Tuesday, July 20, 2021

Which U.S. hospitals are providing Right Care to their communities?

The Lown Institute, which has partnered with American Family Physician since 2018 on a series of Right Care articles addressing clinical scenarios of overuse and underuse in primary care, recently released the second edition of its Hospitals Index. Unlike traditional metrics that are primarily based on a hospital's revenue and reputation, the Lown Institute Hospitals Index ranks U.S. hospitals by equity, value, and outcomes nationally and by state. This year, Lown produced separate rankings of hospitals by overuse of low-value tests and procedures, racial inclusivity, and community benefit.

A key finding of this year's community benefit ranking is that more than 7 in 10 private nonprofit hospitals spend less on charity care and community investment than they receive in tax breaks (what Lown calls a "fair share deficit"). These hospitals' collective fair share deficit was $17 billion, with the bottom ten hospitals representing $1.8 billion of that national total. Although pre-2010 data are not available for comparison, the size of this deficit seems to suggest that the Affordable Care Act's requirement for nonprofit hospitals to conduct community health needs assessments (CHNAs) every 3 years hasn't led to greater investments in community health. However, New York State appears to be a notable exception. Its Prevention Agenda legislatively required nonprofit hospitals to collaborate with local health departments on CHNAs starting in 2013. A recent analysis of Internal Revenue Service data found that compared to a control group of hospitals in the other 49 states and District of Columbia, New York hospitals increased their mean spending on population health improvement by $393,000-$786,000.

More information on the Lown Institute Hospitals Index methodology is available in a JAMA Network Open article and in recorded webinars and explanatory videosU.S. News & World Report, which once hosted my blog Healthcare Headaches, has announced that its 2021-22 Best Hospitals ranking will incorporate Lown's metric for overuse of spinal fusion. In an editorial in the May 15 issue of AFP, Drs. Alan Roth and Andy Lazris pointed out that a silver lining of the COVID-19 pandemic is that many patients avoided unnecessary spinal fusions and other interventions of questionable benefit, such as electrocardiograms in asymptomatic, low-risk adults. Whether these gains in Choosing Wisely will be preserved after the pandemic ends is unclear; it will likely depend on changes in the ways that physicians are paid (or not), which is a good topic for a future blog post.


This post first appeared on the AFP Community Blog.

Wednesday, July 7, 2021

Coming home

After eleven months of living and working in Salt Lake City, I returned to my home in Washington, DC in mid-June and officially resumed my faculty and clinical positions at Georgetown University Medical Center and Medstar on July 1. In the past week, I've been catching up with patients whom I hadn't seen (virtually or in person) for a year, meeting the new family medicine residents (and adjusting to the reality that the interns I remembered are now beginning their third and final residency year), and working from my quiet office on campus, which was just as I left it in March 2020.

Somewhat to my surprise, my practice is still seeing more patients virtually than in-person, even though 73% of adults in DC have received at least one COVID-19 vaccine dose and 63% are fully vaccinated. My sense from my first clinic day back is that some patients continue to prefer telehealth not because they are afraid of COVID-19, but because it's more convenient for them. And though researchers are still studying if and how telehealth affects quality of care, the early results are promising. A study of more than a million U.S. adults with type 2 diabetes published this week in JAMA Internal Medicine found that despite a steep decline in visit frequency and many visits transitioning to telehealth, medication fill rates and blood sugar control were essentially the same during the pandemic as before it began.

Georgetown's medical school and family medicine residency program did all-virtual interviews of prospective students and residents for the first time last year and plan to do so again this year. I have mixed feelings about this. Having interviewed for years, I would much prefer to meet a candidate in person (even socially distanced, wearing masks) than on Zoom, where so much body language is hidden from view. On the other hand, I recognize that traditional interviews are expensive, time-consuming, and disadvantage students with fewer financial resources.

What's it like to be back home after almost a year away? In general, it feels great. Unpacking is always a chore (and there's still much unpacking and rearranging to do), but settling back in to a familiar environment and rediscovering the things, spaces, and people I reluctantly left behind has been a pleasure. I enjoyed most of my time in Utah and appreciated the opportunity to teach and practice family medicine outside of my comfort zone. But it's great to be back.

Monday, July 5, 2021

Continuous glucose monitors are overrated and overused

The popularity of continuous glucose monitoring (CGM) is surging in the U.S., but whether patients are being helped is unclear. Not only is CGM currently being used by 2 million patients with type 2 diabetes, but start-ups promote them as biofeedback "wellness tools" for people without diabetes even though there is no evidence that CGM improves dietary choices, weight loss, or other outcomes in persons with obesity or prediabetes. Arguing in an American Family Physician editorial a year ago that "Continuous Glucose Monitoring in Type 2 Diabetes Is Not Ready for Widespread Adoption," Dr. Sandy Robertson and colleagues pointed out that no long-term studies had demonstrated that CGM improved patient-oriented outcomes in this population compared to finger-stick or no self-glucose monitoring, and that "unnecessary monitoring not only wastes money but can negatively impact quality of life." I've also written before that patients with type 2 diabetes who are not using insulin do not benefit from self-monitoring.

In this context, two articles in the June 1 issue of AFP emphasized the relatively narrow evidence-based indications for considering CGM. A POEM (Patient-Oriented Evidence That Matters) reported on a systematic review and meta-analysis that found little benefit except in "patients using intensive insulin therapy" who are insensitive to extreme hyperglycemia or hypoglycemia; and a Diagnostic Tests review of the FreeStyle Libre 14-Day "flash" CGM system reported "convenience, possible cost savings, and improvement in treatment satisfaction" for selected patients, but noted that "in adults with insulin-treated type 2 diabetes, there is conflicting evidence whether it reduces [hemoglobin] A1c levels and hypoglycemic time and events."

Two recent studies in JAMA shed additional light on the effects of CGM on glycemic control in patients with insulin-treated type 2 diabetes. In the first study, a multicenter randomized, controlled trial of 175 adults using basal-only insulin with a mean hemoglobin A1c level of 9.1%, participants assigned to the CGM group spent more time in the normal glucose range (70 to 180 mg/dL) and had a lower average hemoglobin A1c at 8 months of follow-up (8.0% vs. 8.4%) than participants in the traditional glucose monitoring group. Severe hypoglycemic events were rare in both groups. In the second study, a retrospective cohort of more than 40,000 patients with type 1 and insulin-treated type 2 diabetes at Kaiser Permanente California, those who initiated CGM "had significant improvements in hemoglobin A1c and reductions in emergency department visits and hospitalizations for hypoglycemia" compared to those who did not initiate CGM. Though the study authors attempted to control for the many baseline differences between the two groups (for example, CGM initiators were "more likely White and English-language speakers and less likely living in a deprived neighborhood"), unmeasured residual confounding may still have affected the results.

Financial conflicts of interest complicate interpretation of the evidence regarding the effectiveness of CGM. A bullish "summary review of recent real-world evidence" on flash CGM published last year in the American Diabetes Association's Clinical Diabetes journal not only was funded by Abbott Diabetes Care (which makes the FreeStyle Libre system) and acknowledged the assistance of a medical communications company in writing the manuscript, but both authors also served on Abbott's advisory board. Such close ties to a manufacturer of CGM devices would have automatically disqualified these authors from writing a review article in AFP on diabetes or related topics, as we recognize that disclosure is not enough to mitigate biases introduced by these conflicts.


This post first appeared on the AFP Community Blog.