Tuesday, April 28, 2020

Mitigating the effects of widespread school closures

Excepting a few countries like Denmark that have managed to flatten their infection curve, primary and secondary schools around the world have now been closed for a month or more due to the public health imperative to slow the spread of COVID-19 through physical distancing. Parents and guardians, many of whom have lost jobs or recently transitioned to telework themselves, have struggled to keep track of and connect their children with online educational activities designed to replace in-person learning. I know - I'm one of those parents.

Unfortunately, evidence suggests that distance learning, no matter how carefully designed, does not fully replace in-person instruction. A 2016 report from the National Alliance of Public Charter Schools found that students who attended full-time virtual public charter schools had consistently lower engagement, academic gains, and performance than those in traditional public schools, regardless of demographics. Worse, a considerable proportion of U.S. students have not participated in online learning due to not having personal computers or home Internet access.

Extrapolating from studies of summer learning loss, the educational nonprofit Northwest Evaluation Association recently projected that relative to a typical academic year, students returning to school this fall may only retain 70 percent of reading gains and 50 percent or less of math gains. To make up for these losses, some school districts are planning to extend school into the summer, shrink their curricula, or repeat some of last year's lessions next year. Another controversial idea for high-poverty schools is having all students repeat their current grade, given the potential for further interruptions due to a second or third wave of COVID-19 in the fall.

Prior to COVID-19, chronic absenteeism (defined as missing at least 10 percent of the academic year, or about 18 days) already affected about 14% of American students from kindergarten through 12th grade. According to an American Family Physician article on school absenteeism, it not only has negative effects on academic performance and graduation rates, but also worsens future social functioning, health status, and life expectancy. Reasons for absenteeism vary from chronic or serious illness (including mental illness) to academic challenges, parenting problems, bullying and victimization, and other social stressors such as food insecurity and homelessness. Family physicians and pediatricians can help by performing an assessment of students with frequent absences and referring students and families to one or more appropriate interventions.


This post first appeared on the AFP Community Blog.

Tuesday, April 21, 2020

Don't miss these important prostate and lung cancer screening studies

In a time when the most common cause of death in older Americans is COVID-19, it seems nearly old-fashioned to write about screening for prostate and lung cancers, which, respectively, account for a small proportion of overall deaths in men (prostate) and only in smokers rivals mortality from heart disease (lung). But while the pandemic has riveted media attention on COVID-19 studies of questionable value, including non-peer reviewed preprints and uncontrolled case series, I think it's still important to highlight two notable recent publications on pitfalls of cancer screening.

I generally advise my average-risk patients not to have prostate cancer screening. Even viewing the evidence in the most optimistic light, few men are helped and many more are harmed. Notably, for this linked graphic the U.S. Preventive Services Task Force used the prostate cancer mortality risk reduction estimated in the European screening trial, the only one of three major PSA screening trials (the others were conducted in the U.S. and United Kingdom) to show any benefit whatsoever. And, as I explained in an earlier blog post, relying on observational trends in prostate cancer mortality to deduce benefits from screening is fraught with problems.

In a new analysis in the New England Journal of Medicine, Drs. Gil Welch and Peter Albertsen dive deeper into the prostate cancer mortality data and its implications for screening. They propose an explanation for a trend that I had always found puzzling: before starting to decline in the early 1990s (which some experts attribute to the effect of screening, but Welch and Albertsen argue convincingly must also be the result of improved treatment), mortality rose between 1970 and 1990 by more than 30 percent. This earlier mortality increase likely resulted from "sticky diagnosis bias," which occurred because transuretral resections of the prostate (TURP) procedures were widely used to treat benign prostatic hyperplasia (BPH) in older men, leading to many more incidental diagnoses (or overdiagnoses) of prostate cancer that ended up on death certificates. Welch and Albertsen go on to explain why "decreasing prostate cancer mortality may be a misleading metric in evaluating PSA screening":

Screening may more easily change the distribution of causes of death (trading off one cause for another) than extend life (as implied by promises to “save lives”). This issue is particularly relevant to PSA screening, since the median age at death due to prostate cancer is so high — 80 years (as compared with 72 for lung cancer and 68 for breast cancer). For the elderly, the combination of a high burden of competing risks for death and high rates of intervention-related complications conspires to limit any reduction in all-cause mortality offered by screening.

Of course, length of life is not the only relevant outcome; quality of life is equally important. If screening helped avert the pain that can be associated with metastatic disease, that would change the calculus, but it is not clear that it often does. Furthermore, the quality-of-life question has two sides. Prostate cancer treatment itself results in substantial morbidity: surgery and radiation can produce impotence and bowel and bladder problems; antiandrogen therapy leads to hot flashes, decreased stamina, and metabolic syndrome. Which group of men — the treated or the untreated — feels a bigger effect on quality of life can be debated.

From a statistical perspective, screening for lung cancer has always held more promise than screening for prostate cancer, since many more people (men and women) die prematurely from the former. Based on consistent results from several randomized trials, the medical consensus is that low-dose CT screening in carefully selected older smokers (or former smokers) reduces lung cancer mortality, and, possibly, all-cause mortality. However, as I've argued in the past, the potential harms of LDCT make it essential that clinicians discuss the pros and cons of screening with patients first, rather than universally recommending it.

A study in JAMA Internal Medicine assessed the informational content of 162 lung cancer screening program websites, half at academic medical centers and half at community medical centers. The authors found that 98 percent of web sites described potential benefits, but only 48 percent described potential harms, with community centers being even less likely (40 percent) to mention any harms. Overdiagnosis, which is arguably the most substantial harm since it usually leads to unnecessary invasive treatment, was mentioned by only 14% of academic centers and none of the community centers. Granted, going to a website is only the first step toward actually being screened for lung cancer, but it's discouraging that this content is so unbalanced.

On the Lown Institute blog,  Judith Garber pointed out one reason for the "big benefit, little or no harm" messages that these websites send:

It is important to acknowledge the profit motive behind screening. If we reimbursed hospitals not for the volume of procedures done, but the outcomes for patients, we would likely a much greater effort to target individuals who would most benefit from screening, rather than hospitals trying to persuade as many people as possible to get screened.

Thursday, April 9, 2020

Learning health policy during a pandemic

Last week marked my first major foray into virtual teaching. At Georgetown, the first-year medical student class was told to stay home after Spring Break in order to slow the spread of COVID-19 in Washington, DC and its suburbs. The week of teaching health policy went about as well as I could have expected - my home wireless network held up, no one Zoom bombed any lectures or large group activities, I figured out how to use Panopto, and with fewer distractions than during a normal year, few students missed learning sessions. I also updated my podcast from last year, recording a new conclusion to the episode (embedded below) on health care reforms since the Affordable Care Act.

We are living in unprecedented times, with our health care system under enormous stress from the COVID-19 pandemic and little relief in sight. At this time last year, I predicted that incremental health care reforms would be the most likely outcome of the upcoming Presidential and Congressional elections, regardless of who won. But the evolving U.S. response to the novel coronavirus has exposed glaring deficiencies in our national preparedness, as well as the organization of the health care workforce and the usual way we practice medicine. It’s forced us to re-examine questions such as: how much health care really needs to be provided in person? Does our current physician-centered payment system discourage developing innovative models of care? And perhaps most importantly, in the face of a highly contagious disease, is excluding 25 or more million uninsured persons from the health care system no longer justifiable, if it ever was?

As the COVID-19 curve begins to show signs of flattening in New York and New Jersey after a staggering death toll, the pandemic continues to expand rapidly in Illinois, Michigan and Louisiana. And public health observers are starting to realize that this novel coronavirus does, indeed, discriminate, hitting majority-minority communities much harder than others. Perhaps that explains why Alabama, whose population is 26 percent African American, was projected just a few days ago to have the highest COVID-19 mortality rate in the nation - even greater than New York's? (A revised projection now places it in the middle of the pack.)

Coincidentally, there's a feature article in this week's New Yorker about another deadly health disparity in Alabama that disproportionately affects minorities. Cervical cancer is one of clinical prevention's great success stories. Women who have periodic Pap smears and, more recently, tests for cancer-causing subtypes of human papillomavirus (HPV), can have precancerous lesions identified and treated long before they progress to cancer. Vaccines against high-risk HPV subtypes, when administered before exposure through sex, prevent infections in the first place, and are routinely recommended for women and men between the ages of 11 and 26. So nearly all of the 13,000 U.S. women who are diagnosed with cervical cancer and the 4,000 who die from it each year have one thing in common: it's been too long since they saw a gynecologist or family doctor.

Why is this tragedy more likely to occur in Alabama, as compared to New York City (25% African American) or Washington, DC (47%)? In Alabama, to qualify for Medicaid as a parent in a family of four, one's household income must be below 18% of the federal poverty level - that is, less than $393 per month. Try to house, feed and clothe a family of four and pay for health insurance or health care of any type (including inexpensive direct primary care) on $400 or $500 a month! The numbers don't even come close to adding up.

Enter health policy. In 2014, a key provision of the Affordable Care Act went into effect that provided at least 90% federal matching funds to states that expanded Medicaid eligibility to 138% of the poverty level. Alabama said no, and it and 13 other states - including most of the solid South, continue to say no, even though studies suggest that additional budgetary costs to states from Medicaid expansion would be more than offset by improvements in the health and earning potential of their residents and the financial footing of their health care institutions.

Developing preventable cancers while being poor and uninsured in Alabama and 13 other states is not only a problem for African Americans, but for persons of all races and backgrounds. If Alabama expanded Medicaid today, the expansion "would provide coverage for roughly three hundred and forty thousand additional Alabamians. About half of the newly insured would be low-income whites." Among other benefits, these newly insured persons could then access coronavirus testing and treatment. 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.