the volume of health care services, Congress passed legislation that empowered the Center for Medicare and Medicaid Services to create a quality payment program. Physicians can enroll in one of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

In December, the American Academy of Family Physicians published an 11-page position paper that proposed an APM called "Advanced Primary Care." My friend and fellow family physician Richard Young has been dissecting the nitty-gritty details of the proposal in a series of posts on his blog, here, here, and here. It's clear to me that some smart people at the AAFP invested a great deal of time and energy into its development, addressing thorny issues such as how to adjust for social risk factors that make even the best physicians' quality measures look bad and could, if not taken into account, have the unintended effect of reducing access to health care for those who need it the most. It's also extremely complicated, and I have no idea if it would improve quality or lower costs.

Family physician-turned-financial planner and Forbes blogger Carolyn McClanahan has been arguing that a simpler strategy for reducing the nation's health care bills that doesn't involve rationing care for the poor is to remove primary care services from health insurance entirely. This is a strategy that direct primary care advocates have championed; by eliminating administrative burdens and inflated charges for low-cost services, it results in unhurried in-person visits, more flexibility to provide care by phone or electronic communications, and truly personalized care. But McClanahan added a new twist: make basic primary care free to all by giving community health centers enough funding and capacity to provide services to every American who desires it. (Those who would still prefer to see a private family doctor could presumably pay a monthly fee to be part of a direct primary care practice.) Her plan is worth a long look: you can read an abridged version on Jacksonville.com or a more detailed proposal here.

Although it's been hard for me to see much upside to the Trump presidency, revisiting the Affordable Care Act doesn't need to be bad news. A Hillary Clinton presidency and a Republican-controlled Congress would have likely resulted in continued stalemate: no ACA repeal, but no forward progress in repairing its significant flaws, either. Instead, the political impetus to imagine something better than the health system status quo may galvanize positive change. Family medicine leaders can continue to tinker on the margins, developing iterative proposals for "advanced" primary care that won't make our specialty any more appealing to medical students than the 2004 Future of Family Medicine project or the 2013 Family Medicine for America's Health initiative did. Or they can choose to commit fully to a vision of a health system where everyone has a family doctor, that doctor doesn't change when health insurance changes, and "advanced" primary care means direct primary care.