Is there enough time for prevention in primary care?

Family physicians are being squeezed by two accelerating trends: (1) too few of us to care for the growing US population and (2) the rising number of tasks that we are asked to accomplish for each patient. A 2024 analysis projected that by 2040 a shortage of 58,000 primary care clinicians (including nurse practitioners and physician assistants) will occur. Meanwhile, the estimated time needed to provide guideline-recommended preventive care, chronic disease care, and acute care to a nationally representative panel of 2,500 adult patients is an impossible 26.7 hours per day, with more than one-half of that time (14.1 hours) allocated to preventive care.

As science advances, the number of US Preventive Services Task Force (USPSTF) A and B graded recommendations grows, and the size of the affected populations expands. Since 2020, the starting ages for breast, lung, and colorectal cancer screening were lowered to 40, 50, and 45 years, respectively. The USPSTF also has endorsed screening most adults for anxiety disorders and unhealthy drug use. In an editorial in the February 2025 issue of American Family Physician, Dr. Mark Ebell and I discussed concerns about the quality of the evidence for several recommendations. "To justify the extra time and effort associated with implementing new or expanded screening recommendations," we cautioned, "clinicians must have confidence in the reliability of USPSTF assessments regardless of the task force’s membership at any point in time."

A 2025 commentary in the BMJ proposed a radically different solution to the workforce crisis: Take prevention for low-risk patients off the plate of primary care. The authors noted that as measured by the number of patients needed to treat to prevent one negative outcome, “care for symptomatic patients provides substantially greater benefit than preventive care.” Rather than counseling patients individually to quit smoking, drink less alcohol and sugar-sweetened beverages, and consume fewer highly processed foods, medicine should defer prevention to public policy measures (eg, taxes on cigarettes and laws restricting where people can smoke) that achieve these goals more effectively. Not only would this approach free time for family physicians to focus on patients with acute complaints and chronic diseases, the authors argued, but it would also remove the “ethical stress” that comes with “the mismatch between the patient’s needs and the burden of preventive care” in the form of quality metrics.

The problem with this proposal is that in the United States, the public health workforce is not positioned to handle routine screenings and immunizations. This month, the Centers for Disease Control and Prevention (CDC), the federal agency sponsor of the USPSTF’s sister panel, the Community Preventive Services Task Force (CPSTF), was forced to lay off 10% of its work force. Portions of the CPSTF’s website, including the biographies of its current members, are still missing after thousands of CDC web pages were abruptly removed or altered. There may not be enough time for prevention in primary care, but family physicians need to keep providing it the best we can.

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This post first appeared on the AFP Community Blog.

Book Review: Booster Shots by Dr. Adam Ratner

In two decades of practicing family medicine, I've never seen a patient with measles. But if there was ever a more fertile environment for this age-old contagion to come roaring back in the U.S., this is it. As a measles outbreak in West Texas approaches 100 cases and the national percentage of kindergarten-age children who have received measles, mumps, and rubella (MMR) vaccine has fallen below 93%, vaccine conspiracy theory amplifier Robert F. Kennedy, Jr. has taken the reins as Secretary of Health and Human Services (HHS). In his first week on the job, Kennedy declared his intention to re-evaluate the entire recommended vaccine schedule and indefinitely postponed next week's meeting of the CDC's Advisory Commission on Immunization Practices, which creates the schedule and had been holding uninterrupted meetings to provide guidance for clinicians for the past 60 years. (Oh, and the CDC's National Immunization Survey has been canceled by the so-called Department of Government Efficiency, even if the Epidemic Intelligence Service seems to have received a temporary reprieve.)

This real-life scenario is probably Dr. Adam Ratner's worst nightmare, but it couldn't have come at a better time for his book. Ratner, a pediatric infectious diseases specialist at NYU Grossman School of Medicine, wrote Booster Shots: The Urgent Lessons of Measles and the Uncertain Future of Children's Health to retrace the history of human interactions with measles and explain why our mastery of the science of vaccination hasn't led to enduring eradication of this highly transmissible, damaging, and occasionally lethal infection. In the introduction, Ratner conveys the fury of two grandparents at their adult daughter for refusing measles vaccination for their granddaughter, who becomes one of the first of hundreds of New York City children to be hospitalized for measles in a 2018-19 outbreak:

What happened between those two generations, the vaccine-hesitant mother and her own parents, dumbstruck at the idea of someone opting out of the miracle of vaccination? How did we go from eliminating measles in the United States ... to a massive resurgence in 2019, presaged by smaller blips in the prior years? And should those blips have warned us about some of the problems that we would face with the COVID-19 pandemic - the vaccine hesitancy, the demands for unproven (and sometimes rigorously and scientifically disproven) medications, the distrust of doctors and public health professionals, the underestimation of the new virus's effect on children?

Ratner does an exceptional job describing the epidemiology and virology of measles without watering down the science for a general audience, and the fascinating narrative of the history of measles epidemics over the centuries left me wondering if he had a master's degree in history rather than public health. The most impactful chapters, though, are "Making Nothing Happen," about the laboratory breakthroughs that led to the licensing of the first measles vaccines; and "Amnesia," which juxtaposes the immune system amnesia that often results from measles infection and the human amnesia that causes declines in cases to make people forget why it's necessary to protect children and adults against measles in the first place.

In the concluding chapter, written long before Kennedy was nominated or confirmed as HHS Secretary, Ratner emphasizes the importance of confronting him and other purveyors of vaccine misinformation with the same resolve and attention to detail that have produced the unrivaled medical success of the routine childhood immunization schedule: preventing 508 million cases of illness, 32 million hospitalizations, and 1,129,000 deaths in the U.S. over the past 30 years. This is the perfect book for a very imperfect era, when the future health of our nation very much hangs in the balance. Fortified by Booster Shots, champions of prevention will be able to stand their ground.

Direct-to-consumer advertising distorts prescription drugs’ benefits and costs

In 1998, a Letter to the Editor in American Family Physician expressed concerns about the relatively new practice of pharmaceutical advertising directly to patients. Dr. Robert Thompson observed that the effect of direct-to-consumer advertising (DTCA) was to consume precious time at an office visit by prompting patients to request expensive new “me too” therapies that often were not on their drug formularies. He argued that "the pharmaceutical industry should concentrate its efforts on educating physicians about its new products, not coercing patients to put pressure on physicians to make decisions that may not be necessary, beneficial or cost-effective."

A quarter of a century later, the United States remains the only country besides New Zealand where DTCA for prescription drugs is completely legal. In November 2024, a new U.S. Food and Drug Administration (FDA) rule went into effect requiring television and radio advertisements for drugs to communicate risk and contraindications in a “clear, conspicuous, and neutral manner.” On the surface, this rule aligns with the American Academy of Family Physicians’ policy that information provided in DTCA "should be accurate, balanced, objective, and complete, not false or misleading, and should not promote unhealthy or unsafe practices."

But a recent perspective in the American Journal of Preventive Medicine pointed out that the rule is silent about advertisements on online and social media platforms. It also does not change the context that most patients overestimate drug safety and that the most heavily advertised drugs have lower added benefit compared with similar medications.

To take one example, a television ad for the moderate-to-severe plaque psoriasis drug risankizumab (Skyrizi) was ubiquitous during the just-concluded National Football League regular season and playoffs. On Sensible Medicine, Dr. Edward Livingston pointed out that the manufacturer, AbbVie, spent $580 million on DTCA for this drug in 2023, or $290 for each of the 2 million potential patients in the United States. The annual price of risankizumab is $288,000, so this is still a huge bargain for the company given the potential returns. Dr. Livingston explained that the ad misleads viewers about the indication and cost of risankizumab:

It shows a psoriatic lesion involving less than 1% of body surface area (BSA). Drugs like risankizumab are only indicated for moderate (3-10% BSA) or severe (>10% BSA) plaque psoriasis. Viewers of the ad might believe this drug can be used to treat small, isolated lesions. They will be influenced by the visuals and are not likely to understand that risankizumab should only be used for more severe disease than is shown in the ad.… The ad states that patients may pay as little as $5 per dose, 4 times per year.… The price on the website is even better: $0 per dose. Who could blame a patient for believing the drug doesn’t cost much. If it did, why give it for free? But it is not free. Rather it is one of the most expensive psoriasis treatments available. Who pays? All of us.

A 2023 commentary in BMJ Evidence-Based Medicine contended that DTCA may "encourage patients to self-diagnose or to misinterpret their symptoms, contributing to often unnecessary diagnostic testing and the twin risks of overdiagnosis and overtreatment."

Potential reforms short of making DTCA illegal in the United States include legislation requiring manufacturers to include drug prices in ads and Secretary of Health and Human Services Robert F. Kennedy, Jr.’s previously stated intention to ban DTCA from television. However, the DTCA bill has repeatedly died in every Congress since 2019, and executive action on DTCA would almost certainly prompt a First Amendment court challenge by pharmaceutical companies.

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This post first appeared on the AFP Community Blog.

Does transitional care management improve outcomes after discharge from the hospital?

I've spent the past week as the attending physician on my residency program's adult inpatient service. Since the turn of the century, the rise of hospitalists and the corresponding decline in the number of office-based family physicians who provide inpatient care for their own patients has magnified the value of optimizing the handoff from hospital-based teams to primary care physicians. Chronic conditions that frequently lead to readmissions, such as heart failure, have been targets of transitional care interventions that may include self-care education, home visits, telephone contacts, and office visits. A 2014 Agency for Healthcare Research and Quality review found consistent evidence that high-intensity, multicomponent interventions for patients with heart failure reduced readmissions and mortality for 3 to 6 months after hospital discharge.

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.