Saturday, February 1, 2025
Does transitional care management improve outcomes after discharge from the hospital?
Recognizing their potential to save money and improve outcomes, in 2013 the Centers for Medicare and Medicaid Services began allowing practices to bill separately for transitional care management (TCM) services that included an interactive contact within two business days of discharge and a dedicated face-to-face office visit within 14 days. Practices developed novel workflows to support TCM and to ensure that it is financially sustainable, as reviewed in a 2023 article in FPM. Although use of TCM has gradually increased, some have expressed concern that these billing codes were not supporting primary care as expected, with one-fifth of Medicare TCM claims being billed by a practice that was not the patient’s primary care practice. A recent study found that TCM was less likely to be delivered to Medicare patients at the highest risk of readmission:
Racial and ethnic minority status, dual [Medicare and Medicaid] eligibility, dementia, and frailty were common among patients at high risk for readmission as well as those who were less likely to receive TCM service. These findings suggest that poor socioeconomic status and impaired functional status may act as factors for readmission as well as barriers to TCM access.
More than a decade into the program, it remains uncertain whether TCM actually improves outcomes. An analysis of Medicare data from 2012 to 2017 found that "using TCM codes was linked to a modest reduction in the number of patients readmitted to the hospital within 30 and 90 days after discharge, with the greatest improvements seen in 2017. However, we did not observe a significant association with patient deaths after discharge overall."
Also, a systematic review and meta-analysis of 13 studies (including 11 randomized trials) published since 2012 found that post-discharge contacts (mostly telephone calls) within 7 days of discharge had no effects on 30-day emergency department use or hospital readmissions compared with usual care.
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This post first appeared on the AFP Community Blog.
Wednesday, January 22, 2025
Can food policy changes make America healthy again?
Shortly after Donald Trump because the only politician since Grover Cleveland to be re-elected to a non-consecutive second Presidential term, I discussed why Robert F. Kennedy, Jr.'s conspiracy-fueled positions on childhood vaccines and fluoridated drinking water make him unqualified to be the next Secretary of Health and Human Services (HHS). Now that the newly inaugurated President has withdrawn the U.S. from the World Health Organization, presumably paving the way for RFK Jr., if confirmed as HHS Secretary, to "go wild on health," it's time to examine the other side of "Make America Healthy Again": his more mainstream belief that overconsumption of ultra-processed food is the cause of a wide spectrum of chronic health problems.
A side note: medical historians have pointed out that the "again" part of the MAHA slogan, harkening back to a time in the past when our country was healthier than it is today, is nonsensical, as in no past era have Americans lived longer or had a better quality of life with less disability than today. The 19th century, for example?
It’s true that agriculture at the time was organic, food was locally produced and there were no ultraprocessed foods. But fresh fruits and vegetables were in short supply because they were difficult to ship and because growing seasons were so short. ... Common conditions, like hernias, were untreatable — men had hernias as big as grapefruits, held in by trusses. Nineteen percent of those soldiers had heart valve problems by the time they were 60, compared with about 8.5 percent today.Sunday, January 19, 2025
Family physicians perform high-quality colonoscopies, but access is an issue
Most patients who choose colonoscopy as a screening test for colorectal cancer are referred from primary care to a gastroenterologist or other specialist who performs endoscopy. But that wasn’t the case for the estimated 1 in 15 US patients whose screening colonoscopies were performed by family physicians in 2021. A study of an insurance claims database found that family physicians are more likely to perform colonoscopies in older, male patients residing in more rural areas of the Midwest, South, and Western United States.
The American Academy of Family Physicians (AAFP) maintains that clinical privileges should be based on documented training and experience rather than the physician’s specialty. In 2000, American Family Physician published an AAFP position paper (an updated version currently resides on the AAFP website) emphasizing that “colonoscopy can be a natural extension of the total care provided by a well-trained family physician.” In 2008, a Society of Teachers of Family Medicine consensus statement classified colonoscopy as a core procedure that family medicine residents should not only be exposed to but also “have the opportunity to train to independent performance.”
A 2009 meta-analysis of 12 studies (n = 18,292) of screening colonoscopies performed by primary care physicians and a later study of faculty and residents at a single, university-affiliated family medicine center concluded that their performance on quality, safety, and efficacy indicators (reach-the-cecum rate, major complication rate, and adenoma detection rate) was comparable to those recommended by the major gastrointestinal endoscopy societies. In addition, a recent analysis of colonoscopy quality at two high-volume rural programs (University of Texas Southwestern and University of North Dakota) for family physicians, general surgeons, and gastroenterologists found no statistical differences in performance by provider type.
Data indicate that screening colonoscopies are overused and that a colonoscopy-first strategy may only be marginally better than sequential fecal immunochemical testing in reducing colorectal cancer mortality. Nonetheless, millions of US adults older than 50 years have never been screened for colorectal cancer and could potentially benefit from having access to family physician–performed colonoscopy services. Thus, the decline in endoscopic care (including flexible sigmoidoscopy) by family physicians in both urban and rural areas is cause for concern. From 2016 to 2021, the percentage of screening colonoscopies performed by family physicians decreased from 11.3% to 6.7%, and less than 2% of board-certified family physicians report performing colonoscopy in their practices.
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This post first appeared on the AFP Community Blog.
Wednesday, January 15, 2025
PSA screening: shared decision making is a flawed approach
In early 2020, I accepted an invitation to participate in a live debate with a nationally prominent academic urologist at the annual scientific meeting of the American Society for Men's Health. The topic: "The Great Debate of the 21st Century: To PSA screen or not to screen." Unfortunately, the COVID-19 pandemic caused the meeting to the canceled. By the time I was re-invited in 2021, my academic interests had drifted away from prostate cancer screening, so I declined. But over the past 5 years, I have watched with increasing dismay as family physicians and urologists (mis)interpreted the U.S. Preventive Services Task Force's more permissive stance on PSA screening as a license to start screening indiscriminately again without warning men about the adverse consequences of doing so. "We Should Be Doing Fewer PSA Tests, But We Are Doing More," I pleaded in a 2022 Medscape commentary for primary care physicians. I moved to Lancaster and was appalled when my program's residents received a lecture from a urologist chastising us for not ordering enough PSA tests because we apparently cared more about a few patients avoiding erectile dysfunction and urinary incontinence than the "millions" of lives that could be extended by screening. So I dove back into the evidence, read pretty much every paper on PSA screening published since the pandemic began, and concluded that our current approach to shared decision making is fatally flawed, and that we would be better off not using the PSA test for screening at all.
Then I wrote a paper about it. Here is my unfiltered conclusion:
Even though [the PSA] test's flaws, including poor accuracy and the cascade of interventions that follow a positive result, are well established, guideline developers have assumed that shared decision-making would limit the population of men being screened to those prepared to endure the lifelong monitoring and interventions that follow a positive PSA result. The preponderance of the evidence has not reflected this assumption. The net population benefit of prostate cancer screening is too small—particularly in men older than 70 years—to justify continuing this failed approach. Rather than treating PSA as an elective test and trying unsuccessfully to present “both sides” of the screening decision, primary care physicians should go back to discouraging its use.