Wednesday, January 17, 2018

There are few parachute-like practices in family medicine

I try my best to practice evidence-based medicine on a daily basis. When I know that the test or intervention that I am recommending for my patient is based on expert opinion rather than reliable data on patient-oriented outcomes that matter, I invariably make a point of saying so. It has been my position for several years that despite the impressive effectiveness of newer antiviral medications for hepatitis C at producing a sustained virologic response (SVR), there are still not enough data to be certain that SVR always represents a "cure," and therefore not enough data to warrant age cohort-based screening of adults without known risk factors for the infection. In a recent Medscape commentary, I went one step further, mentioning a famous 2003 BMJ paper on "Parachute use to prevent death and major trauma related to gravitational challenge," which asserted that the health benefits of some interventions are so glaringly obvious that, like parachutes, they do not need to be evaluated in randomized, controlled trials (RCTs). Screening for hepatitis C, I contended, should not be considered a "parachute" for clinical research purposes. As some colleagues and I argued a few years ago, a randomized trial of screening versus usual care would not only be ethical, but logistically feasible and well worth the investment.

In an ingenious analysis published today in CMAJ Open, a team of researchers that included my friend, colleague, and prolific tweeter Dr. Vinay Prasad used Google Scholar to identify articles that cited the BMJ parachute paper to argue that a medical practice was analogous to a parachute - or in other words, so obviously beneficial that RCTs were not needed. The team then searched the literature for previous or subsequent RCTs that tested the practice in question. Of the 35 practices, 22 have, in fact, been tested in one or more RCTs. Guess how many of these practices ended up being backed up by trials that showed a statistically significant benefit? Only 6 out of 22, barely edging out the 5 "obviously beneficial" practices that were actually found to be ineffective in RCTs (the remaining 11 had mixed results or halted or ongoing trials). The investigators concluded: "Most parachute analogies in medicine are inappropriate, incorrect or misused."

Although some interventions that were refuted by RCTs lie outside of the scope of family medicine, I took note of two that not only sounded familiar (because I had once been told by an "expert" that they were true), but where I could personally make an impact on decreasing ineffective, potentially harmful care. Compared to medical therapy, stenting for renal artery stenosis does not reduce cardiovascular events. Compared to standard hemoglobin A1c targets, tighter control of blood glucose levels in persons with type 2 diabetes does not reduce cardiovascular deaths. In particular, I have inherited several adult patients with type 2 diabetes whose previous physicians tried to push their hemoglobin A1c levels to 6.5% or lower by adding expensive second or third drugs that increased their risk for hypoglycemia, based on the faulty assumption (parachute!) that these would prevent a heart attack or stroke somewhere down the line. But I practice evidence-based medicine, not parachute-based medicine. I discontinued those unnecessary medications to prevent further injury to these patients or their pocketbooks.

Monday, January 8, 2018

Does convenience outweigh continuity of care?

Several years ago, after leaving my scientific position at AHRQ and feeling that my patient care skills had become rusty, I took a part-time job as a staff physician at a rapidly growing chain of urgent care centers. I thought that urgent care's relatively limited scope of practice would ease my transition back into the clinic, and though the pace was often intense, I quickly became comfortable sewing up lacerations, draining abscesses, diagnosing fractures, and fishing various objects out of ears and noses. All in all, it was a rewarding experience: my physician colleagues were friendly and experienced, the support staff skilled and professional, and since we stayed open from from 7 AM to 10 PM every day of the year, our walk-in patients were generally grateful to be seen.

After about a year of this work, I decided to return to academic medicine. During my interview, I mentioned to the then-Department Chair that I had been working in urgent care. He visibly grimaced, then said something about urgent care centers "skimming the cream" of primary care and leaving full-service family practices with the more complex and less lucrative types of visits. And I couldn't really disagree. If there's one axiom at the heart of family medicine, it's the importance of continuity of care - meaning, whether you feel sick or well, seeing a doctor who knows you will make it more likely you will get the care you need. A systematic review in the Journal of Family Practice and another review in the Journal of Evaluation in Clinical Practice both concluded that increased continuity was associated with higher quality care, better outcomes, and higher patient satisfaction.

The problem with prioritizing continuity of care is ensuring access. My current practice is open until 8 PM two evenings per week and, for a few years, we also saw patients on Saturday mornings. But none of us really like to work on Saturdays, and we recently learned that of all the primary care practices in our health system, we are the only ones who have even been open on that day. Further, the nature of an academic practice is that my colleagues and I are only each at the office a day or two per week, further limiting the ability of patients to see the same doctor every time. Can continuity of care be said to have the same value if it's only with the same office, rather than the same person? It's a question that needs answering, as a study from the Robert Graham Center found that an increasing proportion of Americans identify an office or facility, rather than an individual clinician, as their usual source of health care.

Finally, retail health clinics (think CVS's Minute Clinics), like urgent care centers, have emerged and prospered as a response to deficiencies in primary care access, but handle a more limited range of acute problems and are staffed by nurse practitioners rather than physicians. On one hand, retail clinics may disrupt continuity of care, but on certain measures of quality, such as antibiotic prescribing for respiratory infections, they are more likely to adhere to national guidelines. And even a respected health policy researcher such as Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University, admitted that he would rather take his child to a retail clinic for a sore throat than deal with the hassle of getting a same-day appointment with their usual physician. So much for continuity of care and the patient-centered medical home that physician groups have been advocating for the past decade as the solution to excessive health spending and mediocre outcomes! Or can these concepts coexist with the convenience of urgent and retail health care?

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This post originally appeared on Common Sense Family Doctor on May 23, 2016.

Thursday, December 21, 2017

The fallacy of expert-centered guidelines

The Health News Review blog posted a story yesterday asking why there was such extensive news coverage of the American College of Cardiology / American Heart Association hypertension guideline but so far, so little of the American Academy of Family Physicians' announcement that it was not endorsing the guideline (the only other news outlets to have reported this decision are the AAFP's own news publication and Medscape). It's a good question, since "de-intensification" (stepping back on intensity or frequency) of recommendations in clinical practice guidelines is relatively uncommon. In this case, the AAFP decided to continue to adhere to blood pressure targets established by the JNC-8 hypertension guideline and its joint guideline with the American College of Physicians for adults aged 60 years or older.

I don't usually read the journal Hypertension, so I only recently came across an editorial (published on June 26) that criticized the ACP-AAFP guideline for the lack of "experts" on its panel. The 30 named authors of this 3-page piece, most of whom I suspect did not meet the International Committee of Medical Journal Editors' authorship criteria, collectively have a list of disclosures of commercial conflicts of interest that takes up nearly a column of text. Those concerns aside, Dr. Franz Messerli and colleagues stated correctly that "guidelines are traditionally scripted by a panel of experts who are intimately familiar with the topic in question." They went on to compare the glittering resumes of the JNC-8 panel ("most of them were indeed true experts") with the more pedestrian ones of the ACP/AAFP panel and asserted that the latter's dearth of expertise did not qualify them for guideline development:

As per PubMed, 3 of the 7 guideline authors have never authored an article on hypertension and 1 has coauthored a single study only. Moreover, not one of the authors of the ACP/AAFP guideline is known to be a hypertension specialist certified by the American Society of Hypertension or of the American Heart Association Council for High Blood Pressure. ... No ACP/AAFP guideline author is currently serving on the editorial board of a journal dealing with hypertension. ... The mere fact that you know how and when to prescribe hydrochlorothiazide does not make you an expert in hypertensive cardiovascular disease.

This argument echoes past complaints by subspecialty groups that the U.S. Preventive Services Task Force (USPSTF), made up entirely of primary care clinicians, could not possibly know what it was doing when it recommended fewer screening mammograms (without any radiologists!) or less prostate-specific antigen testing for prostate cancer (without any urologists!)

The question is not whether subspecialists should be involved in developing guidelines for diagnosis and management of common conditions such as hypertension: of course they should be. The question is, on what level? At the guideline review and revision phase (ACP/AAFP) or in developing the key recommendations? The ACC/AHA selected as one of its guideline co-chairs Dr. Paul Whelton, a renowned expert in hypertension who was the principal investigator for the SPRINT study, the only major trial to show that a blood pressure target of 120/80 yielded more benefits than harms compared to a blood pressure target of 140/90 in a selected group of high-risk patients (as it turns out, even more high-risk than previously reported). In recognition of this intellectual bias, Dr. Whelton was relieved from chairing duties when SPRINT came up, but apparently was able to fully participate in the discussion and vote.

Incidentally, I had the pleasure of meeting Dr. Whelton at a conference 2 years ago and came away enormously impressed by his intelligence and equanimity. But it's very hard for anyone to see something - in this case, harms of lower blood pressure thresholds - if your scientific reputation depends on your overlooking it. Also, in my experience as a staffer for the USPSTF, panel members who did not treat the condition being screened for were able to follow the evidence without being biased by clinical experience. Pediatricians who weren't conditioned to order yearly mammograms or obstetrician-gynecologists who never ordered PSA tests were more often assets than liabilities on these topics.

Finally, primary care clinicians, particularly family physicians, have unrivaled expertise in treating the whole person, not only one body part or organ system. As I wrote in my Medscape commentary on the ACC/AHA hypertension guidelines, "Cardiologists have the luxury of only needing to be concerned with cardiovascular disease, but the vast majority of my patients with hypertension have comorbid chronic conditions and take several medications. Adding one more anti-hypertensive drug means more potential side effects, medication interactions, and costs to the patient and the health system." Kudos to the AAFP for having the courage to stick with the evidence and buck this one-low-blood-pressure-target-fits-all trend.

Monday, December 18, 2017

Twelve months of Common Sense Family Doctor: 2017's greatest hits

Although I don't rule out writing another post or two before the year is out, below is a recap of my favorites from each month, starting in January. I hope that you enjoy reading (or re-reading) each of them. Looking ahead to 2018, I am planning to launch a podcast version of Common Sense Family Doctor, featuring audio versions of selected blog posts and new content, such as interviews with health professionals and others who are revolutionizing family medicine and population health. Stay tuned!

January - Ethical foundations of health reform

As the patchwork U.S. health system seems primed to undergo another political upheaval, I think it's more important than ever to seek consensus on the destination for health reform before embarking on the journey.

February - Tom Price is a physician who doesn't understand cancer screening

Judging by a letter to then-HHS Secretary Kathleen Sebelius that he signed in 2011 objecting to the U.S. Preventive Services Task Force's draft recommendations on prostate cancer screening, Dr. Price either failed to learn anything in evidence-based medicine class or forgot everything he learned.

March - Does family medicine training led to high-value care?

One value-based health care intervention has borne fruit for the past 8 years in a row: attracting more medical students to the specialty of family medicine.

April - Safety net doesn't protect patients against low-value care

Safety net physicians were just as likely as other physicians to provide low-value services, underlining the importance of involving clinicians and patients in underserved practices in the Choosing Wisely campaign against medical overuse.

May - Fear-mongering in thyroid and breast cancer screening

The 40not50 campaign is insulting to women. It says that they can't be trusted to consider the medical evidence, have conversations with their primary care physicians, and make decisions about their healthcare that are right for them.

June - We shouldn't expect anyone to die in childbirth

Maternal mortality in the U.S. is largely a problem of social, economic, and geographic inequality rather than differences in health care, and we must look beyond hospitals for solutions.


July - Unequal treatment: disparities in how physicians are paid

The cause of these salary disparities - and the reason that more and more primary care physicians are choosing to cast off the health insurance model entirely - is a task-based payment system that inherently values cutting and suturing more than thinking.

August - How about ranking how well hospitals serve their communities?

Physicians and health executives have long believed that the responsibility of medicine is solely to provide health care, not social services or economic benefits outside of employment. But it's 2017, not 1967.


September - Ambition, rejection and leadership

Although I have fallen slightly short of my high ambitions, I will find other avenues to demonstrate leadership in medical publishing, evidence-based medicine, and population health.

October - What we choose to name a disease matters

The use of a more medicalized or precise term led patients to prefer invasive management options that were no better than more conservative choices.


November - Artificial intelligence will not make family physicians obsolete

Although Watson and its AI predecessors have made short work of the previously invincible Ken Jennings on Jeopardy! and vanquished world chess champions with ease, it is having a much harder time cracking medicine.


December - As hospitals downsize, what will replace them?

In my view, the role of policymakers should be to encourage a health care environment that makes it easy for hospitals and health systems to do the right thing.

Monday, December 11, 2017

As hospitals downsize, what will replace them?

Last week, I rounded on patients at Providence Hospital as the attending physician on the Family Medicine residency program's inpatient service. Providence recently closed its maternity ward as the first step in a planned redevelopment of the hospital grounds into a "health village." In the short term, the hospital's decision to stop delivering babies may worsen maternal health disparities, as the entire eastern side of Washington, DC is now a "maternity care desert" with no labor and delivery services. In Providence's defense, it lost $23 million in fiscal year 2016, and its long-term plan to replace hospital beds with ambulatory services and spaces that support community health and wellness is part of a broader national trend. As Dr. Neel Shah wrote recently in Politico's "The Case Against Hospital Beds":

Some corners of the health care world are already starting to embrace new, less bed-focused models of care. ... [At a] venture-capital based birthing center franchise, birthing families are often admitted and discharged on the same day, and beds are in the corner of the room (for resting and breastfeeding after the baby is born), rather than in the center; the idea is to encourage the mom to use movement as much as possible to support her labor by literally sidelining the bed. Health systems are increasingly investing in other types of spaces where bedrest is not the default, including skilled nursing and rehabilitation facilities, as well as home visiting nurses and health coaches to help high-need patients with acute and chronic conditions stay out of the hospital.

Before the hospital building boom that began after World War II, most acutely ill persons were cared for at home by family members with the help of visiting physicians. Emerging technology may enable this historical arrangement to become the future of health care. A recent JAMA Viewpoint argued that the expansion of telehealth and virtual care capabilities means that it's time to start training and credentialing a new physician specialty called the "medical virtualist," who would possess specific expertise in providing remote care the way a hospitalist possesses expertise in hospital care. (I'm not sold on this idea, as studies continue to show that primary care physicians who care for their own patients in the hospital have as good or better outcomes than do hospitalists.) In "A Hospital Without Patients," Arthur Allen described the Mercy Virtual Care Center, where teams of doctors and nurses use wireless devices to remotely monitor homebound patients around the clock and act as consultants in intensive care units in faraway hospitals:

For now, the future looks like this: Hospitals will keep doing things like deliveries, appendectomies and sewing up the victims of shootings and car wrecks. They’ll also have to care for people with diseases like diabetes, heart failure and cancer when they take bad turns. But in the future, the mission of the hospital will be to keep patients from coming through their doors in the first place.

For a family physician with a natural orientation toward prevention and public health, this is certainly an appealing vision. As the years have passed, I find myself enjoying my time at the hospital less and less, mostly because most of the patients on my service wouldn't need to be there if outpatient health and social services simply worked better. So many admissions could have been avoided if primary care clinicians were able to easily check on patients in their homes and intervene early on in flares of chronic obstructive pulmonary disease or congestive heart failure. If my homeless patient didn't have to wait months for housing; if my uninsured patient with diabetes didn't have to choose between buying insulin and glucose monitoring supplies; if my debilitated patient with Medicare could be transferred directly to a rehabilitation center rather than needing a hospital stay first.

There should be plenty of dollars available to redirect into prevention as hospitals downsize. Since 2014, Maryland has piloted a successful statewide experiment in giving hospitals financial incentives to keep patients well (and beds empty), overriding the traditional goal of keeping beds full to maximize revenue. The ever-present danger is that savings from hospital downsizing will go to pad executive salaries rather than flowing back into the community, as seems to be occurring at the fabulously wealthy "nonprofit" Mayo Clinic system.

Perhaps the future will see Providence Hospital's shuttered maternity ward replaced by a modern birthing center and comprehensive prenatal and postpartum care enhanced by telehealth services. Or today's maternity care desert could remain just that: a desert, where minority mothers continue to suffer pregnancy complications and deaths at appalling rates. In my view, the role of policymakers should be to encourage a health care environment that makes it easy for hospitals and health systems to do the right thing.

Thursday, December 7, 2017

Why don't doctors discuss cancer screening harms?

A few years ago, 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 ("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 2013 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?

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This post originally appeared on Common Sense Family Doctor on November 3, 2013.