The recently published American College of Cardiology / American Heart Association cholesterol treatment guideline, which updates the National Heart, Lung, and Blood Institute's Adult Treatment Panel III recommendations that have guided clinicians for more than a decade, has generated controversy for several reasons: primary care groups did not participate in development of the guideline; several panelists had financial conflicts of interest; its cardiovascular risk calculator may substantially overestimate risk in certain populations; and the lowered risk threshold for prescribing medication, if adopted worldwide, could potentially result in more than a billion people taking statin drugs.
Family physicians who have grown comfortable with ATP III's "treat to target" paradigm for cholesterol management were likely surprised by the new guideline's "fire and forget" approach, which advises prescribing fixed doses of statins based on cardiovascular risk assessments and not routinely rechecking cholesterol levels. The latter approach is more consistent with the evidence from randomized controlled trials, but this change is, nonetheless, a significant reversal of an established medical practice. Although such reversals are surprisingly common, they can be unsettling to clinicians.
In an editorial in the December 1st issue of American Family Physician, Drs. Caroline Wellbery and Rebecca McAteer review reasons for other dramatic reversals such as hormone replacement therapy and tight glucose control in diabetes, which include poor design and small size; focus on disease-oriented evidence, application of findings to nonstudy populations; unidentified harms; and economic factors. They have several related suggestions to help physicians avoid pitfalls associated with currently accepted practices that may be vulnerable to later reversal:
To minimize the dizzying impact of changing recommendations, physicians should focus on patient-oriented evidence, and not be distracted by disease-oriented evidence. Physicians should become familiar with the basic principles of good research, and avoid drawing premature conclusions from observational studies or studies with design flaws. Physicians should also recognize the pharmaceutical industry's influence on research studies and practice recommendations.
**
This post first appeared on the AFP Community Blog.
Monday, December 9, 2013
Monday, December 2, 2013
What can Rwanda teach the U.S. about primary care?
As reviewed on this blog and in many other sources, the relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world but rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although economic inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I'd argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.
Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of an Atlantic headline that caught my eye earlier this year: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a recent BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to only 33% of eligible U.S. girls in 2012.
Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? (That's right, 2 dollars for an entire year. According to the Kaiser Family Foundation, the average monthly individual premium for generally healthy persons in 2010 was $215, or just over $2500 per year.)
They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:
Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.
The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this (apologies for my poor graphical skills):
At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.
The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's sometimes easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that probably don't require any imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.
Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of an Atlantic headline that caught my eye earlier this year: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a recent BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to only 33% of eligible U.S. girls in 2012.
Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? (That's right, 2 dollars for an entire year. According to the Kaiser Family Foundation, the average monthly individual premium for generally healthy persons in 2010 was $215, or just over $2500 per year.)
They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:
Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.
 |
| Image courtesy of BMC Health Services Research. |
The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this (apologies for my poor graphical skills):
At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.
The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's sometimes easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that probably don't require any imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.
Thursday, November 21, 2013
Care transitions: 4 key questions to ask your doctor
Doctors do the best they can to keep patients healthy and out of the hospital. Sometimes, though, hospitalization is necessary despite the best possible care. At the first private practice I joined after residency training, my colleagues and I admitted patients to a local hospital and took turns caring for those who needed inpatient treatment. This system ensured we'd have easy access to their previous medical records and often know them on a personal level. Arranging office appointments after discharge was almost never a problem, and we were guaranteed knowledge of what had happened to our patients in the hospital.
That's all changed. The way patients receive hospital care has transformed radically in the past 15 years. Many primary care physicians, pressured to take on more patients and exhausted from being on call too many nights, have stopped seeing their patients through a hospital stay. Instead, they now rely on "hospitalists," a relatively new breed of specialists whose exclusive responsibility is to care for hospitalized patients.
There are potential advantages to being treated by a hospitalist rather than a family doctor. Because hospitalists spend all their time on the wards rather than trying to juggle obligations to hospital and office patients, they're usually easier to reach with questions or concerns. Also, hospitalists may be more up-to-date on the latest medical research on inpatient treatments. These advantages should theoretically translate into better care and shorter stays for hospital patients. And they do, according to a 2007 study published in the New England Journal of Medicine; researchers found that patients cared for by hospitalists indeed had shorter hospital stays and lower medical costs than those cared for by primary care physicians.
There are potential advantages to being treated by a hospitalist rather than a family doctor. Because hospitalists spend all their time on the wards rather than trying to juggle obligations to hospital and office patients, they're usually easier to reach with questions or concerns. Also, hospitalists may be more up-to-date on the latest medical research on inpatient treatments. These advantages should theoretically translate into better care and shorter stays for hospital patients. And they do, according to a 2007 study published in the New England Journal of Medicine; researchers found that patients cared for by hospitalists indeed had shorter hospital stays and lower medical costs than those cared for by primary care physicians.
But as hospitalists are replacing family doctors on hospital wards, concern is mounting that poor communication between hospital and office physicians could lead to worse health outcomes after discharge. I personally know the frustration of seeing a patient in the office after a recent hospitalization having not received critical information about what medication changes were made, what procedures he underwent, or what tests are needed to monitor his condition. Patients whose doctors don't have access to complete information during follow-up visits may be more likely to end up in the emergency room or be hospitalized yet again. (Same goes for patients who don't schedule follow-up visits at all.)
A study published in the Annals of Internal Medicine in 2011 seemed to confirm these fears. In a nationally representative sample of Medicare patients admitted to hospitals between 2001 and 2006, those who were cared for by hospitalists had slightly shorter average hospital stays and slightly lower hospital bills than those cared for by primary care physicians. However, in the 30 days after discharge, hospitalist patients were more likely to be readmitted or land in the emergency room. One possible explanation: poor communication, since hospitalist patients were significantly less likely to follow up with their primary care physicians after discharge.
To improve the quality of "care transitions" between hospitalists and family doctors, some health systems have devised programs to ensure patients get the recommended follow-up care. Two other studies published in 2011 evaluated such programs. In one study, seniors who'd been hospitalized for heart failure at Baylor Medical Center in Garland, Texas received several home visits by specially trained nurses between three days and three months after discharge. Those enrolled in the nurse-visit program were only half as likely as past heart failure patients to be readmitted within 30 days. In another study, patients at six Rhode Island hospitals were assigned health coaches (nurses or social workers) who visited them once in the hospital, once at home, and telephoned them twice to encourage follow-up with primary care physicians and ask about any worrisome signs or symptoms. Patients in that program were nearly 40 percent less likely to be readmitted within 30 days than patients who received no health coaching.
Because it's impossible to predict whether you or a loved one will need to be hospitalized, it's important to understand your doctor's policies for patients who require hospital care. You can start by asking these 4 questions:
1. Do the practice's physicians care personally for patients in the hospital, or do they rely on hospitalists?
2. If you live in a metropolitan area with multiple hospitals to choose from, which hospital does your doctor prefer?
3. If you are seen by a hospitalist, what protocols are in place to ensure timely communication between the hospital and your doctor's office about follow-up plans?
4. Are you eligible for any programs that assist patients with care transitions?
Given all of the changes that have taken place in medicine, many communities are unlikely to return to the "old days" when the same doctors were responsible for caring for their patients both in and out of the hospital. Consequently, patients need to be proactive to be sure that they receive the best post-hospital care. Being hospitalized is always stressful, but knowing that your follow-up care won't fall through the cracks may give you peace of mind.
**
This post first appeared on Common Sense Family Doctor in a slightly different form on August 11, 2011.
A study published in the Annals of Internal Medicine in 2011 seemed to confirm these fears. In a nationally representative sample of Medicare patients admitted to hospitals between 2001 and 2006, those who were cared for by hospitalists had slightly shorter average hospital stays and slightly lower hospital bills than those cared for by primary care physicians. However, in the 30 days after discharge, hospitalist patients were more likely to be readmitted or land in the emergency room. One possible explanation: poor communication, since hospitalist patients were significantly less likely to follow up with their primary care physicians after discharge.
To improve the quality of "care transitions" between hospitalists and family doctors, some health systems have devised programs to ensure patients get the recommended follow-up care. Two other studies published in 2011 evaluated such programs. In one study, seniors who'd been hospitalized for heart failure at Baylor Medical Center in Garland, Texas received several home visits by specially trained nurses between three days and three months after discharge. Those enrolled in the nurse-visit program were only half as likely as past heart failure patients to be readmitted within 30 days. In another study, patients at six Rhode Island hospitals were assigned health coaches (nurses or social workers) who visited them once in the hospital, once at home, and telephoned them twice to encourage follow-up with primary care physicians and ask about any worrisome signs or symptoms. Patients in that program were nearly 40 percent less likely to be readmitted within 30 days than patients who received no health coaching.
Because it's impossible to predict whether you or a loved one will need to be hospitalized, it's important to understand your doctor's policies for patients who require hospital care. You can start by asking these 4 questions:
1. Do the practice's physicians care personally for patients in the hospital, or do they rely on hospitalists?
2. If you live in a metropolitan area with multiple hospitals to choose from, which hospital does your doctor prefer?
3. If you are seen by a hospitalist, what protocols are in place to ensure timely communication between the hospital and your doctor's office about follow-up plans?
4. Are you eligible for any programs that assist patients with care transitions?
Given all of the changes that have taken place in medicine, many communities are unlikely to return to the "old days" when the same doctors were responsible for caring for their patients both in and out of the hospital. Consequently, patients need to be proactive to be sure that they receive the best post-hospital care. Being hospitalized is always stressful, but knowing that your follow-up care won't fall through the cracks may give you peace of mind.
**
This post first appeared on Common Sense Family Doctor in a slightly different form on August 11, 2011.
Thursday, November 14, 2013
Tackling the problem of too few family physicians
Researchers at the American Academy of Family Physicians' Robert Graham Center have estimated that the U.S. will require 52,000 additional primary care physicians by 2025 due to the effects of population growth, aging, and insurance expansion. Since it takes at least eleven years of post-secondary education to train a family physician, even a renewed surge of student interest in primary care careers is unlikely to meet this anticipated need. Another recent Graham Center study concluded that expanding the scope of practice of nurse practitioners and physician assistants would still result in an overall shortage of primary care clinicians.
This month's issue of Health Affairs contains several proposals to expand the capacity of the existing primary care workforce. Scott Shipman and Christine Sinsky review effective strategies for reducing waste and improving efficiency in office practice: delegating clerical and administrative tasks, using medical assistants as work "flow managers," establishing non-physician protocols for routine chronic care and test ordering, and moving some types of acute care visits online. If each practicing primary care clinician could free up capacity to see one more patient each working day, that would translate into 30 to 40 million additional visits per year.
Another review by Jonathan Weiner and colleagues projects increases in efficiency and reductions in future demand for office visits from expansion of health information technology and e-health applications. Based on the published literature, they estimate that even incomplete implementation of existing technologies could increase physician visit capacity by up to 21 percent.
Finally, Arthur Kellermann and colleagues propose creating the new occupation of "primary care technician," analogous to the existing profession of emergency medical technicians (EMTs), who provide the vast majority of first-contact emergency medicine in the field. This is their job description:
What we need are primary care extenders with local ties and cultural competence of community health care workers, the procedural skills of PAs, and ready access to the knowledge of NPs and primary care physicians. They should be easy to train, inexpensive to employ, and capable of working miles apart from their supervising providers. ... Primary care technicians could be quickly trained to deliver basic preventive, minor illness, and stable chronic disease care to populations that currently lack access to care.
Are these proposals, taken individually or in combination, adequate solutions to the problem of too few U.S. family physicians?
**
This post was originally published on the AFP Community Blog.
This month's issue of Health Affairs contains several proposals to expand the capacity of the existing primary care workforce. Scott Shipman and Christine Sinsky review effective strategies for reducing waste and improving efficiency in office practice: delegating clerical and administrative tasks, using medical assistants as work "flow managers," establishing non-physician protocols for routine chronic care and test ordering, and moving some types of acute care visits online. If each practicing primary care clinician could free up capacity to see one more patient each working day, that would translate into 30 to 40 million additional visits per year.
Another review by Jonathan Weiner and colleagues projects increases in efficiency and reductions in future demand for office visits from expansion of health information technology and e-health applications. Based on the published literature, they estimate that even incomplete implementation of existing technologies could increase physician visit capacity by up to 21 percent.
Finally, Arthur Kellermann and colleagues propose creating the new occupation of "primary care technician," analogous to the existing profession of emergency medical technicians (EMTs), who provide the vast majority of first-contact emergency medicine in the field. This is their job description:
What we need are primary care extenders with local ties and cultural competence of community health care workers, the procedural skills of PAs, and ready access to the knowledge of NPs and primary care physicians. They should be easy to train, inexpensive to employ, and capable of working miles apart from their supervising providers. ... Primary care technicians could be quickly trained to deliver basic preventive, minor illness, and stable chronic disease care to populations that currently lack access to care.
Are these proposals, taken individually or in combination, adequate solutions to the problem of too few U.S. family physicians?
**
This post was originally published on the AFP Community Blog.
Friday, November 8, 2013
The best recent posts you may have missed
Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from August, September, and October:
1) I oppose Obamacare; I support the Affordable Care Act (9/30/13)
2) Conservative Medicine: Why am I the best person to write it? (8/27/13)
3) Doctors are the biggest driver of health care costs (10/29/13)
4) Conservative Medicine: Why is now the right time for it? (9/4/13)
5) Mindful communication, physician burnout, and patient satisfaction (9/22/13)
If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!
1) I oppose Obamacare; I support the Affordable Care Act (9/30/13)
2) Conservative Medicine: Why am I the best person to write it? (8/27/13)
3) Doctors are the biggest driver of health care costs (10/29/13)
4) Conservative Medicine: Why is now the right time for it? (9/4/13)
5) Mindful communication, physician burnout, and patient satisfaction (9/22/13)
If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!
Sunday, November 3, 2013
Why don't clinicians discuss cancer screening harms?
Recently, I attended a conference that included an exercise where attendees were asked how many patients they thought it was acceptable to diagnose and treat needlessly (or "overtreat") in order to prevent one death from cancer. We stood at various points along a wall that represented different thresholds: at one end, 100 persons overtreated for every 1 life saved; at the other, 1 person overtreated for every 1 life saved. Not surprisingly, attendees held a wide range of opinions (I stood somewhere in the middle), but the exercise illustrated the tradeoff inherent in effective screening tests for breast, colorectal, and cervical cancer: for every person who benefits from screening, others will be harmed. This fact has led many physicians to advocate that shared decision-making be used more widely to integrate patients' preferences and values with the decision to accept or decline a screening test.
How often do physicians take the time to explain the harms of cancer screening to their patients? A research letter published in JAMA Internal Medicine explored this question in an online survey of 317 U.S. adults between 50 and 69 years of age. 83 percent of participants had attended at least 1 routine cancer screening; 27 percent had undergone 3 or more. However, less than 10 percent of participants had ever been informed by their physicians of the risk that the screening test(s) could lead to overdiagnosis and overtreatment. The few physicians who did attempt to quantify this risk generally provided information that was inconsistent with the medical literature.
If the results of this survey are representative of the practices of U.S. primary care clinicians, then more than 90 percent aren't telling patients that there are downsides to undergoing routine mammograms, colonoscopies, and Pap smears. Why not? Is it because they aren't familiar enough with the data to accurately describe these harms? Or is it because they fear that patients who receive information about cancer screening harms will choose to decline these tests?
**
This post originally appeared on the AFP Community Blog.
How often do physicians take the time to explain the harms of cancer screening to their patients? A research letter published in JAMA Internal Medicine explored this question in an online survey of 317 U.S. adults between 50 and 69 years of age. 83 percent of participants had attended at least 1 routine cancer screening; 27 percent had undergone 3 or more. However, less than 10 percent of participants had ever been informed by their physicians of the risk that the screening test(s) could lead to overdiagnosis and overtreatment. The few physicians who did attempt to quantify this risk generally provided information that was inconsistent with the medical literature.
If the results of this survey are representative of the practices of U.S. primary care clinicians, then more than 90 percent aren't telling patients that there are downsides to undergoing routine mammograms, colonoscopies, and Pap smears. Why not? Is it because they aren't familiar enough with the data to accurately describe these harms? Or is it because they fear that patients who receive information about cancer screening harms will choose to decline these tests?
**
This post originally appeared on the AFP Community Blog.
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