Partnering with community health workers for better primary care

In developing countries, most primary health care is provided not by doctors or nurses, but by community health workers who have limited or minimal medical training. In the U.S., in contrast, most primary care services are provided by physicians with extensive residency training in family medicine, internal medicine, pediatrics, and obstetrics/gynecology. Even the emerging concept of the primary care team largely remains centered around the physician and his or her office practice.

But when patients with multiple uncontrolled chronic medical conditions need intensive primary care, health services researchers are discovering that the critical role of the community health worker may be just as relevant in the U.S. as it is in the Third World. An Innovation Profile in the March issue of the journal Health Affairs describes a pilot program in Vermont where patient-centered medical homes are supported by community health teams consisting of registered nurses, behavioral counselors, and dietitians, and community health workers. These teams have reduced hospital admissions, emergency department visits, and overall costs. As the profile notes, community health workers play multiple vital roles in helping patients access and navigate the care system:

Community health workers on the team help patients fill out insurance applications, follow treatment plans, manage stress, and work toward their personal wellness or disease management goals. In some cases, community health workers accompany patients to appointments and help them find transportation or child care. ... Providers said that they felt they could respond to a range of patient needs - nonclinical as well as clinical - with the community health team's support. As [one physician] puts it, "Having access to the community health team removes the fear of asking a patient the simple open-ended question, 'So, how are things?' If the patient breaks into tears or admits that things at home are chaotic, I do not feel that I need to solve all of their social woes then and there by myself. I have a whole team to help."

As Vermont moves toward becoming the first state in the nation to enact a single-payer health system for all of its residents, its thus-far successful experiment with community health teams as primary care partners bears watching closely.

Should pharma have unrestricted access to doctors' prescribing profiles?

For many years, it has been a common practice for pharmaceutical companies to use individual physicians' prescribing profiles to tailor their marketing and sales strategies. For example, if a drug rep had access to data showing that a particular family doctor was prescribing more of a competitor's anti-hypertensive drug, he or she might make a point of dropping off a batch of samples to change that doctor's prescribing practices. As explained in a previous AFP Journal Club, this strategy is often very effective for the drug company, but ends up increasing patients' out-of-pocket expenses in the long run.

Recently, state legislatures in Vermont, Maine, and New Hampshire have passed laws that restrict access to a physician's prescribing profile for marketing purposes. Drug companies and other groups argue that these laws violate the First Amendment, equating a doctor's prescribing data to constitutionally protected "free speech." A news article in the New York Times reported that the Supreme Court will hear arguments in a lawsuit brought against Vermont's confidentiality law by prescribing data collection companies and the industry group Pharmaceutical Research and Manufacturers of America.

In order to balance the sometimes deleterious effects of aggressive drug marketing, AFP provides numerous online resources to support our readers in decision-making about prescriptions. These resources include a systematic eight-step approach to prescribing and individual reviews of new drugs that utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) approach. Are there other ways that we could help you and your patients make informed drug choices?

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The above post was originally published on the AFP Community Blog.

Incidentalomas: reasons to think twice about getting a CT scan

Mrs. Smith (not her real name) fidgeted in her chair in my examination room as I scanned the radiology report she had given me. She had visited the emergency room the previous evening with severe abdominal pain that had eventually been diagnosed as gastritis, or swelling of the stomach lining due to a virus. During her evaluation, the ER physician had ordered a CT scan of her abdomen and pelvis. Although Mrs. Smith's liver and intestines appeared normal, the radiologist had noted a tiny mass on one of her kidneys.

The report stated that the mass was consistent with a harmless cyst, but concluded with a statement that was all too familiar to me: "Cannot rule out malignancy. Clinical correlation required." Translation: it was almost certainly nothing serious, but there was a very small chance that it might be cancer, and now it was my job to make sure it wasn't. But further investigation of this incidental finding, which had no relationship to Mrs. Smith's original symptoms, would involve a painful biopsy, and if the biopsy was inconclusive, surgery to remove her kidney. In similar situations with other patients, I had suggested the alternative of regular monitoring with additional scans to make sure that the mass wasn't growing; however, this option requires that a patient live each day with the anxiety of not knowing if she has cancer.

That episode happened almost a decade ago. Yet the dilemma that my patient faced is, if anything, much more common today. A study published recently in the journal Radiology found that children visiting U.S. emergency rooms had five times as many CT scans in 2008 as in 1995. By 2008, 6 percent of pediatric ER visits involved a CT scan. The same research group, led by Dr. David Larson at Cincinnati Children's Hospital Medical Center, previously found an even greater rise in scanning during adult ER visits, with 25 percent of patients age 65 and older, and 12 to 16 percent of younger adults, getting a CT scan in 2007.

In addition to increasing risks associated with radiation exposure, all of those CT scans turn up an awful lot of "incidentalomas," the term that doctors use for incidental findings that could be (but probably aren't) cancer. A study published last year in the journal Archives of Internal Medicine found that nearly 40 percent of CT and MRI scans performed for research purposes at the Mayo Clinic from January through March 2004 turned up at least 1 incidental finding. In the 35 patients in whom doctors took further action (additional testing, specialist consultation, or surgery), only 6 were judged by researchers to have clearly benefited from an investigation, while in the rest there was no clear benefit or clear harm, such as complications from surgery for a benign tumor. Of all types of scans, CT of the abdomen and pelvis - the very same scan that my patient got - was the most likely to turn up an incidental finding.

In fact, the American College of Radiology has become so concerned about the problem of incidentalomas on CT scans of the abdomen and pelvis that they recently published detailed guidance for clinicians about how to approach such findings. "Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures," the radiology group warns, advising that doctors carefully consider an individual patient's risk for cancer in deciding whether or not to recommend further evaluation.

So what can you do to reduce the chance you will be harmed by an incidentaloma? Three experts in diagnostic medicine at the the Dartmouth Institute for Health Policy and Clinical Practice recently recommended that patients who are told about an incidental finding always seek a second opinion to verify that the radiologist's interpretation of their scan is correct, and understand that clinical observation of an incidentaloma is often a safer option than more testing or surgery. Also, they advise that patients adopt a "healthy skepticism" about testing and only consent to scans that are absolutely necessary to establish a diagnosis or plan of action, rather than ordered “just to be sure.”

To be honest, I don’t remember what Mrs. Smith chose to do about her incidentaloma. If I saw her as a patient today, I would definitely consult a second radiologist to be sure that the kidney mass was actually there. If it was, I would probably recommend a wait-and-see approach, given that additional testing could create more risk than reward.

And if I had the power to turn back to clock and warn my patient before she arrived in the ER, I’d advise her to ask the physician there if the CT scan was really needed at all.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Andy Rooney on the problem of "partialists"

In lieu of a blog post this week, I'm linking to a short 60 Minutes video featuring CBS's Andy Rooney on the problem of excessive subspecialization in medicine. I prefer the term "partialists," a term described on DB's Medical Rants blog as "those who ignore any problem that does not fit their tunnel vision of their purview."

Book Review: "Overdiagnosed" and the paradox of cancer survivorship

According to the National Cancer Institute and the Centers for Disease Control and Prevention, the number of cancer survivors in the U.S. has increased dramatically in my lifetime, from 3 million in 1971 to 11.7 million in 2007. From 2001 to 2007 alone, the number of persons living with a cancer diagnosis rose by nearly two million. Most people would probably see these statistics as good news: an indication that our cancer treatments are improving and allowing people to live longer, or that earlier diagnoses are giving people a better chance to survive by catching localized cancers before they spread and become impossible to cure.

Although there is some truth to both of these explanations, they are far from the whole story. As H. Gilbert Welch and colleagues argue convincingly in their new book, Overdiagnosed: Making People Sick in the Pursuit of Health, much of the rise in cancer diagnoses over the past several decades has been the result of overdiagnosis: the detection (through screening or incidental finding on medical images obtained for other reasons) of cancers that would otherwise never have caused problems for patients. In the absence of screening, patients would not have developed symptoms because the "cancer" would not have progressed, or the patient was destined to die from some other cause (typically, heart disease). In the presence of screening, however, they suffer the psychological effects of knowing that they have cancer, the complications of diagnostic procedures, and the consequences of unnecessary treatments.

Seen in this light, the rise in cancer survivorship is not a modern medical success story. For millions of patients who received diagnoses that they didn't need and would do nothing to improve their health, it is a catastrophe.

Consider the example of prostate cancer. In a 2009 analysis published in the Journal of the National Cancer Institute, Dr. Welch and prostate cancer expert Dr. Peter Albertsen used data from the NCI's Surveillance, Epidemiology, and End Results (SEER) program to estimate that the introduction of prostate-specific antigen (PSA) screening in 1986 led to an additional 1.3 million U.S. men receiving a prostate cancer diagnosis through 2005. More than 1 million of those men were treated with surgery, radiation, or both. If one assumes optimistically that the entire decline in prostate cancer deaths during this time period can be credited to earlier detection of curable prostate cancers, then 22 out of 23 men who were diagnosed, and 17 out of 18 men who were treated, received no health benefit from their cancer diagnosis. (And that's an optimistic estimate; a 2009 European study put the figure at 47 out of 48.)

When we look harder for asymptomatic cancers and other "silent" diseases such as diabetes and osteoporosis, Dr. Welch argues, we occasionally catch them at more curable stages, but far more commonly find diseases years earlier than we needed to, or that we didn't need to find in the first place. I recall the timeless advice passed on by one of my attending physicians in residency regarding the dangers of heroic interventions: "Don't just do something, stand there!" But doctors (myself included) have a very hard time doing nothing in a patient with a cancer diagnosis, even if patients weren't already conditioned by the popular "War on Cancer" to want to eradicate every abnormal cell from their bodies, regardless of the risks.

I recommend Overdiagnosed to all health professionals and patients as a highly readable cautionary tale of the excessive diagnostic capacity inherent in modern medicine. Screening for selected diseases has its place, of course, but overenthusiastic and uninformed screening in the pursuit of health is more likely to do harm than good, by making people sick for no reason. And stripping away a person's sense of wellness is no small thing, as Dr. Clifton Meador wrote in his 1994 essay "The Last Well Person":

The demands of the public for definitive wellness are colliding with the public's belief in a diagnostic system that can find only disease. A public in dogged pursuit of the unobtainable, combined with clinicians whose tools are powerful enough to find very small lesions, is a setup for diagnostic excess. And false positives are the arithmetically certain result of applying a disease-defining system to a population that is mostly well. ... If the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick. Like the invalids, we will all be assigned to one diagnosis-related group or another. How long will it take to find every single lesion in every person? Who will be the last well person?

A doctor's practical guide to prescription drugs

When I was in residency training, one of my more challenging patients was a woman in her sixties who ended up in the hospital again and again with complications from heart failure and diabetes. I and her other physicians prescribed a dozen powerful medications to keep her conditions under control, but nothing seemed to work. Her blood sugar level was always too high or too low, and, despite our repeated instructions and reminders, it wasn't clear that she understood what each of her medications was for or how to take them on schedule.

Finally, I made a house call in the hope of sorting things out. As soon as I entered my patient's apartment, I realized just how big the problem was. A jumble of prescription bottles sat on a table in her living room. But when I compared this collection to the copy of her medication list that I had brought with me, mismatches emerged. She had been taking a few medications twice or three times as often as prescribed, and several not at all. It turned out she had been confused by the instructions printed on the labels. Did "take three times daily" mean the same as "take once every eight hours"? And when was it okay to take medications labeled "as needed"?

Some medications made her feel weak or lightheaded, so she used them less often or stopped taking them altogether. And she admitted she had been unable to afford one particularly expensive drug, but had been too embarrassed to tell me before.

In medical school, my classmates and I spent long hours memorizing the right drugs to prescribe for patients with particular diagnoses. We assumed that this would be the hardest part of our jobs, and that once it was done, the patient would obediently take the drug and get better. Since much of medical training takes place in hospitals, where drug supplies are plentiful and nurses administer correct doses at appropriate intervals, our assumption wasn't completely wrong.

But it isn't entirely correct, either—especially when the patient isn't in the hospital. A study of nearly 200,000 outpatient electronic prescriptions published last year in the Journal of General Internal Medicine drew a stunning conclusion: nearly 3 in 10 new prescriptions were never filled at the pharmacy.

To make matters worse, patients who pick up their medications frequently find the instructions difficult to understand. There is little consistency in how pharmacies format their prescription labels, which can lead to confusion if a patient uses more than one pharmacy. Taking several medications is even more challenging. According to a report last month in the journal Archives of Internal Medicine, only 15 percent of older adults were able to correctly consolidate a 7-drug regimen into 4 doses per day, and adults with lower literacy or less formal education were even less capable of doing so. Although researchers have developed quick questionnaires to help family doctors judge a patient's literacy level, I don't have any colleagues who routinely use them in practice.

The good news is that efforts are underway to design standard prescription labels that are easier to read and follow; the bad news is that these commonsense changes probably won't be coming to your pharmacy any time soon. So what can you do to make sure that you and your doctor are on the same page regarding your prescriptions?

First, don't be afraid to ask how much a new medication costs. If you can't afford it, chances are you won't take it. A previous blog post discusses several options for saving money on medications, including substituting older medications or generics. Also, make a point to communicate concerns about unwanted side effects; your doctor can usually manage these by lowering the dose or switching to a different drug.

Most importantly, go over your dosing schedule with your doctor, nurse, or pharmacist as often as it takes to be confident that you know exactly how much medicine to take, and at what times of the day. Commonly prescribed drugs for conditions such as high blood pressure and diabetes can be harmful, even fatal, in excessive doses. I encourage patients who take 3 or more medications to bring all their prescription bottles to office visits, so doctors or medical staff can compare them to the office record and correct any discrepancies.

These simple steps should go a long way toward improving your health—just what the doctor ordered.

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The above post was first published on my Healthcare Headaches blog at USNews.com.