Monday, December 28, 2020

Common Sense Family Doctor's 2020 Year in Review

With a total of 48 posts (this will be the 49th), this has been my most prolific year of blogging since 2017. Nearly a third of these were on or related to the COVID-19 pandemic and its public health consequences, but I wrote about many other topics, too. With a nod to the ongoing 12 days of Christmas, I've picked 12 posts to highlight here, one from each month.

January 15 - When a cancer diagnosis predicts future good health

For early prostate, breast (including ductal carcinoma in situ, which was considered separately), thyroid cancer, and melanoma, relative survival was not only better than disease-specific survival, but greater than 100%. In other words, patients with these particular early cancer types were more likely to survive than similar individuals without cancer.

A year's membership in a DPC practice can generally be had for about one month of Presidential candidate Andrew Yang's Freedom Dividend, making it accessible not only to the middle and upper classes, but to patients who are can't afford traditional primary care. Medical schools should prioritize exposing more students to this new primary care model for us to have any hope of attracting one-quarter of them into family medicine.

While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk [of death from breast cancer] than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years.

Social distancing, widespread testing, contact tracing, and vaccine development won't be enough to halt the pandemic if we leave millions of Americans behind; it's no wonder that Medicaid expansion has been proposed as a potent policy tool for mitigating the health and economic impact of COVID-19.

Whether it's the President of the United States repeatedly lying about the impact of COVID-19; the closing of essential hospitals in underserved minority or rural communities; or a modern-day epidemic of amputations in black Americans in Southern former slave states; these protests are an expression of deep-seated rage about an epidemic of inequality that men and women in power have long minimized, dismissed or ignored.

Just as COVID-19 has accelerated an overdue transition to providing more health care virtually, I hope that it will also inspire researchers to "study what was gained" from postponed or cancelled appointments with family doctors and surgeons. If the pandemic has a silver lining, this might be it.

For their "Best Hospitals for America" rankings, Lown created a Hospital Index that incorporated not only patient outcomes (mortality, safety, and satisfaction), but also civic leadership (community benefit, representativeness of patients compared to the surrounding community, and institutional salary distribution) and medical overuse.

Just as emergency medicine physicians are often justified at taking a more aggressive testing and treatment approach to a patient with chest pain than a family physician evaluating a patient in his or her office, it's arguable that the greater long-term risk of cardiovascular events in patients who see cardiologists warrant more intensive treatment of blood pressure than patients in primary care settings.

Although age and race inequalities largely explain America's uneven experience of COVID-19 to date, that is no assurance that it will stay that way. HIV/AIDS was a viral disease that only affected urban gay men and intravenous drug users - until it wasn't.

Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized.

I don't believe that prisons should be abolished, any more than I believe that police departments should be defunded. But if the U.S. is going to continue to pour hundreds of billions of dollars into incarceration every year, a large chunk of those dollars ought to be devoted to peacemaking - making the offender whole and less likely to offend again - rather than punishment.

State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

Thursday, December 24, 2020

My favorite public health and health care books of 2020

Christmas Eve may be a little late in the holiday season to be recommending books, but then again, e-books can be a great last-minute gift for procrastinators. One constant that has helped keep me sane during this tumultuous pandemic year has been always having a physical or virtual shelf of intriguing books to read next. As in previous years (see 2019, 2018, 2017, 2016, and 2015), this favorite books list is ordered alphabetically and includes a few that were new to me even though they were published before 2020.


1. Fallible: A Memoir of a Young Physician's Struggle with Mental Illness, by Kyle Bradford Jones

2. Heart: A History, by Sandeep Jauhar

3. Hidden Valley Road: Inside the Mind of an American Family, by Robert Kolker

4. Inside the FDA: The Business and Politics Behind the Drugs We Take and the Food We Eat, by Fran Hawthorne

5. Malignant: How Bad Policy and Bad Evidence Harm People with Cancer, by Vinay Prasad

6. The Long Fix: Solving America's Health Care Crisis with Strategies That Work For Everyone, by Vivian Lee

7. Together: The Healing Power of Human Connection in a Sometimes Lonely World, by Vivek Murthy

8. Upstream: The Quest to Solve Problems Before They Happen, by Dan Heath

9. When Death Becomes Life: Notes From A Transplant Surgeon, by Joshua Mezrich

10. When We Do Harm: A Doctor Confronts Medical Error, by Danielle Ofri

Saturday, December 19, 2020

New guideline for managing acute pain from musculoskeletal injuries

In a 2017 practice guideline based on a systematic review of noninvasive treatments, the American College of Physicians (ACP) recommended superficial heat, massage, acupuncture, and spinal manipulation as initial treatment options for patients with acute low back pain, in addition to a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant if desired. But is a similar approach effective for treating pain from acute musculoskeletal injuries not involving the lower back? To answer this question, the American Academy of Family Physicians (AAFP) joined the ACP in developing another practice guideline on management of acute pain from non-low back, musculoskeletal injuries in adults, a synopsis of which appeared in Practice Guidelines in the December 1 issue of American Family Physician. These are some key practice points from the guideline:

• Topical NSAIDs are the most effective intervention for acute musculoskeletal pain other than low back pain.

• Although oral NSAIDs and acetaminophen are effective for acute pain relief, combining them does not improve effectiveness.

• Although moderately effective for pain relief, opioids increase gastrointestinal and neurologic adverse effects and lead to long-term use in 6% of people treated.

• Acupressure and transcutaneous electrical nerve stimulation techniques are effective nonpharmacologic options for acute pain.

In an accompanying editorial, Dr. David O'Gurek and I, who represented the AAFP on the guideline committee, and Dr. Melanie Bird, AAFP Clinical and Health Policies Manager, discussed some of the guideline's highlights and limitations. A systematic review and network meta-analysis of randomized, controlled trials provided direct and indirect comparisons of various treatment options on outcomes that included pain relief and physical functioning, symptom relief, treatment satisfaction, and adverse events.

Topical NSAIDs improved all efficacy outcomes with minimal adverse effects, while oral NSAIDs and acetaminophen improved fewer outcomes and were more likely to cause adverse events. We suggested against using opioids, including tramadol, for acute musculoskeletal injury pain due to their poor adverse effect profile and the risk of prolonged use, ranging from 6% in low-risk to 27% in high-risk populations. We also noted that "equitable coverage and affordability of first-line treatments" are essential to reduce well-known racial and socioeconomic disparities in pain management; for example, though a topical NSAID is now available over-the-counter, it costs significantly more than oral NSAIDs and acetaminophen and may not be covered by health insurance plans.


This post first appeared on the AFP Community Blog.

Sunday, December 13, 2020

Long-term benefits of newborn metabolic screening

State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. A 2017 American Family Physician article reviewed various conditions that are targeted by newborn screening: amino acid disorders, fatty acid oxidation disorders, organic acid disorders, hemoglobinopathies, endocrine disorders, and miscellaneous diseases (including congenital hearing loss and critical congenital heart defects). With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

After tandem mass spectrometry made it possible to test for many conditions using a single blood sample, the federal Health Resources and Services Administration's Maternal and Child Health Bureau commissioned the American College of Medical Genetics (ACMG) to create a uniform list of conditions for newborn screening panels in 2005. However, the ACMG's recommended core panel of 29 conditions was criticized by the U.S. Preventive Services Task Force (USPSTF) for not taking an evidence-based approach. In a position paper, the USPSTF noted that the ability to detect a condition with high diagnostic accuracy was insufficient to include it in the panel:

A newborn screening program is not just a panel of screening tests. ... It is also parental education, follow-up, diagnosis, treatment and management, and program evaluation, and all of the various parts of the system must be in place and working well to realize the benefits of screening. ... Moreover, a newborn screening panel should be expanded only if the newborn screening program is fully prepared to make all the components of the complex system available for the new disorders. Expansion would be costly and might not be the best use of scarce health care resources, given the many other unmet child health needs.

Reinforcing the USPSTF's concerns, an analysis by the Centers for Disease Control and Prevention projected that if all 50 states expanded their newborn screening panels to align fully with the ACMG recommendations, "although such an expansion would have increased the number of children identified by 32% (from 4,370 to 6,439), these children would have had many rare disorders that require local or regional capacity to deliver expertise in screening, diagnosis, and management." A cross-sectional survey of Ontario primary care clinicians found that family physicians had limited knowledge of conditions identified by newborn screening tests, and many were not comfortable leading detailed discussions of abnormal results with parents or guardians.

The U.S. Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (SACHDNC) subsequently developed a more rigorous framework to evaluate conditions nominated as additions to the uniform screening panel, requiring an independent systematic evidence review of key questions based on an analytic framework similar to those used for USPSTF reviews. In a separate document, the SACHDNC outlined questions for newborn screening long-term follow-up data systems to answer to make sure that programs achieve their goals of improved outcomes for children and families.

An observational study published last month in Pediatrics reported the clinical outcomes of 306 individuals with inherited metabolic diseases identified by a university hospital laboratory performing Germany's newborn screening panel from 1999 to 2016. The German national panel is less extensive than the ACMG's, consisting of 2 endocrine and 12 inherited metabolic diseases, and the nearly 2 million newborns screened during the study period represented 15 percent of Germany's live births. 28 individuals presented with metabolic symptoms prior to newborn screening results being available; the rest were successfully enrolled in specialized metabolic/nutritional therapy while still asymptomatic. Although nearly 1 in 4 individuals eventually developed irreversible disease-specific clinical signs, 88% had normal cognitive outcomes, and more than 95% showed normal development and attended regular kindergarten and primary schools.


This post first appeared on the AFP Community Blog.

Sunday, December 6, 2020

To beat COVID-19, focus on vaccine distribution and building trust

Even as the numbers of persons hospitalized for and dying daily from COVID-19 are surpassing all-time highs, America is suffering from pandemic fatigue. Although millions have curtailed social gatherings or changed holiday travel plans, exhortations by public officials, school closings, and renewed stay-at-home orders don't seem to be slowing the spread of the virus in most states. In September, I warned that a vaccine against SARS-CoV-2 was unlikely to be a "magic bullet" for the pandemic unless it had very high efficacy and population uptake well beyond the historical standard set by annual influenza vaccines. As it turns out, though, the first two messenger RNA vaccines developed by Pfizer/BioNTech and Moderna/National Institutes of Health appear to be highly efficacious (despite these important caveats) in preventing mild to severe COVID-19 infections, and both could receive an emergency use authorization from the U.S. Food and Drug Administration to begin administering the first doses within the next two weeks. Historians of medicine will likely chronicle the "warp speed" development of these vaccines as an amazing achievement given the intense political and humanitarian pressures involved. But in terms of ending the pandemic, that may turn out to be the easy part.

Physicians like me have some sayings about other strongly recommended medical interventions. "The best screening test for colorectal cancer is the one that gets done." "The best blood pressure medication is the one the patient can afford to buy and is able to take every day." Conversely, I agree with the title of a recent Washington Post article by the director of the Yale Institute of Global Health: "Rapid development of a [coronavirus] vaccine won’t help much if people refuse to take it." On one hand, I don't place a great deal of stock in (and feel that there's been entirely too much journalistic hand-wringing about) surveys that found that sizeable percentages of Americans were reluctant or unwilling to receive a coronavirus vaccine; nearly all were polled when no viable vaccine candidate existed, and it's unsurprising and, frankly rational, that people would have reservations about being injected with a completely theoretical foreign substance.

Since it will be at least several months before enough vaccine doses are available for the entire population, the first wave will be administered to health care workers and residents of long-term care facilities, followed by essential workers and adults at high risk due to age or other medical conditions. I suspect that the vast majority of persons in these categories will choose to receive a vaccine. Personally, it will be a great relief to have protection against becoming severely ill due to an occupational exposure to COVID-19, and potentially (if the vaccine prevents asymptomatic viral transmission, which is uncertain but probable) protecting my spouse and children until they are eligible to receive the vaccine themselves.

The big question is: will other Americans who don't consider themselves to be at "high risk" for severe COVID-19, who have suspicions about the motivations of the federal government and/or pharmaceutical companies, or are concerned about the safety of the vaccine (whose long-term side effects are obviously not known, though it's hard to imagine that they could be worse than what thousands of COVID-19 "long-haulers" are already suffering) accept vaccination in high enough numbers to provide herd immunity to the population and halt the pandemic? And will our inefficient, fragmented public health and health care systems be up to the task of delivering a vaccine to everyone who wants it?

A Commonwealth Fund report found that states with higher COVID-19 case counts and larger percentages of Black, Latino, and American Indian populations (who have a disproportionately higher risk for hospitalization and death than Asian Americans and non-Hispanic Whites) have been less successful than other states in administering annual influenza and H1N1 vaccines, and nearly all states report historically lower vaccine uptake in the same racial and ethnic groups that are at highest risk. A modeling study in Health Affairs suggested that problems with implementation of a national vaccination program - how quickly vaccine doses can be manufactured and deployed, for example - could easily blunt the population benefits of a vaccine that is highly effective in individuals:

The benefits of a vaccine will decline substantially in the event of manufacturing or deployment delays, significant vaccine hesitancy, or greater epidemic severity. Our findings demonstrate the urgent need for health officials to invest greater financial resources and attention to vaccine production and distribution programs, to redouble efforts to promote public confidence in COVID-19 vaccines, and to encourage continued adherence to other mitigation approaches, even after a vaccine becomes available.

The stakes could not be higher, and there is no more time to waste. The vaccine scientists have done their job, and we owe them an enormous debt of gratitude. Now it's time for medical professionals and their allies (you, who are reading this blog post) to spread the word that being vaccinated against COVID-19 when your turn comes is not only good for your own health and personal safety, but benefits our communities, our states, and our country. There is no Democratic vaccine or Republican vaccine, and who you happened to vote for President no longer matters. We are all in the fight against this virus together, as we have always been. As Benjamin Franklin is thought to have said at the signing of America's Declaration of Independence, "We must all hang together, or, most assuredly, we shall all hang separately."

Saturday, November 21, 2020

Does COVID-19 harm mental health through stress, enforced isolation, or the virus itself?

Eight months ago, during the first wave of the pandemic, my American Family Physician editor colleague Dr. Jennifer Middleton discussed World Health Organization and Centers for Disease Control and Prevention (CDC)-recommended strategies and resources for optimizing mental health in health care workers, patients, and children. A CDC representative national survey conducted in late June found a strikingly high prevalence of symptoms of anxiety or depressive disorder (30.9%), trauma- and stressor-related disorder (26.3%) and new or increased substance use (13.3%). By comparison, a 2019 survey found that only 8.1% and 6.5% of people had symptoms of anxiety or depression, respectively. 1 in 10 respondents to this year's survey also reported having seriously considered suicide in the preceding 30 days, with disproportionately higher suicidality in younger adults (age 18-24 years), racial and ethnic minorities, essential workers, and unpaid adult caregivers.

In a recent commentary, Dr. Christine Moutier from the American Foundation for Suicide Prevention recommended several COVID-19-specific suicide prevention strategies that fuse clinical, health system, and policy interventions: reduce risk for people with mental illness or addiction; increase social connectedness; address risk at the moment of crisis; reduce access to lethal means; address COVID-19 increases in alcohol consumption and drug overdoses; mitigate financial strain; address domestic violence and unsafe environments; and prevent unsafe media and entertainment messaging on suicide.

The rise in anxiety, depression, stress, and suicidality coincided with the widespread conversion of office-based visits for behavioral and psychiatric conditions to telehealth, which may have restricted access to mental health care for existing and new patients. As three psychiatrists observed in a JAMA Viewpoint:

Patients with psychiatric disorders are particularly vulnerable to COVID-19 due to high rates of overweight, tobacco smoking, medical comorbidities, and poor self-care. ... Daily news of large-scale COVID-19–related disease and death in the community over months or years is almost certain to elevate psychiatric burden in the population. As such, the pattern of stress resembles that experienced by refugees or others exposed to chronic violence. ... A sustained increase in demand for psychiatric services may well exceed the existing capacity of the system over time and may last for years, depending on the course the pandemic takes.

Persons with prior psychiatric diagnoses may be at higher risk of death from COVID-19 infection. A cohort study of 1685 patients hospitalized with COVID-19 from February through April found that after controlling for demographics, medical comorbidities, and hospital location, patients with a psychiatric disorder were 1.5 times as likely to die as those with no psychiatric diagnosis. Citing a kinship network study that suggested that each COVID-19 death in the U.S. leaves nine bereaved close family members, some have suggested that primary care physicians screen relatives of persons who die from COVID-19 for symptoms of depression, prolonged grief, or post-traumatic stress disorder and provide evidence-based interventions if needed.

On the other hand, a diagnosis of COVID-19 may increase the risk for developing a mental health disorder. A retrospective cohort study that utilized electronic health record data from more than 62,000 U.S. patients between January 20 and August 1 found that COVID-19 survivors were more likely to have a first psychiatric diagnosis, a new psychiatric diagnosis, or a relapse of a previously stable diagnosis within 14 to 90 days than six other unrelated health events. However, this study design could not determine if these additional diagnoses were preexisting and unrecognized prior to COVID-19 infection or a direct consequence of the infection or medical interventions (including isolation at home or in the hospital).


This post first appeared on the AFP Community Blog.

Sunday, November 15, 2020

Incarceration, restorative justice and health

Of the barrage of discouraging pandemic statistics - the quarter of a million U.S. deaths to date, the 93 daily new cases per 100,000 residents and current 20+ percent test positivity rate in my adopted state of Utah - one of the most striking is that of the 14 persons who died from COVID-19 in Texas county jails from April to September, 11 were awaiting trial and had not been convicted of a crime. A recent report of COVID-19 deaths in Texas correctional institutions from the University of Texas at Austin found that jail deaths represented only 6 percent of the 231 overall deaths during incarceration (including prison staff). Those serving time for a criminal conviction were, clearly, not sentenced to death by suffocation from a deadly virus. Since Texas accounts for approximately 9 percent of the U.S. population, my conservative estimate is that at least 100 Americans, mostly persons of color, have already died from COVID-19 while detained in jails awaiting trials, unable to physically distance or otherwise protect themselves.

A few years ago, as a member of the American Academy of Family Physicians' Commission on the Health of the Public and Science, I co-authored a position paper that articulated a family medicine perspective on the negative effects of mass incarceration on the health of justice-involved persons, their families, and their communities. We found that in 2016, the U.S. corrections system supervised 6.6 million people (1 in every 50 residents) in jails, prisons, or on probation or parole - the highest incarceration rate in the world and a nearly fivefold increase since 1978. Given these figures, a basic understanding of the justice system has become essential not only for family physicians and internists, but also pediatricians, who are increasingly likely to encounter justice-involved youth. The "Patients, Populations, and Policy" course that I co-direct at Georgetown includes a mandatory screening of the documentary 13th, which argues that a loophole in the 13th Amendment to the U.S. Constitution, which abolished slavery and involuntary servitude for African Americans "except as a punishment for crime," enabled institutionalized racism in policing and criminal sentencing that persists to this day.

This background explains why many progressive Americans are not celebrating the recent election of Senator Kamala Harris, a former prosecutor, to the office of Vice President of the United States. As the current Vice President pointed out during their October 7 debate, during Harris's tenure as California Attorney General, Black persons were much more likely to be prosecuted for minor drug offenses and were disproportionately incarcerated compared to their share of the general population. In a New York Times Magazine article, former felon Reginald Betts reflected on his mixed feelings about prosecutors and mass incarceration. Betts, who was convicted of carjacking and armed robbery and imprisoned from age 16 to 24, was shocked to learn after his release that his mother had been raped at gunpoint just weeks after his arrest. Naturally, even though some of the men with whom he served time were guilty of similar offenses, Betts "thought he [the rapist] should spend the rest of his years staring at the pockmarked walls of prison cells that I knew so well."

Betts observed that most Americans who oppose mass incarceration today imagine that most of the prison population is serving time for nonviolent drug-related crimes. Not so: "You could release everyone from prison who currently has a drug offense and the United States would still outpace nearly every other country when it comes to incarceration." What, then, is the responsibility of progressive prosecutors who, like Vice President-elect Harris, desire to address inequities in the justice system that result not only from unjust policing, but penalties for the crimes themselves? Betts responded:

The prosecutor’s job, unlike the defense attorney’s or judge’s, is to do justice. What does that mean when you are asked by some to dole out retribution measured in years served, but blamed by others for the damage incarceration can do? The outrage at this country’s criminal-justice system is loud today, but it hasn’t led us to develop better ways of confronting my mother’s world from nearly a quarter-century ago: weekends visiting her son in a prison in Virginia; weekdays attending the trial of the man who sexually assaulted her.

Ideally, our criminal justice system should serve two purposes: punishment and rehabilitation. That three-quarters of persons released from state prisons in 2005 were arrested again within 5 years suggests that the system fails miserably at the latter, and if spending time behind bars (punishment) is supposed to deter criminals from committing crimes again, failing at the former as well. As Betts wrote:

It always returns to this for me — who should be in prison, and for how long? I know that American prisons do little to address violence. If anything, they exacerbate it. If my friends walk out of prison changed from the boys who walked in, it will be because they’ve fought with the system — with themselves and sometimes with the men around them — to be different. 

Through the mystery novels of the late Tony Hillerman, I am superficially familiar with the Navajo Nation's concept of "restorative justice", described in a 1994 New Mexico Law Review article by former Navajo Nation Chief Justice Robert Yazzie. Yazzie characterized traditional American justice as an "adversarial" process administered by strangers:

Law, in Anglo definitions and practice, is written rules which are enforced by authority figures. It is man-made. Its essence is power and force. The legislatures, courts, or administrative agencies who make the rules are made up of strangers to the actual problems or conflicts which prompted their development. When the rules are applied to people in conflict, other strangers stand in judgment and police and prisons serve to enforce those judgments.

In contrast, traditional Navajo peacemaking shuns a justice system based on "social control" in favor of pragmatic group problem-solving about "the means to live successfully." In a related article, Yazzie wrote:

Navajo peacemaking is about the effects of what happened. Who got hurt? What do they feel about it? What can be done to repair the harm? ... In Navajo peacemaking, offenders are brought in to a session involving the person accused of an offense and the person who suffered from it, along with the “tag-along” victims of the crime, namely the relatives of the accused and of the person hurt by the accused.  The sessions are moderated by a community leader called a “peacemaker.” The action is put on the table. People talk about what happened and how they feel about it. A harmful act is “something that gets in the way of living your life,” and Navajo peacemaking deals with such an act by identifying it, talking about it, and devising a plan to deal with it.

The recent execution of a Navajo man on federal death row for the carjacking-murder of two Navajos in 2001, despite the opposition of the Navajo Nation, highlighted the potential advantages of incorporating restorative justice into state and federal criminal justice systems. Although it's possible that the victims' loved ones gained some satisfaction from the execution (albeit 19 years after the murders), it's hard to argue that any harm was "repaired" or harmony restored by this second violent act. (Note: as a practicing Catholic, I believe that the death penalty is wrong regardless of the crime.) I don't believe that prisons should be abolished, any more than I believe that police departments should be defunded. But if the U.S. is going to continue to pour hundreds of billions of dollars into incarceration every year, a large chunk of those dollars ought to be devoted to peacemaking - making the offender whole and less likely to offend again - rather than punishment.

Sunday, November 8, 2020

Mobile heart monitoring: advantages and limitations

During the first wave of the pandemic, when hydroxychloroquine was still thought to be an effective treatment for hospitalized patients with COVID-19 (subsequent studies have shown otherwise), some U.S. hospitals used personal electrocardiogram (ECG) devices to monitor these patients for drug-induced QT interval prolongation to conserve personal protective equipment and telemetry monitors. Such devices were already being used by patients with known cardiac conditions to monitor their heart rhythms in out-of-office settings.

As I discussed in a previous post, wearable devices such as the Apple Watch are also being studied to detect atrial fibrillation in asymptomatic primary care patients. In a 2019 study of more than 400,000 U.S. Apple Watch wearers with no self-reported history of atrial fibrillation, about 1 in 200 individuals received an irregular pulse notification and were scheduled for a telemedicine visit with a clinician to confirm study eligibility and triage those with urgent symptoms to the emergency department. Participants without urgent symptoms were mailed an ECG patch to wear for up to 7 days and then mail back to the study center.

Of the 450 participants who returned an ECG patch, 34% were confirmed to have atrial fibrillation, with a higher diagnostic yield in persons age 65 years or older. Of the 86 patients whose watches generated irregular pulse notifications when they were wearing the ECG patch, the positive predictive value for atrial fibrillation was 84%. In a survey completed at 90 days by patients who received an irregular pulse notification, 28% reported being prescribed a new medication, 33% were referred to a specialist, and 36% were recommended to have additional testing.

In the November 1 issue of American Family Physician, Dr. Madhavi Singh and colleagues reviewed the diagnostic test features of KardiaMobile, a $99 single-lead device that connects wirelessly to a smartphone app to generate an ECG tracing with automated interpretation. In studies of patients with known or suspected arrhythmias, KardiaMobile had greater than 90% sensitivity and specificity for atrial fibrillation or atrial flutter compared to a standard 12-lead ECG. However, no studies have compared its accuracy with a Holter or event monitor, and effects on patient outcomes are uncertain, particularly in populations at low risk for arrhythmias. (In 2018, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for atrial fibrillation, which has several potential downsides.) The authors concluded (and I agree) that similar to the Apple Watch, "further studies are needed before KardiaMobile can be recommended for use in seemingly healthy patients."


This post first appeared on the AFP Community Blog.

Monday, October 26, 2020

Debating the pros and cons of Medicare for All

Although neither of the major party nominees for U.S. President in November support a "Medicare for All" style single-payer health insurance program, this issue emerged during the Democratic primary debates as one option for extending coverage to the uninsured and reducing health care administrative costs. Our recent Georgetown Health Policy Journal Club discussed two editorials in the October 1 issue of American Family Physician that offered contrasting answers to the question: "Would Medicare for All Be the Most Beneficial Health Care System for Family Physicians and Patients?"

In "Yes: Improved Medicare for All Would Rescue an American Health Care System in Crisis," Dr. Ed Weisbart argued that the COVID-19 pandemic exposed the shortcomings in an employer-based health insurance system with an patchwork public insurance safety net. He pointed out that 93% of U.S. primary care physicians accept Medicare, and Medicare enrollment has been associated with improvements in age-specific mortality relative to peer nations. In addition, Dr. Weisbart suggested that implementing an expanded version of Medicare with more comprehensive coverage for the entire population would lead to large administrative cost savings, reduce documentation burden, and potentially increase primary care physician satisfaction by eliminating the moral injury associated with being unable to help patients who cannot afford care.

In "No: Medicare for All Would Cause Chaos and Fail to Control Health Care Costs," Dr. Richard Young countered that "expansion of Medicare ... would not address the deeper problems in our health care system." At current payment rates, implementation of Medicare for All could cause substantial financial difficulties for hospitals. Absent new legislation to allow the Centers for Medicare and Medicaid Services (CMS) to negotiate drug prices and consider costs in coverage determinations, he pointed out, expanding Medicare would further inflate the already staggering U.S. health care bill. Dr. Young argued that regardless of their financing mechanisms, other countries with universal coverage have lower costs primarily because their citizens are willing to sacrifice - whether that means practicing within strict budget limits (e.g., fewer cancer screenings, more conservative prescribing of statins) or declining to cover some beneficial but very expensive therapies. Finally, he observed that

many of the things that frustrate family physicians about the current [U.S. health care] system originated with Medicare: the devaluation of primary care services; the relative overpayment for specialist care; the inability to bill for helping patients with more than two or three concerns in one visit; the requirement for face-to-face services (before the coronavirus disease 2019 exceptions took effect); the refusal to pay family physicians for clinic and hospital work on the same day; and the lack of incentives for full-scope family medicine.

A 2019 RAND study estimated that total national health expenditures under a Medicare for All plan would increase by only 1.8%, from $3.82 to $3.89 trillion annually. However, the federal government's direct share of health care spending would rise by 220%, from $1.1 to $3.5 trillion, an increase that would have represented more than half of 2019 federal expenditures and exceeded the $2 trillion plus CARES Act economic relief package passed earlier this year.

We also discussed less ambitious (and, possibly, more politically palatable) proposals for extending coverage that build on the framework of the Affordable Care Act, such as adding a publicly administered insurance option to increase competition (and lower premium costs) in the state health marketplaces. Former Vice President Biden has expressed support for "Medicare for More," extending Medicare eligibility to persons age 60 to 64 and possibly allowing younger adults without affordable insurance options to "buy in" to the program. The upcoming Presidential and Congressional elections will clearly play a critical role in determining if our country moves in that direction.


This post first appeared on The Health Policy Exchange.

Friday, October 23, 2020

Cancer survivorship: what is the family physician's role?

Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized. The National Cancer Institute estimated that in 2019, cancer survivors numbered 16.9 million, or about 5 percent of the U.S. population. During the past few years, American Family Physician has published clinical reviews of the American Cancer Society's guidelines on primary care for survivors of prostate cancer, colorectal cancer, and breast cancer. The American Academy of Family Physicians' policy on Cancer Care recommends that "the physician workforce, including family physicians, should be educated about the protocols for survivorship management."

A recent qualitative study published in the Annals of Family Medicine found that the reality on the ground is more complex than current guidelines and policy suggest. Dr. Benjamin Crabtree and colleagues recorded lengthy interviews with 38 clinicians in 14 U.S. primary care practices that had been previously recognized for workforce innovation by the Robert Wood Johnson Foundation. In these interviews, clinicians were "asked to describe how they viewed their role in cancer survivorship, decisions of when and where to refer patients, and knowledge about new primary care–friendly survivorship care guidelines."

Analysis of the interviews revealed a lack of consensus about the role of primary care in cancer survivorship. For example, several clinicians felt that follow-up cancer care was exclusively the responsibility of oncologists, but the majority expressed that providing this care fell within their purview. However, they reported obstacles ranging from inadequate knowledge / education to "an uneasy relationship with oncology" and a lack of clarity about when care could be transitioned from the oncologist to primary care.

Clinicians also disagreed about whether cancer survivors should be treated as a "distinct patient population" (requiring a systematic health system approach) or like any other patient with a chronic disease. The researchers theorized that these divergent views reflected an "identity crisis" about their care roles for these patients:

Several clinicians expressed mixed opinions, contradicted themselves, vacillated on their stance, or paused when asked about their/primary care’s role in cancer survivorship care. In fact, some clinicians struggled to talk about cancer survivorship at all in their interviews. ... These clinicians, with an identity based on delivering whole-person, comprehensive, coordinated care, appeared to hit a wall of identity confusion when confronted with a swiftly changing highly specialized knowledge base and a highly variable group of patients referred to as “cancer survivors.”

Options for resolving this identity crisis, according to the researchers, could involve developing new cancer-focused curricula for primary care residency programs and continuing medical education; constructing more well-defined management boundaries between primary care and oncology; and/or having their professional organizations "consider coproducing and translating new knowledge about care for cancer survivors that primary care clinicians can prioritize, personalize, and integrate to address patients’ needs and values within a shared decision-making framework." With the population of cancer survivors expected to increase by 30 percent over the next decade, clarifying the appropriate role of family physicians remains an urgent national need.


This post first appeared on the AFP Community Blog.

Thursday, October 15, 2020

Should scientific publications endorse political candidates?

The New England Journal of Medicine and Scientific American are widely considered to be the preeminent medical research and popular science journals in the world. Since their respective foundings in 1812 and 1845, their editorial staffs have had the opportunity to weigh in on at least 43 American Presidential elections. That they both refrained from doing so until this year is testimony to the traditional separation between science and politics, and the recognition that their subscriber bases are ideologically diverse enough that publicly supporting a major party candidate could lead to many cancelled subscriptions. Nonetheless, both journals recently decided that if there was ever a year to endorse a Presidential candidate, it was 2020.

Here's an excerpt from Scientific American's full-throated endorsement of former Vice President Joe Biden:

The evidence and the science show that Donald Trump has badly damaged the U.S. and its people—because he rejects evidence and science. The most devastating example is his dishonest and inept response to the COVID-19 pandemic, which cost more than 190,000 Americans their lives by the middle of September. He has also attacked environmental protections, medical care, and the researchers and public science agencies that help this country prepare for its greatest challenges. That is why we urge you to vote for Joe Biden, who is offering fact-based plans to protect our health, our economy and the environment. These and other proposals he has put forth can set the country back on course for a safer, more prosperous and more equitable future.

In contrast, the New England Journal of Medicine editors mentioned neither President Trump nor his Democratic challenger by name in "Dying In A Leadership Vacuum," but it's clear that they blame the federal government, and by extension its elected leader, for the United States' failure to control the pandemic:

Our current leaders have undercut trust in science and in government, causing damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies. ... Some deaths from Covid-19 were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a pandemic that has already killed more Americans than any conflict since World War II. Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions. But this election gives us the power to render judgment.

Setting aside financial consequences, the danger of a scientific journal, or a medical blog for that matter, taking a partisan stand is that at least some of its readers will perceive it as politically biased and either view all subsequent content through a lens of suspicion or abandon it completely. The handful of times I have endorsed or criticized a prominent politician on Common Sense Family Doctor, there has been a backlash in the form of angry comments and lost subscribers. Because my goal is to reach and influence as many people as possible, I carefully cultivate my reputation as a "straight shooter" on health care and other factors that affect personal and community health.

On the other hand, election results have huge heath consequences, especially in the midst of a pandemic that has already killed more than 216,000 Americans and hospitalized hundreds of thousands more. It's indisputable that the outcomes of our national response have been abysmal compared to that of high-income countries. A study in JAMA this week reported that since May 10, the United States has had more COVID-19 deaths per 100,000 persons than 18 comparable nations; since June 7, we've had nearly 8 times as many deaths per capita than Canada, 23 times as many as Switzerland, and 90 times as many as Finland.

I've written before about how the different ways in which the two major political parties view liberty - as "freedom to" versus "freedom from" - have shaped their perspectives on civil rights and health care legislation. Some people (mostly Democrats) who support more stringent federal and state public health measures to suppress the virus argue that these are necessary to protect the freedom of individuals (and particularly, vulnerable persons) to live their lives without contracting a crippling or potentially fatal disease for which effective therapies and vaccines aren't yet available. Others (mostly Republicans) who oppose these measures or feel that they've gone too far do so from a desire to be free from onerous (and often arbitrary) restrictions on private and public gatherings, schools, businesses, and mask mandates. The scope of this partisan divide is exaggerated by the media's obsessive coverage of behavioral outliers (e.g., mask-less partying college students) and polls that supposedly show mounting distrust in a COVID-19 vaccine that doesn't yet exist. The truth is, the vast majority of Americans want to mitigate the spread of the disease, and nonpartisan behavior change strategies can improve our adherence to protective behaviors regardless of our Presidential preferences.

Returning to the question that is the title of this post, my feeling is that a Presidential endorsement in a scientific journal isn't going to change anyone's mind, but could damage the publication's credibility with some portion of its readers. So you won't see American Family Physician endorsing a candidate in this or any future election as long as I'm a deputy editor, and Common Sense Family Doctor won't be jumping on a Presidential bandwagon, either. What you will get from me is the evidence above that America has thus far done a very poor job fighting the virus. How much of that failure is the fault of President Trump and his administration, and whether a Biden administration could do better, should play a role in who earns your vote, as it did mine.

Friday, October 9, 2020

Is physical therapy helpful for acute back pain with sciatica?

Although a referral to physical therapy is a standard part of my treatment plan for patients with subacute or chronic low back pain, there is little data on the effectiveness of physical therapy for acute back pain. A 2018 Family Physicians Inquiries Network (FPIN) Clinical Inquiry published in American Family Physician found that physical therapy begun within 24 hours of clinical presentation provides minimal improvements in pain, satisfaction, and mental health at one week that disappear by one month. Physical therapy started within 48 to 72 hours of presentation had no significant effects on pain or disability. A 2002 randomized trial found no differences in pain or activities of daily living in patients with acute low back pain with sciatica who were assigned to bed rest, physical therapy, or a control group. A 2008 study reported that physical therapy added to usual care from a general practitioner improved patients' global perceived effect but had no effects on pain or disability. Another FPIN Clinical Inquiry on treatments for sciatica concluded that nonsteroidal anti-inflammatory drugs, systemic steroids, topiramate, pregabalin, traction, and best rest were all ineffective and had potential adverse effects. The authors did not review physical therapy.

A single-blind randomized controlled trial published this week in the Annals of Internal Medicine compared early referral to physical therapy to usual care in 220 adults aged 18 to 60 years with acute back pain with sciatica for less than 90 days. Participants were recruited from primary care practices in two health care systems (Intermountain Healthcare and University of Utah). All participants received an evidence-based patient education booklet about low back pain; patients assigned to the intervention group were scheduled for 6 to 8 exercise and manual therapy sessions over 4 weeks with one of the study physical therapists. The primary outcome was change in the Oswestry Disability Index (OSW) score from baseline after 6 months.

Compared to the usual care group, intervention group participants reported greater improvements in OSW scores at 6 months (5.4 points) and 1 year (4.8 points). They also had lower back pain intensity and were more likely to report treatment success after 1 year (45% vs. 28% for usual care). However, health care use and missed workdays were not significantly different between groups.

Although this study's results appear to support early referral to physical therapy for patients with acute back pain with sciatica, they come with some caveats. The minimal clinically important difference on the OSW for this condition is 6 to 8 points, greater than the mean point estimates of between-group differences seen in this study. Also, since participants were not blinded to their group assignment and the usual care group did not receive sessions with a comparable contact time as the physical therapy sessions, it's possible that the modest improvement had less to do with the therapy than the caring attention that patients received from the therapists. The cost-effectiveness of referring every patient with this condition to a physical therapist is also uncertain.

Nonetheless, given the limited options currently available for patients with acute back pain with sciatica, it seems reasonable to refer to a physical therapist rather than prescribe ineffective drug therapy or order unnecessary and potentially harmful imaging studies.


This post first appeared on the AFP Community Blog.

Friday, October 2, 2020

The President of the United States has COVID-19

Two years ago, I collaborated with colleagues from Georgetown's School of Nursing & Health Studies on a peer-reviewed article explaining the complex interpretation and management of Zika virus test results in the Journal of the American Board of Family Medicine. After COVID-19 began spreading in the United States this spring, our team reunited virtually and added a fifth collaborator (a 4th year medical student in Georgetown's Population Health Scholar Track) to outline a practical approach to the interpretation of COVID-19 test results in clinical settings. This week, JABFM published our new paper online ahead of print in its COVID-19 subject collection.

The paper includes three clinical scenarios that illustrate the application of testing principles to hypothetical persons with a low, moderate, and high pretest probability of having COVID-19, respectively. The manuscript we initially submitted to the journal included the following scenario:

Scenario 3 – High pretest probability (RT-PCR)

A 28-year-old female White House staffer with unremarkable past medical history spent two hours meeting in person with another staffer who was diagnosed the next day with COVID-19. Five days later, she developed a temperature of 101.5 degrees Fahrenheit, a nonproductive cough, and loss of taste and smell. A rapid molecular SARS-CoV-2 test is negative. She is relieved at the test result because she will be meeting with the President tomorrow.

Let’s say that her pretest probability was 80%, given her direct contact with an individual who tested positive and development of classic COVID-19 symptoms. As she is symptomatic, the timing of testing with RT-PCR is appropriate. Suppose her test has a sensitivity of 90% and specificity of 95%. The predictive value for a positive test result is 98.6% and a negative test result is 70.4%. There is a 70% chance the staffer with a negative result actually does have SARS-CoV2 infection. Suppose that she was given a test with lower sensitivity of 80%. While the positive predictive value would still be high at 98.5%, the negative predictive value would drop significantly to 54.3%. In either case, a negative test result does not rule out COVID-19. In other words, a negative molecular test result in an individual with high clinical suspicion or high pretest probability for COVID-19 should be interpreted with caution, especially when tests have low sensitivity. Despite testing negative, this individual should self-isolate for 10 days.

One of the peer reviewers asked us to rewrite this scenario in our revision because he or she felt that using a White House staffer as an example was "gratuitous," "unnecessarily provocative," and "introduces politics into discussion that we need to strive to remain apolitical." We decided to change the patient in the scenario to a college student with a fever who had recently been in close contact with a resident in her dormitory who had tested positive for COVID-19. We in no way intended for it to be prophetic, even though White House senior counselor Hope Hicks, the presumed source for the President's and First Lady Melania Trump's recently diagnosed infections, is 31 years old and tested positive after experiencing mild flulike symptoms on a return flight from a campaign rally on Wednesday evening.

News accounts thus far indicate that White House medical staff have followed CDC guidance since Ms. Hicks's diagnosis, immediately placing the President and First Lady in quarantine since they had been exposed and in isolation now that they have tested positive. They will need to self-isolate for at least 10 days or, should either develop symptoms, 24 hours after fever resolves, whatever is later. Setting aside my personal politics and the upcoming Presidential election, I wish them both a speedy and uneventful recovery. As for the rest of us: if the most powerful man in the world, who has hundreds of highly skilled protective and medical personnel working around the clock to keep him physically safe and in good health, can contract COVID-19, so can you. Wash your hands. Keep your distance. And most importantly, wear a mask.

Friday, September 25, 2020

Coronavirus vaccine is unlikely to be a "magic bullet" that ends the pandemic

Last week, federal health officials announced an ambitious plan to begin free distribution of a vaccine against SARS-CoV-2 within 24 hours of its approval or emergency authorization from the U.S. Food and Drug Administration (FDA). That an efficacious vaccine could, remarkably, become available less than one year after the isolation of the virus that causes COVID-19 is due in part to a public-private program to accelerate vaccine, diagnostic test, and therapy development led by the U.S. Departments of Defense and Health and Human Services known as "Operation Warp Speed." In a New England Journal of Medicine commentary, Drs. Moncef Slaui, Shannon Greene, and Janet Woodcock reviewed the progress of Operation Warp Speed on multiple fronts, including the most promising candidate vaccines in phase 2 and 3 clinical trials. Ultimately, though, the impact of any vaccine on the course of the pandemic in the U.S. and abroad will depend not only on how protective it is against infection and disease transmission, but how the allocation of initially limited supplies is prioritized (e.g., health care and essential workers, vulnerable groups) and what proportion of the population agrees to receive it in the absence of a requirement to do so.

A simulation study in the American Journal of Preventive Medicine estimated the efficacy and percent population coverage that a coronavirus vaccine would need to extinguish the epidemic in the absence of other public health measures such as social distancing and wearing face coverings - in other words, what it would take for a vaccine to allow life to "go back to normal." The effects of a vaccine on productivity losses, hospitalizations, medical costs, and deaths vary depending on what percentage of the population has already been exposed to SARS-CoV-2; one seroprevalence survey from late March to mid-May found a range from 1% to 7% at 10 sites in the U.S., but these figures are likely to be higher four or more months later. To extinguish the epidemic after 5% of the population has been exposed, for example, the AJPM researchers calculated that a vaccine would need to have at least 80% efficacy if administered to 75% of the population.

Unfortunately, expecting any of the coronavirus vaccines in development to have 80% efficacy is unrealistic.  By comparison, the Centers for Disease Control and Prevention (CDC) estimated that the 2019-20 influenza vaccine was only 45% effective, consistent with the 40-60% range in previous years when the available vaccines were antigenically matched to circulating influenza viruses. The highest influenza vaccine coverage was during the 2018-19 season, when 63% of children (state range, 46%-81%) and 45% of adults (state range, 34%-56%) received the vaccine. Although some may be more willing to be vaccinated against SARS-CoV-2 than influenza due to the former's greater morbidity and mortality, influenza vaccine also has a long safety track record that a coronavirus vaccine would not.

It is possible that public health measures in place to slow the spread of COVID-19 will substantially reduce the impact of influenza during the 2020-21 season. A CDC surveillance report showed that U.S. cases of laboratory-confirmed influenza fell sharply after the national COVID-19 emergency declaration on March 1, reflecting not only the natural waning of the flu season but also mitigation interventions implemented by states around this time. In the Southern Hemisphere nations of Australia, Chile, and South Africa, where influenza activity normally peaks in June or July, COVID-19 mitigation was associated with a near-complete suppression of influenza circulation.

For family physicians, preparing for flu season during the COVID-19 pandemic, with a coronavirus vaccine potentially around the corner, means adapting to many uncertainties. What hasn't changed from previous years is that the CDC's Advisory Committee on Immunization Practices continues to recommend influenza vaccination for all people six months and older who do not have contraindications, ideally by the end of October. Whenever it arrives, the coronavirus vaccine is unlikely to be a "magic bullet" that ends the pandemic on its own. So it's critical that clinicians all continue to echo the message about cloth face coverings that CDC Director Robert Redfield, MD delivered at a recent Senate hearing: "These face masks are the most important, powerful public health tool we have" for controlling the pandemic.


The post first appeared on the AFP Community Blog.

Sunday, September 20, 2020

How inequality explains America's uneven experience of the coronavirus

Over the past few weeks, as the number of reported U.S. deaths from COVID-19 approached 200,000, I have puzzled over why the fewer than 3,000 lives initially lost in the terrorist attacks of September 11, 2001 united our country, but the far higher toll of COVID-19 (at one point over the summer, more than 2,000 were dying each day) has only seemed to divide us. One reason is obvious: after 9/11 we quickly identified a clear villain in Al-Qaeda, while - despite attempts to assign responsibility to the Chinese government for its early inaction - rallying Americans against an unthinking viral enemy is more challenging. Another reason is that President Donald Trump is not President George W. Bush. But there's a third reason, too: everyone I know seems to know someone (or know someone who knows someone) who died in the 9/11 attacks. The victims include one of my high school classmates who was working at the Pentagon and a physician who worked at the hospital where I was a family medicine resident at that time. Statistically, it ought to be 67 times as likely that I would know someone who died from COVID-19, but if I wasn't a doctor, that wouldn't be true. (In my DC practice, several patients were hospitalized for in the spring and summer, and the husband of one of my patients died.)

How can that be? It got me thinking about the spectrum of people who have died from COVID-19 compared to the immediate casualties of 9/11. Although one might assume that workers in the Twin Towers, the Pentagon, and United Airlines Flight 93 would tilt white and upper-class, victims included not only stockbrokers and investment bankers but office assistants, cafeteria workers, maintenance workers, and janitors - people from all walks of life. In comparison, about half of those who died from COVID-19 in the U.S. were residents or employees of nursing homes. Of the remainder, Black, Hispanic, and American Indian / Alaska Native persons are  far more likely to have been affected; according to data from the CDC, a member of those groups is 3 times as likely to have been infected, 5 times as likely to have been hospitalized, and up to twice as likely to have died from COVID-19. So if your immediate social circle includes few people over 65 or people of color, there's a reasonable chance that you don't know anyone who's become severely ill or died from the infection.

For the past several years, one of my Georgetown colleagues has shown this map in the first lecture of my medical school course "Patients, Populations and Policy." The brightly colored lines trace the paths of Washington, DC Metro lines; the numbers are life expectancy at birth in years. At first glance, the take home point might appear to be that people live longer in the suburbs than in the inner city. But that's not quite right, since life expectancy east of DC, in Maryland's Prince Georges County, is 78 years, nearly the same as life expectancy of someone living near DC's Metro Center, where three of the subway lines come together. What's different about PG County compared to neighboring Montgomery County and Fairfax and Arlington Counties in suburban northern Virginia? PG County is 63% African American, while the corresponding percentages for DC, Montgomery, Fairfax, and Arlington are 47%, 20%, 11%, and 10%.

As stark as the disparity in longevity appears in this map from 2013, it has actually worsened since then. A recent analysis in the scientific journal Nature found that a non-Hispanic White male resident of DC in 2016 had a life expectancy of 86 years, while a non-Hispanic Black male could expect to live to 68. Among female DC residents, the gap was a smaller but still startling 12 years (89 vs. 77). Deconstructing these life expectancy gaps, the researchers found that heart disease, cancer, and homicide accounted for about half of the gap among men, while heart disease, cancer, and unintentional injuries accounted for more than half of the gap among women. Some of the widening gap is no doubt related to gentrification, residential segregation, and migration of higher-income Black persons from DC to PG County (where the COVID-19 death rate has actually been higher than that in DC itself). Disparities in overall health have thus far been closely tied to COVID-19's impact: deaths in the DC's primarily White and Asian populated Wards have been much lower than those in Wards with larger numbers of Black and Hispanic residents.

A note of caution: although age and race inequalities largely explain America's uneven experience of COVID-19 to date, that is no assurance that it will stay that way. HIV/AIDS was a viral disease that only affected urban gay men and intravenous drug users - until it wasn't. Consider Utah, the youngest state in the nation, where 4 out of 5 residents are White, which has largely been spared from COVID-19 compared to older and more diverse states such as California, Florida, and New York. After averaging 300-400 cases per day during late summer, the state's case count has surged above 1000 for each of the past two days, and though much of this increase is occurring in young adults (age 18-39), hospitalizations are starting to rise, too. As far as this virus is concerned, anyone sick enough to require hospitalization is sick enough to die. This health crisis remains as urgent today as it was in early March, and our best tools remain those of public health, not medicine. Just as America united against Al-Qaeda after 9/11, a unified national response to the coronavirus, which has thus far been sorely lacking, is desperately needed.

Wednesday, September 16, 2020

Preparticipation physical exam and return to sports during the COVID-19 pandemic

For primary care practices that care for children, the preparticipation physical exam (PPE) is an annual rite. My residency program usually sets aside two full days in late summer where the residents and attending physicians do nothing but "sports physicals" in order to meet the demand for these exams from prospective high school athletes. Although the utility and effectiveness of this traditional evaluation has long been debated - a 2019 American Family Physician article on Right Care for Children included the PPE in its list of overused interventions - many clinicians also use the time to address non-sport related issues, making the visit "a potential preventive care entry point and an opportunity to provide routine immunizations, screen for other conditions, and provide anticipatory guidance." Last year, the American Academy of Family Physicians, the American Academy of Pediatrics, and several sports medical societies published the 5th edition of the Preparticipation Physical Evaluation monograph, which was summarized in the June 1 issue of AFP.

The COVID-19 pandemic closed schools and cancelled youth sports nationwide beginning in early March. As schools are now reopening in virtual, in-person, and hybrid models, some students are also returning to competitive sports. To address the medical needs of these athletes, the American Medical Society for Sports Medicine (AMSSM) recently released Interim Guidance on the Preparticipation Physical Exam for Athletes "to provide clinicians with a clinical framework to return athletes of all levels to training and competition during the pandemic."

In addition to the physical risks inherent in playing a sport, student athletes now must also be concerned about minimizing their risk of contracting SARS-CoV-2 where maintaining physical distancing is not possible. The AMSSM notes that unlike professional teams, high school and most college teams will not have the resources to perform testing, contact training, and quarantine. It advises discussing COVID-19 risks in detail with the patient and family at the time of the PPE, and considering factors "such as the disease burden in the community, the overall health of the athlete, the living environment, [and] each athlete's network of friends and family members who have have comorbid conditions" in the decision to play.

Athletes who have apparently recovered from COVID-19 "may have silent clinical pathology in any organ, including the heart," and consequently "should be evaluated in their medical home prior to resuming physical activity and organized sports." Table 2 in the guidance document (p. 27) outlines the recommended cardiopulmonary evaluation in athletes with prior COVID-19 infection, depending on the specific clinical scenario.

The AMSSM also provides guidance on specific conditions that may pose an increased risk for severe COVID-19, including pregnancy, diabetes, hypertension, asthma, and severe obesity. Although athletes with sickle cell trait are not at higher risk for adverse outcomes in general, they may have an increased risk of hypercoagulability complications for several months after recovery.


This post first appeared on the AFP Community Blog.

Friday, September 4, 2020

Maryland's Primary Care Program: incremental progress or breakthrough?

Much has changed in the past six years since our last Health Policy Journal Club at Georgetown. Our residency, formerly a collaboration with Providence Hospital, is now known as the Medstar Health/Georgetown-Washington Hospital Center Family Medicine Residency Program. I stepped down as director of the Robert L. Phillips, Jr. Health Policy Fellowship three years ago, though I still enjoy working alongside these talented family physicians in clinic, such as Dr. Brian Antono, who recently blogged about his fellowship experiences for Harvard Medical School's Center for Primary Care. And this academic year I am not only working remotely due to COVID-19, I am more than 2,000 miles off campus as a visiting professor at the University of Utah in Salt Lake City.

What hasn't changed is that our family medicine residents remain excited about health policy and advocacy. Since their continuity clinic continues to be located in Maryland, we decided that a great topic to revive this series of seminars was the Maryland Primary Care Program (MDPCP), which was recently featured in a Milbank Memorial Fund Issue Brief.

MDPCP is a multi-payer "advanced primary care" program modeled after previous patient-centered medical home projects such as the Center for Medicare and Medicaid Innovation's (CMMI) Comprehensive Primary Care initiative. CMMI partnered with Maryland's Department of Health to launch MDPCP last year with Medicare as the first participating payer. (CareFirst Blue Cross Blue Shield joined the program in 2020.) With 476 participating primary care practices, MDPCP provides prospective, non-visit based payments known as "care management fees" and operational support from a program management office and Care Transformation Organizations (CTO). According to MedChi, the average practice received $176,000 in care management fees in 2019.

Interestingly, Medstar not only participates through its network of Medstar Medical Group practices, but is also a CTO serving Medstar and non-Medstar practices throughout the state. MDPCP practices must implement "data-driven, risk-stratified care management," integrate behavioral health services, screen patients for social needs, convene a patient advisory council, and use health information technology for continuous quality improvement.

We spent some time discussing one unique aspect of MDPCP, a tool to reduce avoidable health services developed by the University of Maryland's Hilltop Institute. This electronic tool uses artificial intelligence to sift through patients' demographics, claims, and other data to produce a list of those with the greatest likelihood of an emergency department visit or hospitalization, theoretically allowing primary care physicians to intervene to prevent the event and its associated medical expenses. However, it wasn't clear to us how easy it would be to apply this information, given that we usually need to prioritize patients on the schedule for that day.

Another feature of the program allows MDPCP practices to identify "high-volume, high-cost specialists" in order to "focus attention on the relative costs between specialists and to have providers engage specialists in conversations and cooperative agreements about creating value." First, though it may be helpful to know which subspecialists are more likely to prescribe (possibly inappropriate) expensive tests or procedures, the tool does not measure excellence in other areas, such as patient satisfaction and quality of communication with primary care physicians. Also, patients may not have a choice of specialists, depending on the insurer's network. Finally, it seems awkward and unrealistic for a family doctor to tell a specialist that his or her practice style is too aggressive, even if there's good data to back it up.

MDPCP promises to narrow the primary care-subspecialist reimbursement gap and provide opportunities to improve patient care in the short term. However, expecting primary care practices to bend the health care cost curve on their own, even with additional funding and support, may backfire in the long run. Whether MDPCP represents incremental progress in primary care, or a genuine breakthrough, remains to be seen.


This post first appeared on The Health Policy Exchange.

Saturday, August 22, 2020

A foolish consistency: topical NSAIDs for acute pain and lung cancer screening

I confess that I don't recall having read Ralph Waldo Emerson's essay "Self-Reliance," which contains the quotation: "A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines." Instead, this sentence permanently etched itself into my mind after watching the 1998 romantic comedy "Next Stop Wonderland," which remains my favorite movie set in Boston. And it feels more applicable today than ever, as health officials from Dr. Anthony Fauci to Surgeon General Jerome Adams have been unfairly pilloried for changing their early positions on the threat that COVID-19 posed to Americans and the need to wear face coverings in public. In both cases, compelling new data convinced them to change their minds; rather than adhering to "a foolish consistency," they adapted their public statements to reflect current scientific understanding of the virus and how it is transmitted from person to person.

In the past week, I've done a couple of about-faces on major medical topics in the face of new evidence. A panel for which I represented the American Academy of Family Physicians published a clinical practice guideline that recommends topical non-steroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for adults with acute pain from musculoskeletal injuries (strains, sprains, and nonoperative fractures) not involving the low back. (A previous guideline covered what to do for patients with acute or chronic low back pain.) I was surprised when the systematic review and meta-analysis we commissioned for this guideline showed that topical NSAIDs were as effective as oral NSAIDs for acute pain; I previously had only prescribed topical NSAIDs for patients with chronic osteoarthritis. In February, in approving the the first topical NSAID for over-the-counter use, the U.S. Food and Drug Administration actually stated that it "is not for immediate relief" and "has not been shown to work for strains, sprains, bruises or sports injuries." That was a true statement at the time, but our understanding of the science has evolved since then. Although cost will be an obstacle for some patients - topical NSAIDs are substantially more expensive than oral NSAIDs - there is now good evidence to prefer the topical versions, which have fewer adverse effects, for acute musculoskeletal pain when feasible.

On a different subject, I announced in a Medscape commentary that "I've Changed My Mind on Lung Cancer Screening." I acknowledge that I am the same Dr. Kenny Lin who nearly a decade ago posted "4 Reasons Not to Be Screened for Lung Cancer" on my now-defunct U.S. News and World Report "Healthcare Headaches" blog. I don't disavow what I wrote previously; it's still important to consider the potential harms I mentioned in 2011 in any conversation with a patient eligible for lung cancer screening (according to the USPSTF's 2020 draft recommendations, adults age 50 to 80 years in good health who have at least a 20 pack-year smoking history and currently smoke or have quit in the past 15 years), and some patients may choose not to be screened, just as some patients decline mammograms or screening tests for colorectal cancer. Given the current evidence that overall benefits of lung cancer screening outweigh the harms, I will recommend this screening test to my patients at the same time I urge them to quit smoking.