Thursday, August 28, 2014

In U.S. and U.K., statin debate goes on

As previewed in a previous blog post, the August 15th issue of American Family Physician features a concise summary of the American College of Cardiology / American Heart Association updated cholesterol treatment guideline. Key points include an expansion of the role of statins in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); elimination of specific low-density lipoprotein cholesterol (LDL-C) target levels; and a new tool for assessing of 10-year and lifetime risk for ASCVD. An accompanying POEM notes that full implementation of the new guideline would increase the number of U.S. adults eligible to take statins by nearly 13 million, with the percentage of adults 60 to 75 years of age for whom statins are recommended rising from 47.8% to 77.3%.

Two editorials in the same issue further explore the implications of the new guideline. Writing for the members of the guideline panel, Dr. Patrick McBride and colleagues emphasize that the recommendations are largely based on high-quality evidence from randomized controlled trials that measured patient-oriented outcomes. They argue that "these changes should simplify the approach to clinical practice by reducing titration of medication, the addition of other medications, and the frequency of follow-up laboratory testing." In a second editorial, Dr. Rodney Hayward concurs with the panel's decision to abandon LDL-C targets, but disagrees with setting a universal 10-year ASCVD risk threshold of 7.5% for treatment with a statin:

My biggest criticism of the new guideline is that it does not acknowledge a specific gray zone—a range in which the potential benefits and harms of a statin make the “right decision” predominantly a matter of individual patient circumstances and preferences. It may be reasonable to set 7.5% as a starting point for discussion (e.g., for every 33 patients treated for 10 years, roughly one heart attack will be prevented [i.e., number needed to treat = 33]). But these risks and benefits are estimates with a nontrivial margin of error. The guideline does note that shared decision making should be used, but it provides no clear direction on when statins should be recommended rather than just discussed.

A similar debate is taking place in the United Kingdom, where its National Institute for Health and Care Excellence (NICE) recently recommended offering a statin to all persons with a 10-year cardiovascular event risk of 10% or more. An editorial in BMJ observed that doctors need better shared decision making tools to help patients understand the tradeoffs involved in taking medications that have potentially large population health benefits but are unlikely to prevent a bad outcome in an individual patient:

Doctors are unlikely to start giving patients clear numerical information simply because they are told to do so. They might do so if NICE can recommend information tools with the same force as when it recommends drugs, and if it becomes as easy to give contextual numerical advice as it is to print a prescription. ... We will need better data, from bigger trials, and better risk communication than for conventional medical treatment. ... Without such innovation in the use of medical data, we can say only that statins are—broadly speaking—likely to do more good than harm. That is not good enough.

If you are a clinician reading this, have you already integrated the ACC/AHA or NICE cholesterol guideline into your practice? If so, how do you decide whether to "recommend" versus "discuss" statins with patients? If not, what reservations or workflow issues have stopped you from transitioning to the new guidelines?


This post first appeared on the AFP Community Blog.

Monday, August 25, 2014

Don't do stupid sh*t in cancer screening

The electronic medical record that my office uses features a clinical protocol button that we are encouraged to click during patient visits to remind us about potentially indicated preventive services, such as obesity and tobacco counseling and cancer screenings. I once tried it out while seeing a 90 year-old with four chronic health problems. The computer suggested breast cancer, colorectal cancer, and cervical cancer screenings - three totally inappropriate tests for the patient.

At the residency program where I precept one afternoon a week, we recently held a "chart rounds" on an elderly patient with advanced dementia: when should you stop cancer screening? The answer boils down to the patient's predicted life expectancy compared to the number of years needed for a patient to benefit from a test. Although forecasting how long someone has left to live is not a precise science, knowing averages is essential to deciding if the inconvenience, expense, and potential adverse effects of screening (and treatment, if an abnormality is discovered) can be justified by the potential benefit. Since advanced dementia is a terminal disease, with more than half of nursing home residents in a National Institutes of Health-sponsored study dying within 18 months, there is virtually zero chance that a patient with this condition would benefit from cancer screening of any type. The same statement applies to a healthy 90 year-old in the U.S., who is expected to live around 4-5 more years.

But as one might expect in our crazy health non-system, cancer screening in patients with limited life expectancies happens all the time. A study published last week in JAMA Internal Medicine found that one-third to one-half of surveyed Americans with a 9-year mortality risk of more than 75 percent reported receiving recent cancer screenings. 55% of men in this group had knowingly been screened for prostate cancer within the previous 2 years - a test that, if it works at all, requires a decade to show a mortality benefit. (Nonetheless, my late father-in-law, who passed away at age 75 from chronic obstructive pulmonary disease, faithfully went in for annual PSA tests up until the year of his death.)

Aside from making me want to pull my hair out (or turning even more of it prematurely gray), reading this study's findings brought to mind President Obama's much-mocked second-term foreign policy doctrine: "Don't do stupid sh*t." I agree with former Secretary of State Hillary Clinton that this pithy four-word directive ending with a four-letter word shouldn't be an organizing principle for foreign policy, health policy, or any national policy. But as an antidote to the ubiquitous practice of too much medicine, it could be be a useful starting point: Don't do stupid sh*t in cancer screening. Think twice before reflexively doing things to elderly patients that can't possibly help and, therefore, can only hurt. And keep in mind that electronic clinical decision support should never, ever substitute for a physician's brain.

Wednesday, August 13, 2014

The problem of pain

My patients lie to me every day. Some tell me that they have been taking their medications regularly when they haven't. Some say that they have been eating a healthy diet and exercising for at least 30 minutes every day and don't know where the extra pounds are coming from. Some lie that they are using condoms every time they have sex, that they have quit smoking, and if they drink alcohol at all, it's only a single glass of wine with dinner. They bend the truth for many reasons: because they want to please their doctor, because they don't like to admit lapses of willpower, or because they are embarrassed to tell me that they can't afford to pay for their medications. I forgive them; it's part of my job to understand that patients (and health professionals) are only human. The only lies that I find hard to forgive are the lies about pain.

Like many doctors, I have complicated feelings about prescribing for chronic pain. On one hand, I recognize that relieving headaches, backaches, arthritis and nerve pain has been a core responsibility of the medical profession for ages. On the other hand, deaths and emergency room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years, and I have inherited many patients with narcotic addictions that resulted from a prior physician's well-intentioned generosity with his prescription pad.

Even worse, I've had patients I trusted turn out to be junkies in need of a fix. An earnest, well-dressed young man once came to my office complaining of a common chronic condition that, he said, had not been relieved by high doses of over-the-counter painkillers. He convinced me to to prescribe him narcotic pills, and didn't bat an eye when I asked him to sign a pain contract that required him to return every month for refills and only receive prescriptions from me in person. For the better part of a year, he never missed an appointment, and seemed genuinely receptive to unrelated preventive care that I recommended based on his age and risk factors. His deceit was exposed only after he stumbled, intoxicated, into an acute care facility staffed by a doctor who knew me and requested an early refill of a prescription for a different brand of painkillers prescribed by a third doctor for another imaginary condition. My colleague told him the gig was up, and I've never seen him again.

I believe that drug addiction is a disease. So why do I find this patient's lies (and those from others like him) so hard to forgive? Because they have consequences for people who are truly in pain. For patients' convenience, I transmit virtually all prescriptions electronically to the pharmacy, but I'm not allowed to do this with "controlled substances" such as painkillers. Wary of encouraging drug abuse, some insurers impose arbitrary limits on the number of pills a patient may be prescribed in one month, which I can only override by spending hours on the phone or not at all. One chain pharmacy recently started demanding signed copies of chart notes that included the pain-causing diagnosis before they would dispense painkillers (a practice that I believe to be an illegal invasion of privacy, but they didn't budge an inch when I told them so). And worst of all, doctors like me who have been burned before are that much more likely to view our patients with suspicion.

In the July issue of Health Affairs, Janice Schuster described a health odyssey that began with a seemingly minor surgical procedure and ended with her becoming "one of the estimated 100 million American adults who live with chronic pain" - in this case neuropathic pain, or pain from nerve damage that in my experience can be the most difficult type to treat. She wrote about how health system restrictions designed to discourage abuse created obstacles to her obtaining adequate pain relief, and about a lack of compassion from her primary care physician (who "dismissed my symptoms") and her surgeon (who "said again and again that he had not heard of a patient experiencing such pain"). As the author of a popular self-help book for persons facing serious illness, Schuster understood better than most the public health crisis posed by prescription painkillers, but that understanding offered little consolation as she navigated "the maze of pain management" that has evolved to deal with it:

Pain patients like me often feel trapped between the clinical need to treat and manage pain and the social imperative to restrict access to such drugs and promote public safety. ... When I am not overwhelmed by pain, or depressed by it, I am furious at the attitudes I encounter, especially among physicians and pharmacists. It has been stigmatizing and humiliating. ... Surely, we can find better ways to ease the suffering and devise treatments and strategies that do more good than harm and that do not shame and stigmatize those who suffer.

A few of my colleagues have become so disillusioned with the dilemmas of pain management that they have sworn off prescribing narcotic painkillers entirely. As often as I've been tempted to take that path, I won't abandon patients in pain, for whom the services of caring and competent family physicians are needed now more than ever.

Monday, August 4, 2014

Misconceptions about palliative care are common

In inpatient settings, family physicians frequently care for patients with progressive, incurable conditions that cause severe pain. Interventions aimed at slowing the progress of a disease often add to patients' physical distress; therefore, pharmacologic management of pain is a key component of end-of-life care, as outlined in an article in the July 1st issue of American Family Physician. However, as Drs. Timothy Daaleman and Margaret Helton discuss in an accompanying editorial, providing analgesia is only the starting point for effective palliative care:

Palliative care generally begins with diagnosis of a life-limiting disease and initiation of an ongoing conversation on the goals of care and treatment. This often begins in patient-centered medical homes, continues through acute hospitalizations, and may conclude in long-term care facilities. At each point, family physicians may be called on to provide primary palliative care and can expect to encounter nonpharmacologic challenges in managing pain.

Misconceptions about palliative care are common. For example, many believe that palliative care, like hospice care, cannot be offered to patients who are still pursuing "aggressive" treatments such as chemotherapy for cancer. On the contrary, one of the American Academy of Hospice and Palliative Medicine's Choosing Wisely recommendations states, "Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment." Palliative care does not necessarily increase patient comfort at the cost of shortening life; in a randomized trial of patients with metastatic non-small-cell lung cancer, patients assigned to early palliative care not only experienced better quality of life and fewer symptoms of depression than patients receiving standard care, they actually lived more than two months longer.

The recent announcement by a large health insurance company in the Pacific Northwest that it will prioritize palliative care by training physicians and caregivers about having appropriate end-of-life conversations; and pay for previously unreimbursed home health services and counseling about advanced directive planning suggests that policymakers are finally recognizing the value of improving the availability of palliative care to appropriate patients. What have been your experiences with connecting patients or loved ones to palliative care services?


The above post originally appeared on the AFP Community Blog.