Prescribing food as medicine lowers weight, blood pressure, and blood sugar

At the health system where I work, I can refer patients with food insecurity and chronic health conditions that are sensitive to diet quality to a “Food Farmacy” to meet with dietitians and receive free produce from local food pantries. Similar “food as medicine” programs have been piloted throughout the United States, including several led by family medicine residencies. As Dr. Jen Middleton wrote on the American Family Physician Community Blog, the 2022 White House Conference on Hunger, Nutrition and Health made a number of policy recommendations to improve the accessibility of nutritious foods, including “accelerat[ing] access to ‘Food Is Medicine’ services to prevent and treat diet-related illness.” However, research on the health outcomes of such programs has been limited.

In a recent study published in Circulation: Cardiovascular Quality and Outcomes, researchers evaluated the impact of produce prescriptions on food insecurity and health status in nearly 4000 adults and children at 22 sites located in 12 states. 63 percent of households were enrolled in the Supplemental Nutrition Assistance Program (SNAP), and 83 percent were enrolled in the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC). Clinicians referred patients for enrollment in nutrition classes, and individuals or households received paper vouchers or electronic cards averaging $63 per person per month to purchase fruits and vegetables from participating grocery stores and farmer’s markets. Program durations varied from 4 to 10 months.

Compared to pre-program enrollment, the daily fruit and vegetable intake of adults and children increased by 0.85 and 0.26 cups, respectively. Produce prescriptions were associated with decreased food insecurity (odds ratio, 0.63) and improvements in self-reported health status in 85 percent of patients. Adults with diabetes saw their absolute hemoglobin A1c levels drop by 0.29 percent, and adults with overweight or obesity had average decreases in body mass index of 0.36 kg/meters squared. Adults with hypertension had lower systolic and diastolic blood pressures of 8.4 mm Hg and 4.9 mm Hg, respectively, at the end of the program.

Although health insurers have not historically paid for patients to fill healthy food prescriptions, a few Medicare Advantage and Medicaid programs now cover produce purchases and other nutrition-focused interventions in high-risk patients. In addition to health gains, the economic case for expanding and sustaining these programs in the long term is strong. A microsimulation modeling study projected that over a lifetime,

implementing produce prescriptions in 6.5 million US adults with both diabetes and food insecurity would prevent 292 000 (95% uncertainty interval, 143 000–440 000) cardiovascular disease events, generate 260 000 (110000–411 000) quality‐adjusted life‐years, cost $44.3 billion in implementation costs, and save $39.6 billion ($20.5–58.6 billion) in health care costs and $4.8 billion ($1.84–$7.70 billion) in productivity costs. The program was highly cost effective from a health care perspective (incremental cost‐effectiveness ratio: $18 100/quality‐adjusted life‐years) and cost saving from a societal perspective (net savings: $−0.05 billion).

A 2018 AFP editorial provided other practical information for clinicians to help patients with food insecurity, including a list of food assistance programs for children and adults.

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This post first appeared on the AFP Community Blog.

CMS announces “top 10” costly drugs list selected for price negotiations

Two weeks ago, the Centers for Medicare & Medicaid Services (CMS) announced the first 10 brand name medications that it will negotiate Medicare Part D prices directly with drug manufacturers to take effect starting in 2026. Several of these medications are commonly prescribed by primary care physicians and were discussed in American Family Physician’s STEPS (Safety, Tolerability, Efficacy, Price, Simplicity) New Drug Reviews feature from 2007 to 2020. Each drug received U.S. Food and Drug Administration (FDA) approval for at least one indication before September 2016 and currently faces no generic competition.

Apixaban (Eliquis)

Empagliflozin (Jardiance)

Rivaroxaban (Xarelto)

Sitagliptin (Januvia)

Dapagliflozin (Farxiga)

Sacubitril/valsartan (Entresto)

Etanercept (Enbrel)

Ibrutinib (Imbruvica)

Ustekinumab (Stelara)

Insulin aspart (Novolog/Fiasp)

Although Medicare began paying for prescription drugs in 2006, the legislation that created the Part D drug benefit prohibited the federal government from using its purchasing power to negotiate prices directly with pharmaceutical companies, as most government health programs in other countries do from the time of market entry. This changed with the passage of the Inflation Reduction Act in August 2022, which not only gave CMS the authority to negotiate prices of selected brand-name drugs, but also penalizes companies that increase prices faster than inflation and caps Medicare beneficiaries’ annual out-of-pocket drug spending starting in 2024.

Manufacturers have until October 1, 2023 to decide if they will participate in negotiations with CMS to establish a “maximum fair price” for the designated drugs in Medicare Part D or accept financial penalties for not doing so. Negotiations that will take place over the next year will ultimately establish a discounted price that is at least 25 to 60% lower than the drug’s list price. Collectively, the federal government is expected to save $100 billion over the next decade. That’s because a small number of brand-name drugs have an outsized budget impact, with the 10 most expensive drugs accounting for 22 percent of gross Medicare Part D spending in 2021. In addition, there may be “spillover” effects from negotiated lower prices because competitors in the same therapeutic class may decide to lower their prices or risk being left off of Part D drug formularies.

Given potentially large financial impacts on the companies involved (Eliquis, Jardiance, and Enbrel comprise 23 to 33 percent of U.S. prescription drug sales of their respective manufacturers, according to STAT), the pharmaceutical industry has already filed multiple lawsuits seeking to stop price negotiations before they take effect in 2026. Although the industry warns that less revenue could discourage innovation and new drug development, the nonpartisan Congressional Budget Office has estimated that price negotiations would have a small impact on FDA new drug approvals, with 15 fewer drugs approved over the next 30 years out of about 1300 projected.

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This post first appeared on the AFP Community Blog.

For accurate blood pressure measurement, cuff size matters

A thought-provoking editorial in the August issue of American Family Physician discussed the reasons for the divergence in treatment guidelines for mild hypertension that followed the publication of the Systolic Blood Pressure Intervention Trial (SPRINT). Dr. Stephen Martin noted that “in SPRINT, blood pressure was measured using ideal techniques that are unlikely to be replicated using standard practice.” These blood pressure (BP) measurement practices, described in a 2018 editorial about the American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline and reiterated in a clinical review article on home BP monitoring, include using an appropriately sized blood pressure cuff:

To determine cuff size, patients should measure their arm circumference at the midpoint of the upper arm. The bladder length should be 75% to 100% of the arm circumference, and bladder width should be 37% to 50% of the arm circumference.

Four adult BP cuff sizes are available in the United States: small (20 to 25 cm mid-arm circumference), regular (25.1 to 32 cm), large (32.1 to 40 cm), and extra-large (40.1 to 55 cm). Although most primary care offices have cuffs in multiple sizes, home BP monitors sold in pharmacies typically use the regular cuff size, which is too small for many adults.

Just how inaccurate is an automated BP reading in an adult patient wearing a cuff that is too small or too large? To answer this question, researchers from Johns Hopkins University performed a randomized crossover trial in 195 community-dwelling adults. The mean age was 54 years, and about one-half had a BP higher than 130/80 mm Hg when using an appropriately sized cuff. Researchers determined that a regular size cuff was appropriate for 54 study participants, whereas 35 required a small cuff and 106 required a large or extra-large size.

Each participant had four sets of triplicate BP measurements, using a cuff size that was appropriate, too small, or too arge in random order, followed by an appropriately sized cuff. Participants for whom a large or extra-large cuff size was appropriate had their systolic BPs overestimated by about 5 and 20 mm Hg, respectively, when using a regular size cuff. Diastolic BP overestimations were smaller but still statistically significant (1.8 and 7.4 mm Hg). Conversely, participants for whom a small cuff size was appropriate had their systolic BP underestimated by 3.6 mm Hg when wearing a regular size cuff. A recent analysis found that more than half of U.S. adults need a large or extra-large size, and the study authors noted the immense global implications of using cuffs that are too small:

In this context, 40% or more U.S. consumers would obtain BP readings overestimated by almost 5 mm Hg when conducting home BP monitoring. On a global scale, an error in SBP measurement of 5 mm Hg could lead to the misclassification of 84 million people to either undertreatment or overtreatment of hypertension.

In a table summarizing lessons learned and cautions raised by SPRINT, Dr. Martin warned, “Prevention and associated overdiagnosis can divert our attention from sick patients to healthy patients.” Whether family physicians and their patients are aiming for the ACC/AHA guideline’s lower BP targets or the 140/90 mm Hg target recommended for most people by the American Academy of Family Physicians, using an appropriately sized cuff is critical to avoid overdiagnosing healthy adults with hypertension.

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This post first appeared on the AFP Community Blog.

Preventing Overdiagnosis: do Americans have too many cancer screening choices?

At the Preventing Overdiagnosis Conference in Copenhagen last week, I joined nearly four hundred like-minded family and subspecialist physicians, health professionals, and researchers who are concerned about reducing the harms to patients of widening disease definitions and resulting overdiagnosis and overtreatment. After the American Board of Internal Medicine Foundation's discontinuation of logistical support for the Choosing Wisely campaign and the retirement of JAMA Internal Medicine editor and "Less Is More" champion Rita Redberg (who also attended the conference), it was reassuring to hear that the vital work of doing less to patients and more for them will go on. In addition, the international composition of conference attendees allowed me to learn more about different medical practices in Europe and around the world. Although overuse isn't the only reason that the U.S. spends by far the most per capita of any nation on health care, it does play an important role.

In Germany, where family doctors have an average of just 9 minutes (!) per patient consultation, the German College of General Practice and Family Medicine nonetheless found time to develop a prioritized guideline on “Protection against the overuse and underuse of health care.” Although we have a little more time per patient in the U.S., much of this extra time is spent administering standardized questionnaires to screen for depression and anxiety, a practice that doesn't occur in Canada or the United Kingdom and may, despite the U.S. Preventive Service's Task Force (USPSTF)'s endorsement, lead to more harm (opportunity costs and overdiagnosis) than good.

Another area where the U.S. and Canada differ is screening for osteoporosis in primary care. While the USPSTF recommends that all women aged 65 years and older undergo bone measurement testing for osteoporosis (a disease-oriented outcome), the Canadian Task Force on Preventive Health Care recommends “risk assessment–first” screening for prevention of fragility fractures (a patient-oriented outcome) in the same age group, and recommends against screening younger women or men at any age. Not only is the Canadian approach more efficient than universal screening, Roland Grad and colleagues have determined that it requires less clinician time. When there isn't nearly enough time for prevention in primary care, argued Sweden's Minna Johansson and the Mayo Clinic's Victor Montori, guidelines should consider clinicians' time needed to treat.

How much time do Danish general practitioners spend discussing various colorectal cancer screening options? None! In the U.S., a substantial part of every health maintenance visit with a patient aged 50 years (or, perhaps, 45) or older is devoted to having an individual shared decision making discussion about the pros and cons of fecal immunochemical testing (FIT), fecal DNA and FIT co-testing, and screening colonoscopy, then either ordering their preferred test or documenting that they declined to be screened. In Denmark, the public health system identifies age-eligible patients and sends them a FIT test in the mail every 2 years. As a result, the COVID-19 pandemic had only modest effects on Danish adults' participation in colorectal screening and adherence to colonoscopy following a positive test. In the U.S., many practices and health systems are still catching up on the backlog.

Although Americans supposedly value choice in health care, our non-system restricts choice at every turn, through narrow preferred provider networks, limited drug formularies, and the bane of every U.S. family physician's existence: prior authorization. Sometimes it seems that the only area where my patients have choices is cancer screening; male patients of a certain age can even choose to have a PSA test, even though most of the world has rightly concluded that the harms of prostate cancer screening outweigh any benefits. And look out for the multicancer early detection blood tests in development; even though these tests have no proven health benefits and will almost certainly increase false positives and overdiagnosis, no doubt Americans will be among the first to embrace them. There is such a thing as having too many cancer screening choices, if most of them are bad.

Get out the vote: supporting civic health in primary care

The national organization Vot-ER has designated August as Civic Health Month, “a time to showcase the link between voting and health and celebrate efforts that ensure each and every voter has the opportunity to support their community’s health at the ballot box.” Partners, including the Association of American Medical Colleges, encourage clinicians and health care organizations to support an inclusive democracy by providing patients with nonpartisan education and voter registration services.

A recent narrative review in The Milbank Quarterly explored the role of primary care in advancing civic engagement and health equity. Research shows that poorer population health is associated with lower voter turnout, with stronger associations occurring in early adulthood rather than in middle age. On the other hand, voting is associated with positive mental health and health behaviors, and higher levels of individual happiness strongly predict future civic engagement. Similarly, volunteers are less likely to be hospitalized and more likely to receive preventive care, even after controlling for age, gender, race, income, education, and insurance status: “In one study of US adults, volunteers spent 38% fewer nights in a hospital and were more likely to receive services such as flu shots, cholesterol screening, mammograms, and prostate exams as compared with nonvolunteers.”

Primary care physicians have successfully engaged patients with “civic health check-ups” at federally qualified health centers and other outpatient locations. In a voter registration project in the waiting areas of two family medicine residency clinics in the Bronx, volunteers registered 114 of 128 eligible patients during a 12-week period, 65% of whom were younger than 40 years. During the COVID-19 pandemic, a general internal medicine clinic in North Carolina used its patient portal to disseminate a REDCap survey containing embedded links to voter resources, including safer alternatives to in-person voting during the 2020 elections.

Outside of these and other individual case studies, voter enfranchisement remains, to borrow from the title of a 2020 perspective article in the Journal of General Internal Medicine, “an underused treatment strategy." To make voting a “standard of care,” Vot-ER and its partners are hosting several online events this month for clinicians who are interested in empowering patients to support their community’s health at the ballot box.

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This post first appeared on the AFP Community Blog.

Current prescriptions for addressing health-related social needs fall short

According to one recent estimate, cumulative poverty (earning less than 50% of median household income in at least one of the past 10 years) and current poverty are the fourth and seventh leading causes of death in the United States, respectively, on par with obesity and dementia and behind only heart disease, cancer, and tobacco use. The knowledge that financial insecurity and resulting social needs have profound effects on health has inspired organized medicine initiatives aimed at identifying and meeting those needs, such as the American Academy of Family Physicians’ (AAFP) The EveryONE Project.

In a 2019 editorial, Dr. Kevin Sherin and colleagues asserted that “family physicians have a leadership role in identifying and addressing issues that affect patients beyond the clinical setting.” They highlighted the AAFP’s Neighborhood Navigator tool (formerly Aunt Bertha/findhelp), which clinicians and primary care teams can use to link patients to available community resources for different types of social needs. A recent Graham Center Policy One-Pager found that the most common Neighborhood Navigator searches since 2018 were for food, housing, and health care.

Some practices and health care systems have begun screening patients for social needs using print or electronic health record-embedded questionnaires. Two articles in FPM (A Practical Approach by Drs. David O’Gurek and Carla Henke and Screening in Daily Practice by Dr. Vinita Magoon) reviewed the logistics of designing a practice workflow for screening and coding and payment considerations. Gaps in the evidence regarding the effectiveness of screening remain, however. Although the U.S. Preventive Services Task Force considers social risk in the majority of its recommendation statements, it has not found sufficient evidence to recommend screening for social needs. In a 2019 editorial, Dr. Alex Krist and colleagues discussed the research that still needs to be performed:

These recommendations highlight what is needed before recommending routine screening for social needs: an accurate screening test to identify patients with the social need, an effective treatment to address the social need once identified, and evidence demonstrating a meaningful health outcome improvement for patients.

In 2017, the Centers for Medicare and Medicaid Innovation launched the Accountable Health Communities Model, a five-year demonstration project that evaluated whether a proactive approach to identifying and addressing patients’ health-related social needs could reduce care utilization and spending. Although primary care referrals to community services increased for eligible patients, an independent evaluation found that they were no more likely to utilize these services or have their needs met than patients in a randomized control group. Patients often had a hard time reaching community service providers, were deemed ineligible for their services, or did not receive sufficient help from the provider to resolve their need (e.g., continued to have food insecurity despite receiving food assistance). A Health Affairs Forefront commentary pointed out the need to solve the “last mile problem”:

Even when patients received navigation and social service providers had capacity, gaining access to timely social services required some combination of hours of free time to make phone calls, important paperwork at one’s fingertips to apply, and a PhD in social work to understand eligibility rules.… Meaningful navigation support must … not only connect patients to appropriate services, but to ensure the patient’s social needs are met.

Equally important, many community organizations have inadequate resources and funding to serve their populations. A microsimulation study in JAMA Internal Medicine estimated the costs of implementing interventions to address social needs identified in primary care practices. Existing federal funding mechanisms (e.g., the Supplemental Nutritional Assistance Program) covered less than half of the cost of providing food, housing, transportation, and care coordination support for patients with at least one of these four needs. Clearly, the health care system cannot address health-related social needs on its own. As the unwinding of Medicaid’s COVID-19 continuous enrollment condition (which expired on March 31, 2023) proceeds, the need for social policy as health policy has never been greater.

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This post first appeared on the AFP Community Blog.

Increasing recognition of Parkinson disease in Black patients

A recent news story in The Philadelphia Inquirer profiled a Black woman who visited her primary care physician for upper body pain, stiffness, and an unusual gait and was surprised when she was ultimately diagnosed with Parkinson disease. Known by many as an “old White man’s disease,” Parkinson disease affects around 1 million Americans but historically has had low visibility in the Black community, with rare exceptions such as the late boxer Muhammad Ali, who lived with it for 34 years before his death.

Although some studies have suggested that Parkinson disease occurs less often in Black patients than in White patients, a 2020 review found mixed evidence that incidence and prevalence differ significantly by race and pointed to disparities in accessing health care at similar degrees of symptomatology as possible explanations for discordant study findings. A study of 74 patients with newly diagnosed Parkinson disease at a Veterans Affairs medical center concluded that Black patients were less likely than White patients to self-report disability, possibly leading to delays in diagnosis.

According to a 2020 article in American Family Physician, Parkinson disease most commonly presents with “a unilateral resting tremor, often localized to the distal muscles of the hand, causing a pill-rolling motion.” Other key features include cogwheel rigidity and bradykinesia, such as shuffling steps and a freezing gait. Nonmotor symptoms “include rapid eye movement sleep disorder, depression, constipation, fatigue, and olfactory dysfunction” and may precede motor symptoms in many cases. Postural instability and falls occur later in the course of illness. In cases of diagnostic uncertainty, a dopamine transport single-photon emission computed tomography scan (DaTscan) may be used to distinguish Parkinson disease from atypical essential tremor and drug-induced Parkinson-like syndromes.

Recommended therapies for motor symptoms (summarized in a Table and treatment algorithm) include carbidopa/levodopa for significant symptoms, monoamine oxidase-B inhibitors or non-ergot dopamine agonists for milder symptoms, and anticholinergic agents and amantadine for patients younger than 65 years with tremors only. Another Table summarizes pharmacologic management of common nonmotor symptoms. Unfortunately, no therapies have been shown to slow disease progression. On average, patients with Parkinson disease progress from impairment to loss of independence between three and seven years after diagnosis. In patients with Parkinson disease, 40% develop dementia, 20% to 40% develop psychosis, and some eventually have swallowing impairments, aspiration pneumonia, and weight loss due to loss of appetite and difficulty eating.

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This post first appeared on the AFP Community Blog.

To break the UK's National Health Service, roll out prostate cancer screening

The United Kingdom's National Health Service (NHS) is celebrating its 75th anniversary this month. Long hailed as a model health system that provided universal coverage and high-quality care without overly taxing the national budget, the NHS has fallen on hard times. It faces challenges of underfunding, an aging and unhealthy population, an inadequate and increasingly exhausted workforce, and a projected shortage of hospital beds. The headline of a New England Journal of Medicine article asked if the NHS was "at breaking point or already broken?" The widely reported failures of the system to meet patients' basic needs since December 2022 - a time when it should have been recovering from the stresses of the pandemic - has caused public confidence to plummet:

The unspoken agreement between the NHS and U.K. residents was that despite some rationing of care, regional differences in service availability, and the often aging and less-than-sparkling premises, in the event of a medical emergency, an ambulance would arrive promptly and high-quality care would be available at a hospital without anyone requiring an insurance card. That agreement has been broken, and satisfaction with the service is at record lows.

It likely provides little consolation to our neighbors across the pond that the U.S. is in an even sorrier state despite spending twice as much of our gross domestic product per capita on health care services. But the U.K. seems determined to add insult to injury. Despite the resoundingly negative result of the country's only major randomized trial of PSA-based screening, the NHS seems poised to roll out a population-based prostate cancer screening program. (Currently, U.K. men over age 50 can request to have PSA testing, but doctors are not encouraged or incentivized to provide the test routinely to their eligible patients.) They need only look to the U.S. to see that this decision would be a public health disaster that would produce millions of new (mostly overdiagnosed) cancer patients and divert resources away from other primary care preventive care services with a much better likelihood of improving health.

As Dr. Andrew Vickers and colleagues wrote in a recent BMJ article, the prevailing approach to PSA screening in the U.S. and other high-income countries of "informed choice" or "individual shared decision making" drives high rates of testing in older patients who are least likely to benefit and most likely to be harmed, leading to overdiagnosis and inequities:

Approaches to PSA testing that rely on people making an informed choice are likely to reflect and reproduce health inequities in preventive healthcare. Data from Canada, the US, and Switzerland suggest PSA testing is inversely associated with income and education; in Canada and the US, PSA testing is less common in people from ethnic minorities. In the UK and Switzerland, rates of PSA testing are lower in economically deprived areas. Although the effects of disparate rates of PSA testing on health outcomes are still unclear, countries should decide who gets offered screening based on a risk assessment rather than leaving it to individuals.

Vickers and colleagues went on to advise that countries either set up government-sponsored, comprehensive, risk-based programs for prostate cancer detection or, alternatively, make a "clear recommendation against PSA-based screening" - a situation that existed in the United States between 2012 and 2018 when the U.S. Preventive Services Task Force gave this service a "D" (don't do) recommendation grade. The former would presumably maximize benefits by only testing persons at the highest risk of dying from prostate cancer, while the latter would minimize harms by declining to prematurely diagnose prostate cancer in well men. Since 2018, the U.S., and now potentially the U.K., have made the worst choice of all.

Many areas of the U.S. lack integrated behavioral health in primary care

A Graham Center Policy One-Pager in the June issue of American Family Physician overlaid the geographic locations of integrated behavioral health clinics in primary care over a color-coded map of U.S. counties’ percentages of residents reporting poor mental health. In an ideal world, these clinics, which are associated with better health outcomes, higher patient satisfaction, and lower costs, would cluster in regions with greater mental health distress. Unfortunately, the Graham Center analysis found that the opposite was frequently the case, with such clinics “notably lacking in … rural Kentucky, Louisiana, Tennessee, and West Virginia.”

What factors could account for this apparent mismatch between integrated behavioral health supply and demand? A recent Health Affairs Forefront article noted that obstacles to widespread adoption include an ongoing debate about the need for high fidelity to the evidence-based Collaborative Care Model, which can be difficult to implement, and inadequate fee-for-service payment relative to costs of practice re-design and ongoing services. Successful efforts to improve behavioral health integration in Rocky Mountain Health Plans, Blue Cross Blue Shield of Michigan, Rhode Island, and Minnesota have relied on multiple approaches customized to primary care structures and community needs.

A 2022 study in the Journal of General Internal Medicine examined characteristics of integrated behavioral health associated with primary care clinician confidence in managing depression in a network of community health centers (CHCs) in 10 mid-western states. Primary care clinicians reported more confidence when their CHCs had depression tracking systems; when they were satisfied with the accuracy of depression screening; when they had access to behavioral health treatment plans; and when they cared for more patients with depression. In contrast, clinicians working at CHCs with more patients living below the poverty line had lower confidence in prescribing antidepressants, while those at CHCs with more Black patients had lower confidence in diagnosing depression.

Integrated behavioral health clinics may or may not provide treatment for persons with opioid use disorder or other substance use disorders, even though these commonly co-occur with mental health problems. In a Substack post, Ben Miller explained that shared vulnerability, dual diagnosis, and bidirectional influence support pairing mental health and addiction treatment. Obstacles to concurrent treatment in primary and specialty care settings include societal stigma, diagnostic classification systems, health system fragmentation, and different treatment philosophies.

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This post first appeared on the AFP Community Blog.

Housing matters for good health

What does a "renter's utopia" in Vienna have to do with optimal treatment of asthma?

Francesca Mari's recent New York Times Magazine article about public housing in the capital city of Austria features images of beautiful, well-maintained apartment buildings with rooftop swimming pools, lots of green foliage and attractive playgrounds. 80 percent of the city's residents qualify for public housing, a staggeringly high percentage that might imply to an American that the vast majority of people living there are poor. Actually, Vienna makes its plentiful supply of municipal housing (which they call "social housing") available to a large portion of the middle class, and tenants cannot be turned out no matter how much their incomes increase after signing the initial rental contract.

To American eyes, the whole Viennese setup can appear fancifully socialistic. But set that aside, and what’s mind-boggling is how social housing gives the economic lives of Viennese an entirely different shape. ... Imagine having to think about [housing expenses] to the same degree that you think about your restaurant choices or streaming-service subscriptions. Imagine, too, where the rest of your income might go, if you spent much less of it on housing. Vienna invites us to envision a world in which homeownership isn’t the only way to secure a certain future — and what our lives might look like as a result.

In contrast, wrote Mari, one of several "fatal" compromises to the real estate industry in the Housing Act of 1937, restricted eligibility for public housing in the U.S. to "those so poor that they could never secure decent housing in the private market." These units were deliberately underfunded and poorly constructed. As millions of past and current residents of American urban housing projects could testify, "America's public housing was designed to fail: to be unappealing to anyone who could afford to rent."

Which brings me to patients with asthma who live in American public housing projects or neighborhoods in similar states of disrepair. In West Philadelphia, the Children's Hospital of Philadelphia (CHOP) partnered with community organizations to implement Community Asthma Prevention Program Plus, a program that performed home inspections of CHOP patients with asthma and completed repairs to 97 homes that were deemed likely to benefit these patients, including carpet removal, roof and plumbing repairs, improving ventilation, and eradicating mold.

That's great, but what if the home is located next to an interstate highway, factory, or power plant emitting pollutants that can't be easily remediated by a contractor? Or if these patients' asthma exacerbations are triggered by the stress of living in a violent neighborhood? The logical next step is to move to a different home. The case settlement for a 1995 lawsuit against the U.S. Department of Housing and Urban Development for discriminatory public housing practices created the Baltimore Regional Housing Partnership (BRHP), which as of October 2020 had provided housing vouchers to more than 5,200 households to move to privately-owned housing in low-poverty neighborhoods. A research team followed 123 children with persistent asthma whose families moved with BRHP's assistance from 2016 to 2020. Compared to a control group, these children experienced fewer exacerbations, fewer days with symptoms, and lower measures of stress.

Hospitals and health systems are now investing in affordable housing to improve health in many areas of the country, reasoning that being homeless or housing insecure presents a huge obstacle to attaining control of asthma, diabetes, and other chronic diseases. Health care payers are also taking notice. In an ambitious experiment, California's Medicaid program is spending $12 billion over the next 5 years on "a new kind of safety net that provides housing and other services for [145,000] people who are homeless or at risk of becoming homeless and have complicating conditions like mental illness or chronic disease." Whether the experiment will achieve its aim of moderating the program's soaring health care costs remains to be seen, but even if it doesn't, giving people access to decent housing is a worthy end in itself. Kudos to Philadelphia, Baltimore, and California for thinking outside of the health care box, but I'd rather be in Vienna: a city where grinding poverty and housing vouchers aren't necessary for persons of modest means to afford a clean and safe apartment for as long as they want to live there.

Patient portals and electronic health record transparency: pros and cons

After completing my fellowship, I considered taking a job filling in for a family physician on sabbatical who had been in solo practice for thirty-plus years. Even for these pre-electronic health record (EHR) days, his written notes were telegraphic. A typical example: "Patient doing fine. Labs normal. Continue current meds and follow up in 6 months." That was it. What he recorded in the chart was for his eyes only. No need to write an essay, or even a paragraph, when the only purpose was to jog his memory for the next time he saw the patient.

A few years later, the federal government handed tens of billions of dollars to physicians and health care organizations to convert their paper charts to digital form in exchange for requirements to use these records to measure quality of care and increase transparency of health information to patients through so-called “patient portals.” Notes became longer and more detailed. The negative effects of EHRs on physician burnout and health care team communication have been well-documented. Aside from initiatives such as OpenNotes, however, transparency was not fully implemented until last year, when the Office of the National Coordinator for Health Information Technology re-interpreted a previous rule against “information blocking” as an expectation that patients would have real-time online access to their office notes and test results rather than having to request them. With little fanfare, the floodgates opened.

In an insightful article in The New Yorker, Dr. Danielle Ofri, a general internist, admitted her newfound reluctance to list an extensive differential diagnosis for anemia in the EHR because she worried that mentioning colon cancer or a duodenal ulcer could scare the patient. After all, she observed, “my inbox was already jammed with panicked messages from people convinced that they had catastrophic illnesses, based on minuscule lab discrepancies and panic-inducing Google searches.” Comparing EHR transparency to the “C-SPAN effect,” in which live, nonfiltered television coverage of Congress made lawmakers more likely to grandstand to the camera, Ofri noted that granting patients instant access to test results has also had unintended consequences:

In one devastating stretch of twenty-four hours, two of my patients learned of their cancers’ metastatic reappearance by way of the portal. Their inboxes pinged with new test results; they read them before either their oncologist or I had even seen the scans, let alone called. … In the past, I’d do the legwork [for the evaluation] before I called the patient. Now that buffer is gone, and I am pressured to act immediately: the patient has seen the result, and further delay would be unconscionable. This timbre of rush imperils thoughtful analysis, and I worry incessantly about missteps.

In contrast to the mixed feelings of primary care clinicians and staff about patients having online access to their health records, research suggests that patients overwhelmingly prefer to see test results immediately, even though those marked as abnormal increased worry prior to discussions with health professionals. Sometimes, portals save time. Rounding on my practice’s adult inpatient service last month, I was pleasantly surprised that in several cases I could skip through the text of a recently resulted blood or imaging test finding – which the patient or their designated decision-maker had already seen on a smartphone app – and jump straight into the implications for their condition and care plan. Finally, portals allow patients to proactively correct or update medications, allergies, and problem lists outside of office visits, rather than taking up precious minutes with medical assistants or physicians in the examination room.

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This post first appeared on the AFP Community Blog.

Counseling parents about the leading cause of death in U.S. children: guns

A former colleague of mine maintained throughout his career that the most logical way for family physicians to provide preventive services for adults was to focus on the most common causes of death. Although the top diagnoses leading to death recorded by the Centers for Disease Control and Prevention in 2021 were heart disease, cancer, and COVID-19, that’s not what he meant. Instead, he was speaking of the “actual causes of death,” or the behavioral causes of the causes, which from 1990 to 2017 were tobacco use, poor diets, and physical inactivity. Clinicians can have the largest effect on preventing death in adults by counseling patients to stop smoking, eat healthier foods, and exercise.

What about children and adolescents? All-cause mortality in Americans aged 1 to 19 years has been increasing since 2019, partially due to COVID-19 but mostly from a rise in fatal injuries that began prior to the pandemic. Motor vehicle accidents, which have long been the top cause of death in this age group, were surpassed for the first time in 2020 by homicides and suicides from firearms. Mass shootings in schools and public places attract media attention, but data from the Gun Violence Archive show that these account for a tiny fraction of firearm-related deaths.

In comparison, a 2022 American Academy of Pediatrics policy statement reported that 28 children and young adults through age 24 die from gun violence in the U.S. every day – the equivalent of a typical classroom. A recent Commonwealth Fund report comparing the U.S. to 13 other high-income countries found that Americans are five times more likely to die from being shot than residents of Canada, Switzerland, or France. The report also noted that nonfatal and fatal firearm injuries generate more than $1 billion in initial medical costs each year.

A cross-sectional study of four major cities (New York City, Los Angeles, Chicago, and Philadelphia) found that firearm assaults in children increased substantially during the pandemic, with Black, Hispanic, and Asian children being significantly more likely to experience violence. In March, a nationally representative poll found that 21% of adults have been personally threatened with a gun, 19% have had a family member killed by a gun (including suicide), and 17% have personally witnessed someone being shot. However, only 26% of parents of children under age 18 said that their child’s physician had ever asked them about having guns in the home, and only 5% said that their doctor had discussed gun safety.

A 2020 American Family Physician article on prevention of childhood injury recommended that physicians “ask patients whether there are guns in the home and counsel them about the risk of gun-related injury and about safe storage practices … [and] consider contacting legislators if local gun laws are not in the best interest of children's safety.” A previous editorial that I co-authored with other AFP editors noted that “child-access prevention laws (e.g., safe gun storage) reduce self-inflicted and unintentional firearm deaths and nonfatal injuries among youth, and may reduce unintentional firearm injuries among adults.” By counseling patients in our offices and advocating for legislation to promote firearm safety, family physicians can complement community health initiatives that reduce the risk of gun violence in children. For example, Communities That Care, a prevention program that addresses risk and protective factors for behavioral problems early in life, was recently shown in a randomized trial to reduce the prevalence of handgun carrying in 4400 adolescents living in 24 small towns in 7 states.

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This post first appeared on the AFP Community Blog.

What's the matter with corporate primary care?

I've been meaning to write about this topic for a while, but Dr. Josh Freeman at Medicine and Social Justice beat me to it last week. Josh is a fellow blogger, retired family physician, and Chair emeritus of the Department of Family Medicine at the University of Kansas. His latest post, "Private equity, private profit, Medicare and your health: They are incompatible," explored in depth the negative effects of private equity and for-profit corporations buying up subspecialty and primary care practices, also discussed in a KFF Health News article and in the New York Times. Put simply, the goal of those purchases is to turn a quick profit - often by "upcoding" to charge more for visits and procedures and slashing critical support staff - rather than to serve the best interests of patients and clinicians. Part of the corporate rush to invest aggressively in primary care is the unintended consequence of privatizing Medicare and moving away from the fee-for-service payment model; private health insurers now receive a lump sum "value based care" payment for every enrolled Medicare beneficiary based on their medical complexity and health risks, a process that Paul Branstad and Claude Maechling observed can easily be gamed:

Value-based contracts with full-risk capitation payments, mostly Medicare Advantage (MA), but also variants of accountable care organization (ACO) models, have grown rapidly to become the majority payment model for Medicare beneficiaries. However, there is no demonstrated proof that these payment arrangements improve the health of beneficiaries more than fee-for-service arrangements. We also fear that, in their current forms, such contracts reward ever-increasing scale and will evolve into a competition that only the very largest consumer companies can win. Once these winners emerge, their vested interests will focus on preserving their oligopoly at an additional cost to US taxpayers of $75 billion a year. Too late will we realize we have lost our last best chance to reinvent a health care system centered around the large-scale provision of high-quality primary care—even though this is what value-based contracts started out trying to do.

Another reason that retail giants such as Amazon and CVS Health have recently invested billions of dollars in primary care companies (One Medical and Oak Street Health) is that they anticipate steering thousands of patients to their pharmacy and disease management products. CVS Health's CEO is confidently projecting that investors will realize "double-digit returns on invested capital over time as clinics mature and synergies are realized."

Although private investment has infiltrated nearly every sector of health care, including oncology clinics, neonatology practices, and the gastroenterology practice where I refer most of my patients for procedures or challenging gastrointestinal problems, the profit motive may do the most damage in primary care, which improves population health when it is treated as a common good rather than as a loss leader for more profitable procedural subspecialties and hospital-based services. As Soleil Shah and colleagues wrote in the New England Journal of Medicine: "Though potentially beneficial for certain well-insured patients, the trend of corporate investment in primary care could threaten equitable access to care, raise health care costs, and reduce physicians’ clinical autonomy."

Sounding the alarm about the "existential threat of greed" in a JAMA Viewpoint and his Institute for Healthcare Improvement 2022 National Forum keynote address, Don Berwick made these stark observations about the wrong direction that the excessive pursuit of financial profit has been taking the U.S. health care system, and now corporate primary care:

Profit may have its place in motivating innovation and higher quality in health care, as in any industry. But kleptocapitalist behaviors that raise prices, salaries, market power, and government payment to extreme levels hurt patients and families, vulnerable institutions, governmental programs, small and large businesses, and workforce morale. Those behaviors, mostly legal but nonetheless wrong, have now accumulated to a level that poses an existential threat to a sustainable, equitable, and compassionate health care system. ... US health care costs nearly twice as much as care in any other developed nation, whereas US health status, equity, and longevity lag far behind. Unchecked greed is not the only driver of that failure, but it is a major one. Few, if any, other developed nations tolerate the levels of avarice, manipulation, and profiteering in health care that the US does. Salve lucrum [Hail, Profit!] is the wrong answer.

Photo courtesy of Pompeii in Pictures https://www.pompeiiinpictures.com/pompeiiinpictures/R7/7%2001%2047.htm

Updated immunization and screening recommendations aim to eradicate hepatitis B

In November 2021, the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP) replaced risk factor-based eligibility in adults with a recommendation for universal hepatitis B vaccination in persons aged 19 to 59 years. The ACIP noted that despite routine administration of hepatitis B vaccine in infancy, as of 2018 only 30% of U.S. adults had received the full vaccine series, and one half of acute hepatitis B cases occurred in persons aged 30 to 49 years. A national survey of family physicians in February 2022 found that more than half of respondents were not aware of the updated guidelines, and only 8% had fully implemented them.

Gaps in screening and treatment also put patients at greater risk of developing chronic hepatitis B and its complications. An analysis of insurance claims data from 2015 to 2020 found that even though all pregnant patients should be screened for hepatitis B at their first prenatal visit to prevent perinatal transmission, 14.6% did not have hepatitis B surface antigen (HBsAg) testing, representing as many as half a million births each year. Another study found that between 2016 and 2019, less than 30% of persons with chronic hepatitis B and cirrhosis started antiviral therapy within 12 months of diagnosis.

Since access to hepatologists is a barrier to patients with hepatitis B receiving appropriate management, a previous AFP Community Blog post described a practice model for family doctors to evaluate and treat these patients “in-house.” However, the complexity of screening and management guidelines has led to calls for a simplified approach to hepatitis B. In response, the CDC recently recommended that adults aged 18 years and older be tested for hepatitis B at least once during their lifetimes, regardless of prior immunizations or risk factors, mirroring the universal screening approach to hepatitis C and HIV. (Notably, the U.S. Preventive Services Task Force currently recommends a risk-based screening strategy in adolescents and adults.) To facilitate interpretation, screening should include HBsAg, antibody to HBsAg, and antibody to hepatitis B core antigen.

In a JAMA Viewpoint, Dr. Samuel So and colleagues asserted that as two-thirds of non-institutionalized persons with chronic hepatitis B are unaware of their infection, universal screening and vaccination of adults “are a major step forward to reducing chronic hepatitis B-related morbidity and mortality in the U.S.” Another commentary emphasized focusing on health equity in the national push to eradicate hepatitis B and hepatitis C, which is the target of a recently proposed national initiative. A white paper that I co-authored for the Hepatitis B Foundation presented challenges to implementing the updated CDC recommendations, best practices in primary care and hospital settings, and priority action items involving education, multi-stakeholder collaborations and technology innovations, and addressing vaccine hesitancy.

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This post first appeared on the AFP Community Blog.

Have pharmaceutical conflicts of interest unduly influenced asthma guidelines?

The single maintenance and reliever therapy (SMART) treatment approach to patients with asthma, outlined in the article on chronic asthma treatment in the April issue of American Family Physician, has consistent supporting evidence from multiple randomized controlled trials. A practical guide to implementing SMART has been widely disseminated to clinicians. However, an editorial by Dr. Steve Brown cautioned that SMART, which is strongly recommended in the 2022 GINA guidelines, has been “heavily influenced by the pharmaceutical industry,” namely AstraZeneca, which markets budesonide/fomoterol (Symbicort), the combination inhaler primarily studied in the trials:

The GINA board of directors and scientific committee members have substantial financial conflicts of interest. Twelve of 17 members, including both chairs, have received personal fees from AstraZeneca. … A 2018 systematic review of SMART for persistent asthma found 16 RCTs, and 15 of those evaluated SMART as a combination therapy with budesonide and formoterol in a dry-powder inhaler. Fourteen of the 15 studies were funded by AstraZeneca, had an AstraZeneca employee as a coauthor, or had authors who received honoraria or fees from Astra-Zeneca.

Why is it problematic that clinical trial investigators and GINA guideline panelists have numerous industry ties? A 2017 Cochrane review concluded that “sponsorship of drug and device studies by the manufacturing company leads to more favorable efficacy results and conclusions than sponsorship by other sources,” an inherent industry bias that “cannot be explained by standard ‘risk of bias’ assessments.” A 2020 systematic review found that guidelines with panelists with financial conflicts of interest were 26% more likely to favorably recommend a therapy than those without such conflicts.

In comparison to GINA, the less-conflicted panelists of the National Asthma Education and Prevention Program (NAEPP) focused guideline update, discussed in a previous AFP editorial, made a narrower “conditional” recommendation for SMART in patients age 12 years or older with moderate to severe persistent asthma.

Although some think that public disclosure of conflicts of interest can prevent or mitigate bias in clinical recommendations, Dr. Jay Siwek, my longtime mentor and editor-in-chief emeritus of AFP, has previously argued regarding clinical review articles and editorials that disclosure of conflicts is not enough. Note: I do not have any conflicts of interest related to the topic of this blog post.

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This post first appeared on the AFP Community Blog.

Raising and lowering barriers to preventive services in the U.S.

The Affordable Care Act's guarantee of no cost-sharing for cancer screenings and other beneficial evidence-based preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) has been put in jeopardy by a district court decision favoring the plaintiffs in a lawsuit claiming that requiring insurance coverage of HIV pre-exposure prophylaxis violated their religious freedom. Judge Reed O'Connor ruled that because USPSTF members are not confirmed by the Senate and their recommendations are not subject to government oversight or approval, health insurers are no longer obligated to cover any preventive services recommended after the ACA was signed into law in March 2010. Mandatory coverage of services endorsed by other governmental bodies, such as the Advisory Committee on Immunization Practices (ACIP) and the Health Resources and Services Administration (HRSA), will remain in effect. In a previous blog post, I called this outcome "an exceedingly dumb and harmful proposition that would result in more preventable illness and poorer quality of life for millions of Americans," but now that it's happened, it is worth exploring why the ACA left the Task Force vulnerable and what can be done to repair the damage.

In 2013, family physicians Steven Woolf and Doug Campos-Outcalt wrote a prescient viewpoint in JAMA noting that the USPSTF's exclusive focus on the scientific evidence of clinical benefits and harms made it ill-equipped to implement insurance policy designs:

Coverage decisions, like other aspects of public policy, should not always be dictated solely by science. ... Just as clinicians must consider individual circumstances that transcend empirical data, the public should be allowed to influence policy choices, like paying for services, when factors other than science pertain. Laws should certainly adhere to the evidence in ensuring public access to a minimum set of services of proven benefit, but the latitude to build on this evidence-based “floor” should also be preserved. ... Placing the USPSTF in this position puts its analytic rigor at risk by preventing members from concentrating on the science. The inescapable reality that their conclusions dictate coverage guidelines may engender a subliminal pressure to reinterpret the evidence, knowing the ramifications, and to lower the threshold for A and B recommendations.

Drs. Woolf and Campos-Outcalt suggested severing the link between USPSTF recommendations and coverage policy "by naming a separate body to advise the secretary of Health and Human Services on appropriate preventive services for first-dollar coverage." This did not happen, of course, even after three former Task Force Chairs published a second commentary a few years later asking "Is It Time for the USPSTF to Inform—But Not Determine—Coverage?" Discussing an attempt by Mylan, the manufacturer of the EpiPen, to pressure the panel to declare its anaphylaxis drug a preventive service so that insurance companies would be forced the bear the full burden of future price increases, the authors noted that "the linkage ... encourages those with a significant financial interest to attempt to influence the direction and decisions of the Task Force."

In a recent Health Affairs Forefront article, Richard Hughes IV and colleagues discussed potential policy solutions that would save the ACA's preventive coverage provision and strengthen the USPSTF's position against inevitable future challenges. (As a physician who has cared for countless patients with this chronic infectious disease, it boggles my mind that 40 years after the discovery of the HIV virus as the cause of AIDS, at-risk and affected patients remain stigmatized for "immoral" behavior.) Although it is unlikely that Congress will act, administrative reforms are possible. For example, "the HHS Secretary could authorize the director of the Agency for Health Care Research and Quality or the CDC director to review and adopt the Task Force's recommendations." Or, echoing Woolf and Campos-Outcalt, "the Administration could establish an additional body within HHS to provide additional review, oversight and approval of recommendations. This group could be a vehicle for badly needed reforms to better align criteria, processes and recommendations across the various recommending bodies."

 

Even if this legal quandary is resolved, either by appeals to higher courts or executive actions such as those proposed above, the fact remains that "free" health care services, preventive or not, are not free if taking time off work to receive them results in lost income. Only 16 states and Washington, DC require employers to provide paid sick leave, and nearly 30% of workers lack it as a result, with higher proportions among people with low incomes, women, and underserved minority groups. An innovative study by Dr. Kevin Callison and colleagues examined the association between paid sick leave mandates and screening for colorectal and breast cancers using administrative claims data. Even though employees presumably use paid sick leave mostly for acute illnesses and non-preventive care, the researchers found that cancer screening rates were significantly higher in metropolitan statistical areas with paid sick leave mandates. Requiring that employers provide paid sick leave throughout the U.S. would not only lower a barrier to receiving beneficial preventive services, but as the COVID-19 pandemic demonstrated, likely drive overall population health improvement as well.

Potential downsides of ADHD overdiagnosis

Over the past few decades, U.S. children have become increasingly likely to receive a diagnosis of attention-deficit/hyperactivity disorder (ADHD), according to multiple national surveys. This unexplained rise in prevalence may be partly due to overdiagnosis, suggested a Lown Right Care article by Dr. Elizabeth Wolf and colleagues in the March issue of American Family Physician. They noted that the characteristic traits of ADHD – hyperactivity, inattentiveness, and impulsiveness – “exist on a continuum with normal behavior,” and that disease cutoffs have been gradually lowered, culminating in the DSM-5 diagnostic criteria which “lowered the percentage of criteria needed for diagnosing ADHD in older adolescents and increased the age by which behaviors must have first appeared (from seven to 12 years).” Evidence of situational ADHD overdiagnosis includes wide variations in stimulant prescriptions across states, higher rates in children who are young for their school grade, and comorbid learning and psychiatric disorders that may be mistaken for ADHD.

Although children diagnosed with ADHD can qualify for individualized education plans, and those with moderate to severe symptoms who take stimulant medications show improvements in math and reading performance, the benefit of diagnosing a child with mild symptoms is less clear. Harms of an ADHD diagnosis include labeling, disempowerment, lowered school expectations, the opportunity costs of medical visits (e.g., missed work for parents), and medication adverse effects, including insomnia. In an accompanying patient perspective, Helen Haskell and John James expressed concern that “medicating children to change their behavior may help them sit quietly at school, but viewing medication as a first-line solution may mask problems with the school or home environment and inhibit the development of important life skills.”

A recent episode of the Pharmanipulation podcast, featuring interviews with a licensed clinical psychologist and an investigative journalist, further explored the subjectivity involved in ADHD diagnoses and educational and societal pressures that may be driving these diagnoses in borderline cases. For example, the Vanderbilt Assessment Scales that are completed by a child’s parents and teachers to assist with diagnosing ADHD “[take] a subjective impression and quantify it so that it makes it seem objective.” If the parent or teacher already thinks that the child has ADHD, they will be more likely to complete the questionnaire in a way that leads to the diagnosis. Having ADHD makes a child likely to receive pharmacologic treatment, even though psychosocial interventions such as parent training in behavioral management and classroom behavior interventions can also be effective, particularly in younger children.

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This post first appeared on the AFP Community Blog.

Carried by deer ticks, babesiosis is spreading in the northeastern U.S.

The Centers for Disease Control and Prevention reported last week that the incidence of babesiosis rose substantially in 10 northeastern states from 2011 to 2019, including Maine, New Hampshire, and Vermont, where it was not previously considered to be endemic. Maps from a previous American Family Physician article on tickborne diseases illustrate the geographic distribution of babesiosis compared to other tickborne diseases such as Lyme disease. Babesiosis is usually transmitted to humans by the bite of an infected deer tick (Ixodes scapularis), though rare cases of transfusion-associated and perinatal transmission have been reported.

The Environmental Protection Agency has concluded that the expanding range of disease-carrying ticks to northern latitudes has been influenced by ongoing climate change:

Deer ticks are mostly active when temperatures are above 45˚F, and they thrive in areas with at least 85-percent humidity. Thus, warming temperatures associated with climate change are projected to increase the range of suitable tick habitat. … Because tick activity depends on temperatures being above a certain minimum, shorter winters could also extend the period when ticks are active each year. … Unlike some other vector-borne diseases, tick-borne disease patterns are generally less influenced by short-term changes in weather (weeks to months) than by longer-term climate change.

After an incubation period of one to nine weeks, patients with babesiosis can experience nonspecific flulike symptoms, including fever, generalized weakness, and myalgias. More severe complications may develop, including acute respiratory distress syndrome, congestive heart failure, and disseminated intravascular coagulation. The diagnosis can be made by polymerase chain reaction (PCR) or microscopic identification of intraerythrocytic organisms on a Giemsa-stained peripheral blood smear.

First-line treatment for mild to moderate babesiosis is oral atovaquone and azithromycin for 7 to 10 days. More severe infections should be treated with intravenous clindamycin and oral quinine. Exchange transfusions are “reserved for patients who are extremely ill – with blood parasitemia of more than 10 percent, massive hemolysis and asplenia.” Since co-infection with Lyme disease and ehrlichiosis can occur, clinicians can consider starting oral doxycycline while awaiting the results of serologic testing. Babesiosis may persist for more than two months after effective treatment and for months to years in patients with unrecognized infections.

A previous AFP editorial provided advice on use of effective insect repellents to prevent diseases carried by ticks and mosquitoes. A patient education handout reviewed strategies for preventing tick bites and safely removing attached ticks. Finally, readers interested in mitigating infectious and other health impacts of warming temperatures in their clinics and communities can consult a curated collection of articles on environmental health and climate change.

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This post first appeared on the AFP Community Blog.

Aspirin, preeclampsia, and heart disease in later life and children

Preeclampsia affects an estimated 4 million pregnancies worldwide each year and has lifelong health consequences for women and children. The U.S. Preventive Services Task Force (USPSTF) recommends screening for preeclampsia with blood pressure measurements throughout pregnancy; last month it released an updated draft statement that expands the screening indication to identify all hypertensive disorders of pregnancy. Exercise during pregnancy is recommended to reduce risk of gestational hypertension and preeclampsia. Additionally, the USPSTF and the American College of Obstetricians and Gynecologists recommend that pregnant patients at high risk for preeclampsia start taking daily low-dose (81 mg) aspirin at 12 weeks’ of gestation and continue until delivery. The high prevalence of preeclampsia risk factors has made preventive aspirin use increasingly common in the U.S. An analysis of 2019 birth certificate data found that low-dose aspirin was indicated in more than half of all pregnancies and could have been considered in more than 85 percent based on USPSTF criteria.

Since aspirin may increase peripartum bleeding risk, an open-label, noninferiority randomized trial in Spain compared discontinuing aspirin at 24 to 28 weeks’ gestation to continuation until 36 weeks (the standard of care in Europe) in pregnant patients judged to be at lower risk of preeclampsia based on second-trimester biomarkers. The incidence of preterm preeclampsia, the primary outcome, was similar between the groups. Of note, the aspirin dose was 150 mg daily, and high risk individuals were identified in the first trimester based on a screening algorithm that combined clinical factors with objective measurements such as mean uterine artery pulsatility index and serum placental growth factor. Differences in the European approach to preeclampsia prevention make it difficult to determine this study’s implications for U.S. practice.

A 2017 systematic review and meta-analysis of 22 studies found that preeclampsia is associated with a 4-fold increase in future heart failure risk and 2-fold increases in heart disease, stroke, and cardiovascular death. Should a history of adverse pregnancy outcomes be considered in atherosclerotic cardiovascular disease (ASCVD) risk assessments? To shed light on this question, Swedish researchers did a cross-sectional study of a population-based cohort of 10,000 women with one or more deliveries in 1973 or later who underwent coronary computed tomography angiography at age 50 to 65 years as part of a study from 2013-2018. Patients with histories of gestational hypertension and preeclampsia were more likely to have coronary atherosclerosis and significant stenosis even if their predicted ASCVD risk was low. Whether intensive primary prevention with statin therapy would improve outcomes in these patients is not known.

Finally, maternal preeclampsia has been associated with increased cardiovascular risks in children. In a population-based cohort study of individuals born in Denmark, Finland, and Sweden from 1973 to 2016, offspring of pregnancies with preeclampsia had increased risks of ischemic heart disease (adjusted hazard ratio, 1.33) and stroke (aHR, 1.34), independent of preterm or small for gestational age birth.

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This post first appeared on the AFP Community Blog.

Springing forward and building my Substack

Today marks the first day of daylight saving time in 2023. Many U.S. health reporters and bloggers have devoted newsprint or digital space to the pros and cons of shifting our clocks one hour forward so that there is more late-day sunshine during the warmer months. In 2019, my colleague Jen Middleton discussed how to minimize sleep disruptions caused by the time change. This year, Rita Rubin wrote a terrific news article in JAMA that highlighted the contrast in public support for making daylight saving time year-round with the positions of major medical organizations, including the American Academy of Sleep Medicine and the American Medical Association, that support abolishing daylight saving and sticking with permanent standard time.

For nine months in 1974, the U.S. actually instituted year-round daylight saving time in the hope of reducing energy consumption during the OPEC oil embargo. Unfortunately, noted Rubin, "the shift to daylight saving time in the middle of winter meant that many schoolchildren had to go to school in the dark," contributing to the publicized deaths of 8 Florida students in early-morning car accidents. Public support for the change waned rapidly, and President Gerald Ford signed a law that reverted to standard time that fall.

Switching topics, I've been working to build Common Sense Family Doctor's presence on Substack, where I started cross-posting in January after I was briefly locked out of Twitter. Although my Twitter access was eventually restored, that platform is going rapidly downhill, with qualified health professionals fleeing in droves while purveyors of misinformation have been emboldened by Elon Musk's "anything goes as long as it can be monetized" stance. So I appreciated a recent shout-out from fellow blogger Hans Duvefelt, MD, whose long-running A Country Doctor Writes features thoughtful and absorbing observations on the pleasures and pains of practicing family medicine in rural Maine, and is now available as a subscription on Substack. Hans has also written three books based on his blog writings and videos, the first of which entertained my family for many hours as we drove back from Salt Lake City to Washington, DC in the summer of 2021. If you haven't previously visited his blog or Substack, they are well worth a few minutes of your day, regardless of your feelings on daylight saving.

"I want to be a regular doctor" - making primary care the norm

Today I spent a few hours updating my "Introduction to the U.S. health care system" lecture for the first-year medical student course I directed before my 2020-21 Salt Lake City sabbatical and last year's move to Lancaster, Pennsylvania. (I continue to hold a Georgetown faculty appointment as a guest lecturer for this course and a health policy elective for 4th year students and residents.) The last several slides are taken from a series of reports from the Commonwealth Fund illustrating that as U.S. health care spending has accelerated in comparison to spending in peer countries, key health outcomes, such as infant and maternal mortality and average life expectancy, have fallen farther and farther behind. I then ask the students: why are our outcomes worse than those of other countries that spend much less?

There isn't a single correct answer to this question. Culprits include high administrative costs, poor continuity of care due to lack of insurance portability, and the fact that too many people (insured and uninsured) can't access routine health care services because they are not affordable or not convenient. But the explanation that resonates with me most, as a family physician who has worked in public health, is that public health and primary care have been systematically undervalued and have insufficient resources to do their jobs well. Consider the latest evidence: a primary care scorecard developed by the Robert Graham Center shows that primary care's share of overall U.S. health care expenditures fell from 6.2% in 2013 to a paltry 4.6% in 2020.

Providing primary care is generally inexpensive, and no one is arguing that it should have a 50% or even 25% share, but achieving even the 8% average share among Organization for Economic Co-operation and Development countries would be transformative for American medicine. Absent new investments, the primary care workforce will continue to shrink and fewer and fewer adults will be able see a primary care clinician without waiting for weeks to months. Efforts to date to improve income equity between generalists and subspecialists have been anemic; a recent study found that adjustments to the Medicare Physician Fee Schedule designed to increase the value of "cognitive work" (activities that don't involve performing procedures or using technological tools) that went into effect in 2021 only narrowed the payment gap by 2%.

Other well-intentioned efforts to prime the primary care pipeline that may yield modest gains. Several, like Texas Tech University's Family Medicine Accelerated Track, condense medical school into 3 years for students who commit early to family medicine or primary care careers. This approach eliminates one year of tuition payments and allows the medical school graduate to start earning an attending physician's salary one year sooner. A less conventional path to primary care is switching medical specialties mid-career. One of my friends, a longtime colleague and previous personal physician, began her career as a radiation oncologist and later re-trained in family medicine, where she practiced until her retirement. Doing so required that she complete a second residency, with long hours and relatively low pay, and the strain that this arrangement might put on significant others and families is not insignificant. Thus it's unlikely even if artificial intelligence eventually reduces demand for some subspecialties (e.g., pathology and radiology) that enough doctors will migrate into primary care to address future workforce shortages.

A recent episode of the Society of Teachers of Family Medicine (STFM) podcast featured Dr. Margot Savoy, one of the most talented family physicians I know and the Senior Vice President of Education for the American Academy of Family Physicians. Asked to describe the origins of her interest in a family medicine career, she spoke about wanting to be a "regular doctor," the health professional you saw when you needed a checkup or had an acute injury or illness. Innocent of the divisions that existed in medicine, she had to be educated that this type of "regular doctor" was called a primary care physician and about the differences between physicians who took care of kids only, adults only, and family physicians. Countless others have begun medical school considering primary care careers to be the norm before being seduced by the siren song of higher paid subspecialties with narrower bodies of knowledge to master. We need schools to continue producing subspecialists, of course, but to bring U.S. health outcomes back to par with the rest of the world, we need primary care physicians more.