Saturday, July 30, 2016

Can point-of-care tests reduce inappropriate antibiotic use?

Why do physicians prescribe antibiotics for viral infections when they ought to know better? An editorial from the Centers for Disease Control and Prevention in the August 1st issue of American Family Physician suggests several talking points that may persuade the patient who wants "Vitamin Z" (azithromycin) for his (or his child's) common cold and reviews evidence that delayed antibiotic prescriptions, effective communication strategies, and public commitments to use antibiotics appropriately reduce unnecessary antibiotic use. But what if these interventions aren't enough?

The rapid strep test helps to distinguish a viral sore throat from streptococcal pharyngitis. In patients with an intermediate pre-test probability, a negative rapid strep test lowers the post-test probability of strep enough for doctors (and most patients) to feel comfortable withholding antibiotics. Wouldn't it be nice if other point-of-care tests could effectively rule out bacterial infections and curb antibiotic prescribing in patients with acute respiratory symptoms?

Procalcitonin seems ready to go. A FPIN Clinical Inquiry in the July 1st issue of AFP evaluated the effects of a procalcitonin-guided antibiotic therapy algorithm on antibiotic use and clinical outcomes. A Cochrane review and meta-analysis of 14 randomized, controlled trials (RCTs) comparing procalcitonin-guided to standard care in European adults with acute respiratory infections found that patients in the procalcitonin group received 3.47 fewer days of antibiotic therapy with no differences in 30-day mortality or treatment failure. In a single RCT of 337 children presenting to pediatric emergency departments in Switzerland, patients in the procalcitonin group were as likely as the standard care group to receive antibiotic prescriptions, but received nearly 2 fewer days of therapy.

C-reactive protein (CRP): the jury is still out. A Cochrane for Clinicians examined the performance of point-of-care measurement of CRP on similar outcomes. Although treatment thresholds varied, most studies considered a CRP level of less than 20 mg per L to suggest a viral infection and no need for antibiotics. A Cochrane review of 6 RCTs conducted in primary care settings (mostly in adults) in Europe and Russia found that groups assigned to CRP-assisted evaluation were 22 percent less likely to receive antibiotic prescriptions for acute respiratory infections, with no differences in clinical improvement at day 7, complications, or mortality. However, Dr. Irbert Vega observed in the Practice Pointers that "the meta-analysis did not identify an optimal algorithm and therefore should be considered proof of concept until further research can be performed, including research in the U.S. population."


This post first appeared in a different form on the AFP Community Blog.

Monday, July 25, 2016

Giving it away: philanthropy and medicine

My wife and I aim to give about 10 percent of our pre-tax income to charity each year. Much of this amount goes to our church, which struggles to make ends meet despite being situated in a rapidly gentrifying area of Washington, DC. We divide the remainder between a variety of causes, such as historical preservation efforts, summer programs for poor kids, and education and leadership programs for young family physicians. Historically, we have allocated a very small fraction of our charitable contributions to our college, graduate, and medical school alma maters (Harvard, Johns Hopkins, and NYU for me; Cornell, Cornell, and Stony Brook for her), and then generally give directly to student organizations, such as the Big Red Marching Band and the Phillips Brooks House Association. It isn't that we don't have fond memories of attending these schools or don't appreciate the education we received there, but in our view they have deeper pockets than almost every other organization that asks for our financial support.

Two recent episodes of Malcolm Gladwell's "Revisionist History" podcast provided more convincing arguments against making big donations to top ranked universities. Gladwell made headlines last year with an Twitter rant criticizing hedge fund manager John Paulson's $400 million donation to Harvard (whose endowment at that time was valued at more than $36 billion). In "Food Fight," Gladwell compared the funding priorities of Bowdoin and Vassar, two small Northeast liberal arts colleges that appear pretty similar on the surface. One notable difference is that cafeteria food at Bowdoin is gourmet dining, while Vassar's is mediocre at best. Using public information sources and interviews with staff and students at both colleges, Gladwell drilled down to a major reason for this dining disparity: Vassar devotes more of its endowment income to financial aid in order to increase the social and economic diversity of its student body. If you're a wealthy individual who wants to advance social justice, Gladwell argued, choose Vassar over Bowdoin and supporting education for poor students over serving the rich breakfasts of eggplant parmesan pancakes.

Then, in "My Little Hundred Million," Gladwell explored the phenomenon of philanthropists such as Nike's Phil Knight choosing to give hundreds of millions of dollars to private universities that educate the elite rather than public universities who reach many more students of modest means. Gladwell included excerpts from an almost comical discussion with Stanford president John Hennessy, who accepted a $400 million donation from Knight to endow a graduate program for 100 students per year, even though Stanford's endowment is $22 billion. In comparison, a $100 million donation to little-known Glassboro State College (now Rowan University) in New Jersey in the 1990s transformed opportunities for 16,000 students each year and inspired this moving a cappella tribute from students after their benefactor's death.

As I've written before, hospitals and health care organizations are similar to institutions of higher education in that both have skyrocketing costs, little transparency, and few objective measures of quality. They are also alike in that they rely on philanthrophy to supplement the income they receive from patients/students and insurers/lenders. Famous cancer centers have turned fundraising into an art form, too often relying on emotion rather than fact to attract patients and donors. But just because it may be more attractive to donate to the Memorial Sloan-Ketterings and their associated academic institutions doesn't mean that they should be receiving an outsized share of my or your charitable dollars. Especially since we know that U.S. News top ranked (and well funded) medical schools end up near the bottom of the heap when ranked according to their social mission: the percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities. Similarly, a disproportionate amount of Medicare's $10 billion per year graduate medical education subsidy goes to institutions that train few primary care physicians or clinicians who practice in underserved areas.

Dear Mr. Paulson, Mr. Knight, Mr. Buffet, Mr. Gates, do you want to improve health outcomes in America? Then write a big check to John Peter Smith Hospital in Fort Worth, Texas, #6 on the list of producers of primary care graduates that received a modest $4.5 million from Medicare in 2008. Or Banner - University Medical Center in Phoenix, Arizona, #15 on the list. (Both institutions, not coincidentally, have outstanding family medicine residency programs.) Don't worry about my alma mater NYU, whose hospitals received more than $55 million from Medicare in 2008 but ranked #156 in primary care production. Or Memorial Sloan-Kettering, for that matter, which ranked #158 out of #158 primary teaching sites with at least 150 graduates - dead last.

Saturday, July 16, 2016

The best recent posts you may have missed

Every few months, 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 April through June:

2) Addressing the social determinants of pain (4/4/16)

3) From precision medicine to community vital signs (6/1/16)

4) Obstacles to stopping cancer screening in older adults (4/26/16)

5) Does convenience outweigh continuity of care? (5/23/16)

If you have a personal favorite that isn't on this list, please let me know. Thank you for reading!

Monday, July 11, 2016

A family physician's favorite podcasts

Four days out of the week, my round-trip commute to my academic or clinical offices averages between 60 and 90 minutes (the other day I typically telework). That's between 4 and 6 hours I previously spent listening to the same songs over and over on the radio, until I belatedly discovered podcasts. Aside from a few sports and television-themed podcasts, most entries on my regular listening list relate to topics covered on Common Sense Family Doctor, and occasionally provide inspiration for future posts.


BackStory with the American History Guys
The Civil War (1861-1865): A History Podcast
Radiolab Presents: More Perfect
Revisionist History

Health policy and current events

Health Affairs: Events
POLITICO's Pulse Check
This American Life
Wait Wait ... Don't Tell Me!
Vox's The Weeds

Prevention and fitness

Human Race
The Runner's World Show

Clinical and academic medicine

Academic Medicine Podcast Series
AFP: American Family Physician Podcast
Hidden Brain
Public Health Behind the Scenes

Sunday, July 3, 2016

New USPSTF colorectal cancer recs may risk overscreening

In 2008, the U.S. Preventive Services Task Force recommended routinely screening adults aged 50 to 75 years for colorectal cancer using fecal immunochemical testing (FIT), flexible sigmoidoscopy, or colonoscopy. At that time, it did not endorse two newer strategies, computed tomographic (CT) colonography and fecal DNA testing. But data from the National Health Interview Survey indicated that in 2013, only 60 percent of non-Hispanic white adults in the target age group was up-to-date on one of the three recommended colorectal cancer screening tests, with lower percentages for ethnic and racial minorities. Proponents of CT colonography and fecal DNA testing argued that more widespread insurance coverage of these "noninvasive" tests could potentially increase screening rates.

Last month, JAMA published a USPSTF-commissioned systematic review of more recent studies and an analytic modeling study that compared the effects of different screening tests and strategies. The Task Force's updated recommendation statement said to screen adults aged 50 to 75 years, but expressed no clear preference about the "best" test or tests. A Figure that accompanied the statement showed that assuming perfect adherence, each screening strategy produces a similar number of life-years gained, with a colonoscopy-first strategy predictably leading to more total colonoscopies and procedure-related harms. Rather than recommending that eligible patients undergo a specific test, the USPSTF advised:

Given the lack of evidence from head-to-head comparative trials that any of the screening strategies have a greater net benefit than the others, clinicians should consider engaging patients in informed decision making about the screening strategy that would most likely result in completion, with high adherence over time, taking into consideration both the patient’s preferences and local availability.

Shared decision making is all well and good, but I am concerned about the communication challenges of expanding my standard discussion of colorectal cancer screening options from FIT versus colonoscopy (since physicians in my area no longer perform flexible sigmoidoscopy for colorectal cancer screening) to choosing between FIT, fecal DNA, CT colonography, and colonoscopy. I wish that the Task Force had provided more practical guidance about how primary care physicians can help individual patients select the "best" test for them.

Surprisingly for a group that typically has required the highest degree of evidence to justify an "A" rating, the USPSTF did not emphasize stool guaiac testing and flexible sigmoidoscopy, the only screening strategies that have reduced colorectal cancer deaths in randomized controlled trials. Earlier this year, the Canadian Task Force on Preventive Health Care did not recommend screening colonoscopy because it had not met that standard. (As Dr. Rita Redberg wrote in an editorial published in JAMA Internal Medicine, "It would be interesting to know how many patients would undergo colonoscopy if they knew that there were no data to suggest that this procedure results in longer life.")

Finally, although the USPSTF reiterated that it "does not recommend routine screening for colorectal cancer in adults age 86 years and older," it omitted its previous "D" (don't do) recommendation against this unnecessary and potentially harmful practice. I think that this was a mistake. Plenty of octo- and nonagenarians still receive colorectal cancer screening tests; in a 2015 editorialAmerican Family Physician editor Jay Siwek related his 90 year-old father-in-law's complications from a "routine" colonoscopy as an example of the harms caused by overscreening. The best test isn't only the one that gets done, but gets done in a patient who has a chance of benefiting from that test.


This post first appeared on the AFP Community Blog.