Monday, August 21, 2017

Procedures and prevention: the challenges of Choosing Wisely

A 55 year-old woman with chronic low back pain and symptomatic knee osteoarthritis asks her family physician's opinion about lumbar fusion surgery and some arthritis walking shoes she saw advertised on television. She is prescribed long-acting oxycodone and physical therapy for back pain, and her orthopedist recently began a series of hyaluronic acid injections for her knees. She is up-to-date on cervical and breast cancer screening, but also desires screening for ovarian cancer.

The next patient is her husband, a 60 year-old man with stable coronary artery disease. He was recently hospitalized for an episode of chest pain, and although tests did not show a myocardial infarction, a cardiac catheterization found an 80% stenosis in the left anterior descending artery. He already takes a baby aspirin daily, but his cardiologist has advised adding clopidogrel and having a coronary stent placed. Last year, he quit smoking after going through a pack of cigarettes a day for 40 years, and he is interested in screening for lung cancer. Also, since his brother was diagnosed with colorectal cancer at age 50, he has undergone screening colonoscopies at ages 40, 45, 50, and 55. These have all been normal, and he wonders if it is necessary for him to continue having them every 5 years.

Although both of these patients are fictitious, they represent common clinical scenarios in family medicine that contain enormous potential for overdiagnosis and overtreatment. In the August 15 issue of American Family Physician, Drs. Roland Grad and Mark Ebell presented this year's edition of the "Top POEMs Consistent with the Principles of the Choosing Wisely Campaign," which included the following suggested clinical actions:
As with last year's Top POEMs list, questioning unnecessary procedures or non-beneficial treatments is an effective way to protect patients from harm. But it's important to take a critical approach to preventive care as well to avoid overscreening. For example, as Dr. Jennifer Middleton noted in a previous blog post, one high-profile screening test for ovarian cancer still has big gaps in the evidence regarding its effect on mortality. Drs. Grad and Ebell advised not screening for ovarian cancer and carefully weighing the risks and benefits of lung and colorectal cancer screening:
It is challenging, and sometimes uncomfortable, to question long-accepted practices that feel like "old friends," AFP assistant medical editor Allen Shaughnessy wrote in a 2016 editorial. He suggested that clinicians keep in mind that the purpose of these evidence-based recommendations, and all of those from the Choosing Wisely campaign, is to improve care and reduce harm:

Every aspect of patient care—every word we say, every test or exam we perform, every treatment or procedure we employ—carries with it the possibility of harm as well as the opportunity for benefit. Although eliminating overuse is often perceived as a way of cutting medical costs, it is really about decreasing wasteful, unnecessary testing and treatment that offer only the potential of harm without the corresponding possibility of benefit. Sometimes, we need to leave our old friends behind.

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This post first appeared on the AFP Community Blog.

Wednesday, August 16, 2017

How about ranking how well hospitals serve their communities?

I'm sure that many fabulously talented, skillful, compassionate physicians work at the Cleveland Clinic. If I lived in Cleveland or a nearby town and suffered from a rare or life-threatening disease, I would strongly consider going to the Clinic for specialty care. Maybe I would even work there. But ranking the Cleveland Clinic the #2 hospital in America, as U.S. News and World Report did last week, is outrageous. (Full disclosure: I once blogged for U.S. News.)

My use of the term "outrageous" has little to do with deficiencies in U.S. News's ranking methodology, whose past versions have been criticized for relying more on subjective reputation rather than objective data on safety and quality, and having no correlation with other ratings such as those on Medicare.gov's Hospital Compare website. As Elisabeth Rosenthal has previously reported, hospital rankings are mostly about hype, and it's questionable how much impact they really have on patient choices when every academic or community hospital can probably find at least one high-ranked specialty or service line to brag about.

No, I think this top-notch ranking is outrageous because it only accounts for the patient care that the hospital and its affiliated practices provide, rather than including the health status of the surrounding community - which is awful. Although the Clinic may provide excellent care to patients who walk or are wheeled through its doors, Dan Diamond's recent article in Politico sharply contrasted the overflowing wealth of the medical institution with the barren, crumbling neighborhoods that surround it:

Yes, the hospital is the pride of Cleveland, and its leaders readily tout reports that the Clinic delivers billions of dollars in value to the state. ... But it’s also a tax-exempt organization that, like many hospitals, fought to preserve its not-for-profit status in the years leading up to the Affordable Care Act. As a result, it doesn’t have to pay tens of millions of dollars in taxes, but it is supposed to fulfill a loosely defined commitment to reinvest in its community. That community is poor, unhealthy and — in the words of one national neighborhood-ranking website — “barely livable.”

Hospitals and health systems can't be expected to shoulder the entire burden of improving a community's economic prospects, and many hospitals were originally located in poor neighborhoods because that's where more sick people live. But according to Diamond, its financial figures indicate that the Cleveland Clinic hasn't been doing nearly enough for the community to offset the tax benefits it receives:

[The Clinic's] hospital system cleared $514 million in profit last year and $2.7 billion the past four years, when accounting for investments and other sources of revenue. And since the ACA coverage expansion took full effect, the Clinic’s been able to spend a lot less to cover uninsured patients; its annual charity care costs fell by $106 million from 2013 to 2015. But its annual community benefit spending only went up $41 million across the same two-year period, raising a $65 million question: Did the Clinic just pocket the difference in savings?

“I think we have more than fulfilled our duties,” [Clinic CEO Toby] Cosgrove said in response, pointing to the system’s total community benefit spending, which was $693 million in 2015. The majority of that spending, however, wasn’t free care or direct investments in community health; about $500 million, or more than 70 percent, represented either Medicaid underpayments — the gap between the Clinic’s official rate, which is usually higher than the rate insurers pay, and what Medicaid pays — or Clinic staffers’ own medical education.


It's not that the Cleveland Clinic is blind to the health crisis occurring outside of its doors. Like all nonprofit hospitals, it is required to perform a community health needs assessment (CHNA) every three years. The 189-page document it issued in 2016 provides a dismal accounting of all of the ways in which its local neighborhoods have worse indicators of health than other counties in Ohio and the vast majority of the nation. When Diamond suggested that the Clinic consider increasing its investments in population health, "where fixing community problems like lead exposure and food deserts are viewed as equally important as treating heart attacks," CEO Cosgrove sounded doubtful about what his hospital could or should do about these problems:

"That’s a good direction to go," he allowed. “But how much can we do in population health? We don’t get paid for this, we’re not trained to do this, and people are increasingly looking to us to deal with these sorts of situations,” Cosgrove added. “I say that society as a whole has to look at these circumstances and they can’t depend on just us.”

Judging from readers' comments posted at the end of the article, Cosgrove is far from alone in thinking that it isn't the place of medical institutions to solve the problems of distressed neighborhoods. 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. As Susan Heavey reported for the Association of Health Care Journalists, in many parts of the U.S. health professionals have successfully partnered with advocates, local officials, and housing developers to "reinvent neighborhoods with [an] eye on health." If the leaders of the Cleveland Clinic wanted a road map for how to help rebuild the surrounding community, they could review one of 10 recent case studies posted by the Build Healthy Places Network, an organization whose mission "is to catalyze and support collaboration across the health and community development sectors, together working to improve low-income communities and the lives of people living in them."

On a national level, rather than allowing CHNAs to gather dust on a shelf (or the online equivalent), health policymakers could use them to allocate public funding for graduate medical education where it is needed most, rather than where it is currently going. As Dr. Melanie Raffoul, one of my past Policy Fellows, wrote recently in an analysis of Texas CHNAs and regional health partnership plans in the Journal of the American Board of Family Medicine:

Many [CHNAs] mentioned problems such as “low literacy,” “food deserts,” or “high levels of teen pregnancy.” Many of these concerns cannot be meaningfully addressed by hospitals, but they can be tackled through increased access to primary care and mental health services, and residency training sites are one way to provide this to the community. This should increase institutions' thinking about their role in larger community strategies to tackle community issues that affect health. Workforce gaps similarly need to be seen in this context—a community resource meant to resolve community needs. ... Community assessments could help refocus the use of publicly funded physician training as part of a broader hospital-community partnership for resolving health needs.

I began by stating that I didn't think that the Cleveland Clinic deserved to be ranked the #2 hospital in the nation, but since U.S. News and World Report already put it on that pedestal, the Clinic should live up to it by not only providing the best health care for their patients, but getting serious about improving the health of their community.

Thursday, August 10, 2017

On liberty and health reform in America

Since 2007, I've participated in more than a dozen American Civil War battlefield tours sponsored by the Smithsonian Associates. Even though a handful of Chinese Americans fought on both sides of the Civil War, none of my ancestors did, and friends and family are often perplexed by my endless fascination with this conflict. In Civil War museums and sites thronged by overwhelmingly white tourists, I'm even more of an oddity than the rare African American. This realization got me wondering why so few African Americans are passionate about the history of the war that freed so many of their ancestors from slavery. To Atlantic columnist and fellow Civil War buff Ta-Nehisi Coates, this antipathy stems from the efforts of white Americans over the past 150 years to write them out of the story:

For my community, the message has long been clear: the Civil War is a story for white people—acted out by white people, on white people’s terms—in which blacks feature strictly as stock characters and props. We are invited to listen, but never to truly join the narrative, for to speak as the slave would, to say that we are as happy for the Civil War as most Americans are for the Revolutionary War, is to rupture the narrative. Having been tendered such a conditional invitation, we have elected—as most sane people would—to decline.

As reflected in the Presidential election of 2016, economic and racial divisions are always resurfacing, with the perennial Republican versus Democratic contest being portrayed in the media as a battle between the "rich" and the "poor," or white citizens versus those of every other color. But these stereotypes ignore the inconvenient facts that plenty of low-income rural whites who bear no racial grudges and a few minority voters in heavily Democratic states and the District of Columbia dependably vote Republican.


In his most recent book, subtitled "Why the Civil War Still Matters," historian James McPherson shed some light on this present-day paradox by explaining that liberty meant two different things to Southern and Northern leaders in 1861. To white Democrats in the pre-Civil War South (slaveholders or not - and the vast majority were not), liberty meant "freedom from" interference by a distant federal government. Historical figures such as Confederate general Robert E. Lee traced their cause back to the Virginian Founding Fathers and slaveholders George Washington and Thomas Jefferson, whose Revolutionary War was fought to break away from a distant British ruler whose arbitrary actions offended colonial sensibilities.

On the other hand, the Republican Party in the North viewed liberty as "freedom to," arguing that it's hard to achieve anything noteworthy when one is penniless, starving, or a slave. Even though the North won the Civil War, achieving full citizenship for African Americans took nearly a century after passage of the the Fifteenth Amendment to the U.S. Constitution. Only after the hard-won passage of the 1965 Voting Rights Act, which prohibited poll taxes and gave the federal government the power to end various discriminatory practices that prevented most Black citizens in Southern states from registering to vote, did African Americans finally gain freedom to participate in the political process.

The more recent history of how and why African Americans turned away from the party of Lincoln to embrace the party of their former oppressors is too long to recount here, but these differing views of personal liberty - "freedom from" versus "freedom to" - go a long way toward explaining the two political parties' diametrically opposed views of the Affordable Care Act. For the most part, Republican governors have resisted health insurance exchanges and rejected Medicaid expansions because they and their constituents have perceived these provisions of the law as encroachments on freedom by the Washington bureaucracy, while Democratic governors have recognized that it's hard to have freedom to achieve personal success if one is too ill, or too worried about the financial implications of unexpected illness or injury, to plan confidently for the future.

Not only can you find the roots of modern medicine in the American Civil War, but the roots of our current national health policy debate, too.

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This post first appeared on Common Sense Family Doctor on October 2, 2015.

Tuesday, August 1, 2017

Pushing back against prescription drug price gouging

Sometimes missed in the headlines about the stratospheric costs of new specialty drugs is the contribution of price hikes for older, established drugs, including generics, to prescription spending increases. In an editorial in the July 1 issue of American Family Physician, Dr. Allen Shaughnessy described several situations that drug manufacturers exploit to raise prices excessively (also known as price gouging):

- Limited to no alternatives
- Older products with few producers
- Same product, different use
- Single producer, no generic available
- Evergreening (minor changes to gain patent exclusivity)
- Pay for delay (paying generics manufacturers not to sell a generic version of an off-patent drug)

In the United States, Dr. Shaughnessy observed, "The biggest driver of the cost hike is, simply put, that pharmaceutical companies can charge whatever they want. Drugs cost what the market will bear. Many medications could be a lot less expensive, but because an insurance company, the government, or a patient is willing to pay the asking price, there is no push to lower the costs."

Price gouging has become such a problem for patients and insurers that the Maryland General Assembly recently passed legislation to discourage price gouging on essential off-patent or generic drugs. As explained by Drs. Jeremy Greene and William Padula in the New England Journal of Medicine:

The law authorizes Maryland’s attorney general to prosecute firms that engage in price increases in noncompetitive off-patent–drug markets that are dramatic enough to “shock the conscience” of any reasonable consumer. ... To establish that a manufacturer or distributor engaged in price gouging, the attorney general will need to show that the price increases are not only unjustified but also legally unconscionable. ... A relationship between buyer and seller is deemed unconscionable if it is based on terms so egregiously unjust and so clearly tilted toward the party with superior bargaining power that no reasonable person would freely agree to them. This standard includes cases in which the seller vastly inflates the price of goods.

The scope of the Maryland law is limited. It restricts action to off-patent drugs that are being produced by three or fewer manufacturers, and requires that manufacturers be given an opportunity to justify a price increase before legal proceedings are initiated. It is too early to know if the law will be effective against price gouging, or if it will be copied by other states that are also struggling to contain prescription drug cost increases in their Medicaid programs.

In the meantime, what can family physicians do to help patients lower their medication costs? In a 2016 editorial on the why and how of high-value prescribing, Dr. Steven Brown recommended five sound strategies: be a healthy skeptic, and be cautious when prescribing new drugs; apply STEPS and know drug prices; use generic medications and compare value; restrict access to pharmaceutical representatives and office samples; and prescribe conservatively.

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This post first appeared on the AFP Community Blog.

Tuesday, July 25, 2017

Community health workers can complement primary care

Several years ago, I attended an academic meeting where the subject of community health workers came up in a discussion. Earlier that year I had read about Vermont's ambitious blueprint for medical homes integrated with community health teams, so I volunteered that we needed fewer specialists and more trained laypersons with ties to their communities to implement prevention strategies. Another physician objected that while community health workers might work well in lower-income countries like India, we didn't need to deploy them in America, where people already know from their doctors that they should eat healthy foods, watch their weight, exercise, and not smoke and don't need others nagging them about it.

But should community health workers be viewed merely as extensions of medical institutions when large proportions of the population will not visit a doctor in a given year? An alternative model, wrote Health Affairs editor Alan Weil,

views CHWs as part of the communities in which they work. The roles of community health workers are defined by the community and CHWs through a process of community engagement. CHWs are valued for their contribution to community health, not for the savings they generate for health plans or providers. CHWs are embedded in the community, not in a clinician’s office or hospital. Advocacy is required to effect a transfer of resources out of clinical care into the community.

On the other hand, a New England Journal of Medicine commentary observed that the absence of connections between community health workers and family physicians can leave them working at cross-purposes:

CHW services are commonly delivered by community-based organizations that are not integrated with the health care system — for example, church-based programs offering blood-pressure screening and education. Without formal linkages to clinical providers, these programs face many of the same limitations — and may produce the same disappointing results — as stand-alone disease-management programs. CHWs cannot work with clinicians to address potential health challenges in real time, and clinicians can't shift nonclinical tasks to more cost-effective CHWs. Indeed, clinicians often don't recognize the value of CHWs because they don't work with them.


How can we bridge this gap? A review in the Annals of Family Medicine provided a list of structure, process, and outcome factors to consider for patient-centered medical homes to partner with peer supporters (a.k.a. community health workers).

For complex patients with multiple health conditions, care coordination is a key role where community health workers could potentially be more successful and cost-effective than expensive projects led by registered nurses or physicians. Reviewing the past decade of Medicare demonstration projects, researchers from the Robert Graham Center drew five lessons for future coordinated care models:

(1) Minimize expenses by sharing resources and avoiding cost ineffective interventions
(2) Concentrate on high utilizers
(3) Foster relationships with both providers and patients
(4) Track patients across the medical neighborhood in real time
(5) Extend rather than duplicate the efforts of primary care practices

Although optimal integration between the roles of community health workers and primary care teams is easier to describe than to achieve, moving both groups toward the common goal of communities of solution will be essential to protecting the health of the whole population.

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This post first appeared on Common Sense Family Doctor on September 11, 2015.

Thursday, July 20, 2017

Unequal treatment: disparities in how physicians are paid

As a family physician and medical school faculty member, I'm naturally a big booster of primary care. America needs more generalist physicians, not fewer, and much of my professional activity involves encouraging medical students to choose family medicine, or, failing that, general pediatrics or general internal medicine. But it's an uphill battle, and I fear that it's one that can't be won without major structural changes in the way that generalist physicians are paid and rewarded for their work.

In a recent Medicine and Society piece in the New England Journal of Medicine, Dr. Louise Aronson (a geriatrician) described visits with two of her doctors, a general internist and an orthopedist. The primary care physician worked in a no-frills clinic, often ran behind schedule, and devoted much of the visit and additional post-visit time to electronic documentation. The orthopedist worked in a newer, nicer office with an army of medical and physician assistants; generally ran on time; and was accompanied by a scribe who had competed most of the computer work by the end of the visit. Although there are undoubtedly a few family doctors with income parity to lower-earning orthopedists, according to Medscape's 2017 Physician Compensation Report, the average orthopedist makes $489,000 per year, while an average general internist or family physician makes around $215,000 per year. Here's what Dr. Aronson had to say about that:

It would be hard, even morally suspect, to argue that the salary disparities among medical specialties in U.S. medicine are the most pressing inequities of our health care system. Yet in many ways, they are representative of the biases underpinning health care’s often inefficient, always expensive, and sometimes nonsensical care — biases that harm patients and undermine medicine’s ability to achieve its primary mission. ...

Those structural inequalities might lead a Martian who landed in the United States today and saw our health care system to conclude that we prefer treatment to prevention, that our bones and skin matter more to us than our children or sanity, that patient benefit is not a prerequisite for approved use of treatments or procedures, that drugs always work better than exercise, that doctors treat computers not people, that death is avoidable with the right care, that hospitals are the best place to be sick, and that we value avoiding wrinkles or warts more than we do hearing, chewing, or walking.


Medical students are highly intelligent, motivated young men and women who have gotten to where they are by making rational decisions. For the past few decades, as the burden of health care documentation has grown heavier and the income gap between primary care physicians and subspecialists has widened, they have been making a rational choice to flee generalist careers in ever-larger numbers.

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. I receive twice as much money from an insurer when I spend a few minutes to freeze a wart than when I spend half an hour counseling a patient with several chronic medical conditions. That's thanks to the Resource-Based Relative Value Scale, a system mandated by Congress and implemented by Medicare in 1992 in an attempt to slow the growth of spending on physician services. Every conceivable service that a physician can provide is assigned a number of relative value units (RVUs), which directly determines how much Medicare (and indirectly, private insurance companies) will pay for that service.

As new types of services are developed and older ones modified, the RVUs need to be updated periodically. Since the Centers for Medicare and Medicaid Services (CMS) chose not to develop the in-house expertise to do this itself, it farms out the updating task to the Relative Value Scale Update Committee (RUC), a 31-member advisory body convened by the American Medical Association (AMA) and nominated by various medical specialty societies. Here is where the fix is in. Only 5 of the 31 members represent primary care specialties, and over time, that lack of clout has resulted in an undervaluing of Evaluation and Management (E/M) and preventive services (the bulk of services provided by generalist physicians) compared to procedural services. Although an official AMA fact sheet pointed out that some RUC actions have increased payments for primary care, a 2013 Washington Monthly article countered that these small changes did little to alter the "special deal" that specialists receive:

In 2007, the RUC did finally vote to increase the RVUs for office visits, redistributing roughly $4 billion from different procedures to do so. But that was only a modest counter to the broader directionality of the RUC, which spends the vast majority of its time reviewing, updating—and often increasing—the RVUs for specific, technical procedures that make specialists the most money. Because of the direct relationship between what Medicare pays and what private insurers pay, that has the result of driving up health care spending in America—a dynamic that will continue as long as specialists dominate the committee.


We teach our medical students to recognize that inequities in where patients live, work and play are far more powerful in determining health outcomes than the health care we provide. A child living in a middle-class suburb has built-in structural advantages over a child living in a poor urban neighborhood or rural community, due to disparities in economic and social resources. The same goes for how physicians are paid in the U.S. Until the RUC is dramatically reformed or replaced with an impartial panel, the $3 trillion that we spend on health care annually (20 percent of which pays for physician services) will continue to produce shorter lives and poorer health compared to other similarly developed nations.

Monday, July 17, 2017

Self-monitoring doesn't improve control of type 2 diabetes

"Have you been checking your sugars?" I routinely ask this question at office visits involving a patient with type 2 diabetes, whether the patient is recently diagnosed or has been living with the disease for many years. However, the necessity of blood glucose self-monitoring in patients with type 2 diabetes not using insulin has been in doubt for several years.

A 2012 Cochrane for Clinicians published in American Family Physician concluded that "self-monitoring of blood glucose does not improve health-related quality of life, general well-being, or patient satisfaction" (patient-oriented outcomes) and did not even result in lower hemoglobin A1C levels (a disease-oriented outcome) after 12 months. In their article "Top 20 Research Studies of 2012 for Primary Care Physicians," Drs. Mark Ebell and Roland Grad discussed a meta-analysis of individual patient data from 6 randomized trials that found self-monitoring improved A1C levels by a modest 0.25 percentage points after 6 and 12 months of use, with no differences observed in subgroups. Based on these findings, the Society of General Internal Medicine recommended against daily home glucose testing in patients not using insulin as part of the Choosing Wisely campaign.

Still, the relatively small number of participants in trials of glucose self-monitoring, and the persistent belief that it could be useful for some patients (e.g., recent type 2 diabetes diagnosis, medication nonadherence, changes in diet or exercise regimen), meant that many physicians have continued to encourage self-monitoring in clinical practice. In a 2016 consensus statement, the American College of Endocrinology stated that in patients with type 2 diabetes and low risk of hypoglycemia, "initial periodic structured glucose monitoring (e.g., at meals and bedtime) may be useful in helping patients understand effectiveness of medical nutrition therapy / lifestyle therapy."

In a recently published pragmatic trial conducted in 15 primary care practices in North Carolina, Dr. Laura Young and colleagues enrolled 450 patients with type 2 non-insulin-treated diabetes with A1C levels between 6.5% and 9.5% and randomized them to no self-monitoring, once-daily self-monitoring, or once-daily self-monitoring with automated, tailored patient feedback delivered via the glucose meter. Notably, about one-third of participants were using sulfonylureas at baseline. After 12 months, there were no significant differences in A1C levels, health-related quality of life, hypoglycemia frequency, health care utilization, or insulin initiation. This study provided further evidence that although glucose self-monitoring may make intuitive sense, it improves neither disease-oriented nor patient-oriented health outcomes in patients with type 2 diabetes not using insulin. So why are so many clinicians still encouraging patients to do it?

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This post first appeared on the AFP Community Blog.

Sunday, July 9, 2017

Does health insurance save lives? No: primary care does.

Two recent review articles in the New England Journal of Medicine and the Annals of Internal Medicine discussed the relationship between having health insurance and improving health outcomes (including mortality, i.e., "saving lives"). In my latest Medscape commentary, I analyzed these two articles in the context of the debate over the U.S. Senate's Better Care Reconciliation Act (BCRA), which the Congressional Budget Office has estimated would lead to 22 million more uninsured persons if passed, compared to current law. I concluded that arguments about the effects of gaining or losing health insurance largely miss the point, since any positive effects of insurance are most likely mediated through providing primary care:

It is plausible that the positive effect of insurance on health is real. The next question is, why? It's not because insured people receive more or better care for acute, life-threatening illnesses. Instead, people who gain insurance generally increase their use of preventive services and are more likely to report having a usual source of primary care, which other studies have found is strongly associated with lower mortality. In fact, I would argue that health insurance's positive effects on health are mediated largely through prepaid primary care services.

The American Academy of Family Physicians has joined several other major physician groups in opposing BCRA because absent modifications, it will certainly decrease access to primary care by making insurance unaffordable for low-income and other vulnerable populations who don't qualify for Medicaid or Medicare. But paying for a barely affordable bronze marketplace plan with a $6000 deductible hardly makes primary care affordable, either, outside of a limited list of preventive services. The solution? Make it possible for more people to buy inexpensive primary care without having to go through expensive health insurance.

Health reform proposals should build on the knowledge that primary care saves lives for a fraction of the cost of a health insurance premium. In the long run, Democrats and Republicans could find common ground between their "Medicare for all" and "covering everyone costs too much" positions by removing primary care from the inefficient insurance system entirely. Instead, Congress should guarantee everyone a family doctor through a community health center or direct-pay primary care, as physician and financial planner Carolyn McClanahan has proposed.

Wednesday, July 5, 2017

Strategies to limit antibiotic resistance and overuse

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more. Antibiotic resistance occurs in the community, in long-term care facilities, and in hospital settings. Another CDC report on preventing healthcare-associated infections (also discussed in this American Family Physician article) identified six high-priority antibiotic resistance threats: carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enteroccocus, multidrug-resistant Pseudomonas, and multidrug-resistant Acinetobacter.

In a 2014 editorial, "Antibiotic resistance threats in the United States: stepping back from the brink," Dr. Steven Solomon and Kristen Oliver from the CDC identified three strategies that family physicians can use to limit antibiotic resistance: 1) Preventing infections through immunizations, standard infection control practices, and patient counseling; 2) Reporting unexpected antibiotic treatment failures and suspected resistance to local or state health departments; and 3) Prescribing antibiotics more carefully. Unfortunately, inappropriate antibiotic prescribing (also known as antibiotic overuse) is common in primary care, particularly for patients with acute viral respiratory tract infections.


Antibiotic overuse is a multifaceted problem with many potential solutions. On Sunday, July 9th at 7 PM Eastern, Dr. Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will be taking a deep dive into the evidence on the most effective strategies to curb prescribing of unnecessary antibiotics. American Academy of Family Physicians members and paid AFP subscribers can earn 4 free continuing medical education credits by registering for the #afpcme Twitter Chat, reading three short AFP articles, and completing a post-activity assessment. We hope you can join us!

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This post first appeared on the AFP Community Blog.

Thursday, June 29, 2017

Innovations in primary care for underserved populations

Lately, “innovation” is the buzz word that I am hearing most often at conferences and briefings and reading in medical journals. But what counts as innovation in primary care, and how can physicians and patients quickly distinguish true practice-changers from temporary fads? At a conference I attended last year, Ray Rosin, Chief Innovation Officer at Penn Medicine, described three techniques that can be used to rapidly test promising innovations:

Vapor tests, which help innovators determine the demand for a service or program without needing to build the service or program first.

Fake front ends, which "make ideas tangible to help answer the question 'What will people do with it?'"

Fake back ends, which allow "teams to quickly answer the question 'What happens if people actually use it?'"

Even though these techniques require relatively small investments in time and effort, primary care clinicians still need to know about promising innovations in order to test them. One good source for innovations to improve quality and reduce disparities is the Agency for Healthcare Research and Quality's Health Care Innovations Exchange, a searchable database of case studies ("innovation profiles") submitted by health organizations across the nation. Over the past few months, I've also collected several primary care innovations for underserved populations from the new Annals of Family Medicine feature and various other sources.

1) Using QR codes to connect patients to health information - a rural family medicine clinic in Iowa displays QR codes in its waiting room and other areas that, when scanned by a reader on a smartphone or tablet, load general patient education resources or materials related to the specific reason for the patient's visit.

2) Engaging complex patients with drop-in group medical appointments - a stabilizing program for uninsured, low-income patients with complex mental and physical health needs in North Carolina that over the past 6 years has reduced enrollees' hospital utilization by 50% at the cost of $100 per patient per month.

3) Fresh food by prescription - Central Pennsylvania's Geisinger Health system piloted a free, healthy "food pharmacy" for low-income patients with type 2 diabetes and their families on the grounds of one of its hospitals.

4) Telemedicine screening for diabetic retinopathy - Los Angeles County successfully implemented telemedicine screening in its safety net clinics, reducing the wait time for screening from 158 to 17 days and increasing the percentage of all eligible patients screened by more than 40%.

These innovations probably won't work in every underserved setting, but one or more could be worth a try in your clinic or health system, using one of Rosin's rapid-cycle techniques.

Sunday, June 18, 2017

Start collecting community vital signs in your practice

Primary care physicians and educators are increasingly recognizing the usefulness of assessing social determinants of health (defined by the Centers for Disease Control and Prevention as conditions in the places where people live, learn, work, and play) during health care encounters. A recent National Academy of Medicine discussion paper described the Accountable Health Communities Screening Tool, developed by the Center for Medicare and Medicaid Innovation to identify and address five domains of health-related social needs: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. Since 2011, students at Morehouse School of Medicine and Georgia State University College of Law have participated in an interprofessional medical-legal curriculum; surveys suggested that medical students who completed the curriculum were more likely to screen for social determinants of health and refer patients to legal resources. In March, the American Academy of Family Physicians (AAFP) launched its Center for Diversity and Health Equity, whose planned activities will include

- evaluating current research on the social determinants of health and health equity;
- promoting evidence-based community and policy changes that address the social determinants of health and health equity; and
- developing practical tools and resources to equip family physicians and their teams to help patients, families, and communities.

In an editorial in the June 1 issue of American Family Physician, Drs. Lauren Hughes and Sonja Likumahuwa-Ackman add another potential dimension for action on social determinants of health by introducing the concept of "community vital signs." In contrast to data collected directly from patients, the authors write,

Community-level data are acquired from public data sources such as census reports, disease surveillance, and vital statistics records. When geocoded and linked to individual data, community-level data are called community vital signs. Community vital signs convey patients' neighborhood health risks, such as crime rates, lack of walkability, and presence of environmental toxins. ... This enhanced knowledge about where patients live, learn, work, and play can help physicians tailor recommendations and target clinical services to maximize their impact. Rather than simply recommending that a patient eat better and exercise more, care teams can connect patients to a local community garden, low-cost exercise resources (e.g., YMCA), or neighborhood walking groups.

To get started using community-level data to improve patient care and population health, family physicians can consult The Practical Playbook and the AAFP's Community Health Resource Navigator. The editorial also provides a suggested five-step process for incorporating community vital signs into clinical practice.

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This post first appeared on the AFP Community Blog.

Wednesday, June 14, 2017

We shouldn't expect anyone to die in childbirth

Comparing the performance of health systems around the world is difficult to do in a straightforward way. Should one look at differences in life expectancy? Disability-adjusted life years? The percentage of the population that perceives themselves to be in "good health"? We know that poverty, low education, segregation, and other social disadvantages do more to determine health outcomes than does health care. Since newborns presumably haven't had time to become unhealthy from these social factors, the infant mortality rate is commonly cited to illustrate the failure of the U.S. health care system, which has the highest spending per person in the world, but outcomes worse than those in 27 other high income nations.

But it's not only in infant deaths that the U.S. lags behind the rest of the developed world. Last year, the Institute for Health Metrics and Evaluation reported that the maternal mortality rate (the number of deaths per 100,000 births due to complications from pregnancy or childbirth) was higher in 2013 than in 2005, and more than 50 percent higher than the rate in 1990. Even though maternal deaths remain rare (occurring about once every 3600 births in the U.S., 3 or 4 times as often as in Canada and Western European countries), they should be treated like catheter-related bloodstream infections, where the goal is zero. My wife has had four children, at at no point during any of her pregnancies, labors or deliveries did I have the slightest concern that her life was in danger. That's how it should be for moms in the twenty-first century.

And that's also why I, and doubtless many others, found the recent NPR / ProPublica article "The Last Person You'd Expect to Die in Childbirth" so heartbreaking and disturbing. The article recounts the tragic story of Lauren Bloomstein, a 33 year-old neonatal nurse in good health who died of a hemorrhagic stroke in her own New Jersey hospital, 20 hours after delivering her first child. According to the authors, Bloomstein developed preeclampsia with HELLP syndrome, and her physician did not recognize the early symptoms (high blood pressure and abdominal pain) for what they were until it was too late to stop the catastrophe.

It's possible that her death may have been prevented if the hospital had implemented standardized birth safety practices described in an Atlantic article about Dr. Steve Clark, an obstetrician who previously led obstetric safety for 115 programs in the Hospital Corporation of America. But it would be a mistake to conclude from Bloomstein's tragedy that the rising U.S. maternal mortality rate is due primarily to medical errors, when it is in fact a complex public health problem. Dr. Aaron Carroll reviewed some possible causes in a JAMA Forum, including unplanned pregnancies; poor access to preventive care; the opioid epidemic; and the increased prevalence in pregnant women of obesity, hypertension, and diabetes.

Also, the rising overall rate masks persistent disparities. According to a 2010 report on maternal mortality from the Health Resources and Services Administration, non-Hispanic Black women have 3 times the risk of maternal death than White and Hispanic women; counties where 15% or more of the population lives in poverty have twice the risk as counties with a poverty rate of less than 5%; and women in New England have one-half to one-third the risk of women in the Mid- and South Atlantic states. 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. In the short term, it is important to prevent the U.S. Senate from passing its version of the American Health Care Act, which takes $800 billion from Medicaid, the program that pays for 31 to 72 percent of all births depending on the state, like a thief in the night. The last person you'd expect to die in childbirth? We shouldn't expect anyone to die in childbirth, and we certainly shouldn't be hastening their deaths.

Monday, June 5, 2017

The places in America where doctors won't go

This spring, I attended the annual Teaching Prevention conference in Savannah, Georgia sponsored by the Association for Prevention Teaching and Research. Since I haven't spent much time in Georgia outside of Savannah and Atlanta, the welcoming plenary on improving health outcomes for the state's rural and underserved populations was eye-opening. According to Dr. Keisha Callins, Chair of the Department of Community Medicine at Mercer University, Georgia ranked 39th out of 50 states in primary care physician supply in 2013 and is projected to be last by 2020. 90% of Georgia's counties are medically underserved. Mercer supports several pipeline programs that actively recruit students from rural areas, expose all students early to rural practice and community health, and provide financial incentives for graduates who choose to work in underserved areas of the state. But it's an uphill battle. Even replicated in many medical schools across the country, these kinds of programs likely won't attract enough doctors to rural areas where they are most needed.

When people talk about places where doctors won't go, they tend to focus on international destinations, such as war zones in Syria or sparsely populated areas of sub-Saharan Africa. It's hard to believe that many places in America are essentially devoid of doctors, and access to medical care is as limited as in countries where average income is a tiny fraction of that in the U.S. Providing health care coverage for everyone, while important, won't automatically ensure the availability of health professionals and resources in rural communities. In a recent JAMA Forum piece, Diana Mason discussed the financial struggles of rural hospitals that support community health alongside primary care clinicians, which may become more acute if budget cuts to rural health programs and grants occur as proposed in President Trump's budget.

Georgia is hardly the only state struggling to attract doctors to rural communities. In the Harper's Magazine story "Where Health Care Won't Go," Dr. Helen Ouyang chronicles the evolving tuberculosis (!) crisis in the Black Belt, a swath of 17 historically impoverished, predominantly African American counties in rural Alabama and Mississippi. In Marion, Alabama, a single family doctor in his mid-fifties and an overwhelmed county health department grapple daily with the lack of resources to contain the spread of the disease:

There is no hospital in town. The nearest one, twenty minutes away in Greensboro, has minimal resources. The road to get there is narrow, unlit at night, and littered with roadkill. Perry County has only two ambulances, one of which is on standby for the local nursing home. Life expectancy here is seven years lower than the U.S. average, and the percentage of obese adults is almost a third higher; by the latest count, more than a quarter of births take place without adequate prenatal care. [Dr. Shane] Lee’s clinic is Marion’s only place for X-rays.

Ouyang goes on to describe the University of Alabama's Rural Health Leaders Pipeline, a program that recruits and trains medical students from rural communities to eventually become primary care physicians for those communities. Although the program has been modestly successful (since 2004, "more than half have gone on to work in rural areas, compared with only 7 percent of their classmates"), many Black Belt counties have yet to benefit from it. Many medical schools use a minimum score cutoff on the Medical College Admission Test (MCAT) that tends to penalize applicants from rural and minority communities, even though those students are more likely to become primary care physicians for underserved populations:

The purpose of doctors, after all, is to tend to patients’ ultimate needs. Increasing the supply of primary care physicians is linked to lower mortality rates; after compiling data from studies across different parts of the country, a group of public health researchers found that by adding one more doctor for every 10,000 people, as many as 160,000 deaths per year could be averted. When the same researchers considered race as a factor, this benefit was found to be four times greater in the African-American population than among white people. Studies have also observed that the availability of primary care significantly reduces health disparities that result from income inequality.


The problem of too few primary care clinicians is not limited to rural America, but those communities are where the need is greatest, since a town without a family doctor is unlikely to have any other types of physicians. Medical schools can't easily change social determinants of health on their own, but they can rewrite their mission statements to emphasize providing health care to everyone regardless of geography, and implement recruitment and admissions policies that actually support that goal.

Thursday, June 1, 2017

Selected publications list, updated June 2017

I periodically write guidelines, research articles, editorials, and letters in the medical literature about some of the topics that I write about on this blog. Below is an updated list of selected publications, with links to abstracts or full articles if available:

1. Frost JL, Campos-Outcalt D, Hoelting D, LeFevre M, Lin KW, Vaughan W, Bird MD. Pharmacologic management of newly detected atrial fibrillation: updated American Academy of Family Physicians clinical practice guideline, June 2017.

2. Bird MD, Gersch D, Hoelting D, Lin KW, Mishori R. Incarceration and health: a family medicine perspective. American Academy of Family Physicians position paper, May 2017.

3. Lin KW, Frost JL. Should screening tests for colorectal cancer all have an “A” recommendation? No: when it comes to colorectal cancer screening, test choice matters. Am Fam Physician 2017;95:618-620.

4. Lin KW. Is genetic testing sophisticated enough to make PSA screening viable for mainstream use? No. HemeOnc Today, March 25, 2017.

5. Llano J, Lin KW. Management of binge-eating disorder in adults. Am Fam Physician 2017;95:324-326.

6. Petersen J, Lin KW. Radioiodine therapy versus antithyroid medications for Graves disease. Am Fam Physician 2017;95:292-293.

7. Barreto T, Lin KW. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory tract infections in primary care. Am Fam Physician 2017;95:11-12.

8. Schwartz SR, Magit AE, Rosenfeld RM, Ballachanda BB, Hackell JM, Krouse HJ, Lawlor CM, Lin K, et al. Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg 2017;156(1S):S1-S29.

9. Lin KW, Ebell MH. How to counsel men about PSA screening. Am Fam Physician 2016;94:782-784.

10. Lin KW. Increased alignment in preventive services recommendations for children. Am Fam Physician 2016;94:272-274.

11. Lin KW, Yancey JR. Evaluating the evidence for Choosing Wisely in primary care using the Strength of Recommendation Taxonomy (SORT). J Am Board Fam Med 2016;29:512-515.

12. Ebell M, Lin KW. Counseling women about breast cancer screening. Am Fam Physician 2016;93:652-653.

13. Lin KW, Gostin LO. A public health framework for screening mammography: evidence-based vs politically mandated care. JAMA 2016; 315:977-978.

14. Lin KW. Should family physicians routinely screen patients for hepatitis C? No: one-time screening still has too many unanswered questions. Am Fam Physician 2016;93:17-18.

15. Lin K, O'Gurek D, Rich R, Savoy M. How to help your patients Choose Wisely. Fam Pract Manag 2015;22:28-34.

16. Raffoul M, Lin KW. Cultural competence education for health care professionals. Am Fam Physician 2015;91:523-524.

17. Koretz RL, Lin KW, Ioannidis JP, Lenzer J. Is widespread screening for hepatitis C justified? BMJ 2015;350;g7809.

18. Lin KW. What to do at well-child visits: the AAFP’s perspective. Am Fam Physician 2015;91:362-364.

19. Siwek J, Lin KW. Choosing Wisely: more good clinical recommendations to improve health care quality and reduce harm. Am Fam Physician 2013;88:164-168.

20. Lin KW, Sieber PR, Oyer RA. The controversial prostate-specific antigen (PSA) test: a roundtable discussion of its indications and uses. J Lancaster Gen Hosp 2012;7(4):101-110.

21. Lin KW. Practice guidelines produced by subspecialists must meet higher standards. [Letter] Ann Fam Med published online November 15, 2012.

22. Lin KW. Do electronic health records improve processes and outcomes of preventive care? Am Fam Physician 2012;85:956-957.

23. Lin K, Croswell JM, Koenig H, Lam C, Maltz A. Prostate-specific antigen-based screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 90. AHRQ Publication No. 12-05160-EF-1. Rockville, MD: Agency for Healthcare Research and Quality, October 2011.

24. Lin KW. Challenging the conventional wisdom on colorectal and prostate cancer screening. J Lanc Gen Hosp 2010;5(3):74-77.

25. Lin K, Sharangpani R. Screening for testicular cancer: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2010;153:396-99.

26. Lin K. Adverse effects. Pulse: voices from the heart of medicine. May 21, 2010.

27. Lin KW, Slawson DC. Identifying and using good practice guidelines. Am Fam Physician 2009;80:67-69

28. Lin K, Lipsitz R, Miller T, Janakiraman S. Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149:192-99.

29. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2008;148:535-43.

Monday, May 29, 2017

Should we look for pulmonary emboli in patients with syncope?

The standard evaluation of patients with syncope has changed little over the years, with considerable continuity between American Family Physician reviews published in 2005, 2011, and this March. But the field received an unexpected jolt last October, when Dr. Paolo Prandoni and colleagues published a cross-sectional study in the New England Journal of Medicine that calculated a surprisingly high prevalence of pulmonary embolism (PE) of 17.3% in patients hospitalized for a first episode of syncope. In this study, 230 of 560 patients at 11 Italian hospitals who did not have a low pretest probability of PE by the Wells rule and negative D-dimer assay underwent computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion lung scans. 97 of these patients had evidence of PE. Overall, the investigators identified PE in 25% of patients with no alternative explanation for syncope and 13% of patients with an alternative explanation.

Algorithms for syncope evaluation focus on identifying cardiac and neurally mediated causes and do not include routine testing for PE. The question raised by the Italian study is if all inpatients with syncope need evaluation, since nearly 1 in 6 patients may have PE. There are good reasons not to jump to this conclusion. First, we don't know if the prevalence of PE in this study was representative of the general population of adults hospitalized for syncope, as it only included patients admitted from emergency departments (and not patients initially evaluated in primary care settings). Second, the study did not determine if PE was the etiology of syncope, as opposed to an incidental finding. This is important because evidence suggests that the enhanced sensitivity of CTPA for detecting small, subsegmental PE is increasing overdiagnosis and overtreatment of clinically insignificant clots. Finally, the absence of a comparison group means that it is not known if the systematic workup for PE improved the patients' prognoses or just added additional cost and risk to the evaluation.

A retrospective cross-sectional study in JAMA Internal Medicine recently used clinical and administrative data from 4 hospitals in Toronto to estimate the prevalence of PE in 1305 patients with a first episode of syncope who were not receiving anticoagulation at the time of admission. 120 of these patients received CTPA, ventilation-perfusion scan, and/or compression ultrasonography, leading to the diagnosis of PE in 18 patients. As opposed to the Italian study, where all persons received at least a D-dimer test, the decision to evaluate for PE was driven by clinical judgment. Nonetheless, of 146 patients in the Toronto study who received any test for PE (presumably those who were most likely to have one), only 12% were positive, and the overall prevalence of PE was a mere 1.4%. The authors concluded that "there is little, if any, justification for routine testing for [venous thromboembolism] in all patients hospitalized for a first episode of syncope."

Based on both studies, I agree that evidence does not support routinely looking for PEs in patients with syncope. In patients with possible signs or symptoms, another clinical decision rule may be used to confidently rule out the diagnosis without resorting to the less sensitive Wells rule or less specific D-dimer test, where a positive result often leads to unnecessary CTPA.

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A slightly different version of this post first appeared on the AFP Community Blog.

Monday, May 22, 2017

Colorectal cancer and falls: too much and too little prevention

One of the paradoxes of the U.S. health care system is that excess and waste often exist side by side with insufficiently provided services. Colorectal cancer screening is a prime example. Previous studies showed that 25% of Medicare recipients undergo repeat screening colonoscopies sooner than necessary, but the Centers of Disease Control and Prevention recently reported that nearly 4 in 10 adults between ages 50 and 75 are not up-to-date on colorectal cancer screening. Last year, I argued that the U.S. Preventive Services Task Force's decision to expand the number of recommended screening options based on inadequate evidence was unlikely to improve this situation.

In an editorial in the May 15th issue of American Family Physician, I and Dr. Jennifer Frost explained why the American Academy of Family Physicians disagreed with the new recommendations, and instead chose not to recommend CT colonography or fecal DNA testing and to also reaffirm its previous stance against screening adults older than 85 years. BMJ journalist Jeanne Lenzer's question about whether the USPSTF remains a voice of caution remains relevant in an era of increasingly elastic evidence letter grades (see "C" for prostate cancer screening).

Another area where there may be too much prevention occurring for too little benefit is screening and treatment for osteoporosis, which Ray Moynihan and colleagues reported that in contrast to the medical literature, community-dwelling older women would prefer to describe as a "risk factor" rather than a "disease." I couldn't agree more; we physicians focus too much on prescribing drugs to treat low bone density and too little on interventions to address the other critical risk factor for hip fractures: falling.

So I hope that many patients will read and heed Paula Span's recent New York Times column advising older adults to invest in home modifications that will allow them to move safely around their living spaces as they age. Unfortunately, there aren't nearly enough Certified Aging in Place Specialist (CAPS) contractors to meet national needs. Also, many health insurers that would have no issues paying for a PSA test or screening colonoscopy in a 90 year-old would balk at reimbursing home renovations, even though the latter is much more likely to prevent (rather than cause) a hospitalization.

Tuesday, May 16, 2017

Fear-mongering in thyroid and breast cancer screening

A large part of practicing primary care consists of providing reassurance to healthy persons. The patient who asks me to look at the mole on her back to make sure it isn't melanoma. The patient who recently recovered from a cold but is still coughing and wants to know that it isn't a sign of something more serious. The patient whose friend's doctor found a lump on his thyroid gland and wants to have his neck checked too.

The last time the U.S. Preventive Services Task Force recommended against screening for thyroid cancer was in 1996. That it took more than 20 years to release an updated recommendation statement (still a "D," or don't do) speaks to how non-controversial the Task Force judged this topic to be. Unfortunately, in the interim many clinicians and patients ignored this advice. In South Korea, a national cancer screening program that began in 1999 encouraged general practitioners to routinely perform thyroid ultrasound scans, resulting in an "epidemic" of new thyroid cancers but no change in thyroid cancer deaths. In the United States, papillary thyroid cancer diagnoses have quadrupled since 1995, again with no change in mortality. In both countries and around the world, physicians are finding and treating thousands of pseudo-cancers that would not have otherwise been found and don't need to be treated. Overdiagnosis begets more overdiagnosis: patients who are "successfully" diagnosed and treated tell friends and relatives to have their necks palpated or scanned for thyroid tumors. And if that feedback cycle wasn't enough, advocacy groups such as the Light of Life Foundation initiated fear-mongering awareness campaigns, as Dr. Gilbert Welch described in an editorial accompanying the USPSTF recommendation:

About a decade ago, public service announcements began to appear encouraging people to have their physicians “check your neck.” The Light of Life Foundation campaign featured actual testimonials of patients describing their positive health behaviors on the day before they were diagnosed with thyroid cancer. The ads used compelling language: “Thyroid cancer doesn’t care how healthy you are. It can happen to anyone. Including you. That’s why it is the fastest growing cancer in the US. Ask your doctor to check your neck. It could save your life.” The campaign’s title—and its main slogan—was “Confidence Kills.” That’s a great public health message: if you feel good, you are about to die.


Fear-mongering isn't limited to thyroid cancer, of course. From the 1980s-era American Cancer Society print advertisement that lectured women, "If you haven't had a mammogram, you need more than your breasts examined," promoters of breast cancer screening long used fear to motivate women to undergo screening mammography. In 2015, several advocacy organizations successfully persuaded the U.S. Congress to override the U.S. Preventive Services Task Force's "C" grade (small net benefit) on screening mammography for women aged 40-49 with a "Stop the Guidelines" campaign that included full-page advertisements in major newspapers asking the rhetorical question "Which of our wives, mothers, daughters, and sisters would be be OK to lose?"

The major difference between screening for thyroid and breast cancer is that the latter actually reduces cancer deaths. But women under 50 are less likely to benefit because there is less lethal breast cancer to be found in younger women, and consequently much higher false positive rates that affect more than half of all women receiving annual mammograms from age 40 to 50. And the USPSTF didn't tell clinicians don't screen - more accurately, they said don't screen reflexively, and the message to younger women is not to avoid mammograms, but to talk about the pros and cons with your doctor.

That hasn't stopped a new alliance of radiologists and breast cancer surgeons from targeting the Task Force with a 40not50 campaign which encourages women in their 40s to turn off their brains, eschew shared decision-making, and demand that their doctors start screening them at age 40 because mammograms save lives, and a government-appointed panel (whose 16 members include 7 women) wants to prevent women from seeing their 50th birthdays. Notwithstanding the ulterior motives behind this absurd campaign, it 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.

Sunday, May 7, 2017

American Family Physician translates research for practice

Over the next few months, I'll have more to say about the recent announcement that my longtime mentor Jay Siwek, MD, editor of American Family Physician since 1988 and the only family physician in the journal's 67-year history to hold that position, will be stepping down in January after 30 years at the helm. In the meantime, this post highlights three ways AFP currently translates research for primary care practice: the Top 20 research studies articles, Pro-Con editorials, and Journal Club.

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The May 1 issue of American Family Physician features the latest installment of the "Top 20 Research Studies" series of articles that Drs. Mark Ebell and Roland Grad have been writing annually since 2012. What sets this particular set of study summaries apart from other journals' "best of the year" studies lists? Dr. Jay Siwek explains in his editor's note:

Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.

The research studies from 2016 rated most primary care relevant, valid, patient-oriented, and practice changing include patient-oriented evidence that matters (POEMs) on hypertension; respiratory conditions; musculoskeletal conditions; diabetes mellitus and obesity; and miscellaneous items. The complete POEMs are available in AFP's Evidence-Based Medicine toolkit. Also, Canadian Medical Association members identified four important guidelines published in 2016: the U.S. Preventive Services Task Force (USPSTF) on screening for colorectal cancer and interventions for tobacco cessation in adults; the American College of Physicians on management of chronic insomnia; and the Centers for Disease Control and Prevention on opioid prescribing for chronic pain.

During Dr. Ebell's past membership on the USPSTF, the panel voted to recommend one-time screening for hepatitis C virus (HCV) in every adult born between 1945 and 1965 (also known as birth cohort screening). On the other hand, as a member of the Canadian Task Force on Preventive Health Care, Dr. Grad recently developed a recommendation against screening for HCV in asymptomatic adults without risk factors, including baby boomers. AFP previously presented both sides of this complicated debate in a pair of editorials that outlined the case for birth cohort screening and the case against it (which I wrote). You can find other Pro-Con editorials on controversial family medicine topics in this online collection.

Finally, readers should be aware that essential concepts from AFP Journal Club, a popular journal feature that analyzed key research studies from 2007 to 2015, have been incorporated into our EBM toolkit. This annotated collection of evidence-based medicine pointers provides useful information for clinicians, teachers, and learners at all levels.

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This post originally appeared on the AFP Community Blog.

Monday, May 1, 2017

Every screening test is a calculated gamble

When I was last in Las Vegas to attend the International Consumer Electronics Show, I stayed at one of the city's many combination hotel and casinos, with a layout designed to funnel guests and other visitors through the gaming floor to get practically anywhere. While walking past a row of pulsating slot machines in the lobby one morning, I remembered the title of a terrific New York Times editorial I read a few years ago, "You Have to Gamble On Your Health."

Courtesy of www.lasvegas.com

In this editorial, Dr. H. Gilbert Welch (whom I've lauded before for his work on the subject of overdiagnosis) explained why even though most people who receive screening tests for cancer think that they are playing it safe, every test has tradeoffs. Just as a gambler rarely hits the jackpot in Vegas, a patient who undergoes cancer screening is rarely the lucky one whose life is extended from the test, and much more likely to figuratively lose his or her shirt. Common harms of screening include false positive results, risks associated with subsequent diagnostic procedures, and possible unnecessary treatment (and associated side effects) for "cancer" that looks dangerous under the microscope but is actually destined to never cause health problems.

Courtesy of www.lasvegas.com

The good news is that for a few very well-studied screening tests such as mammography, an informed patient can assess the odds of all of these outcomes based on scientific data and decide whether screening is a better choice for her than no screening. A mammography screening decision aid by Dr. Jill Jin that appeared in JAMA did a great job of illustrating these tradeoffs, and may help to explain why one prominent health journalist announced that she had decided to forego mammography because she believed that "the numbers are in my favor."

Yes, every screening test is a gamble, but I give credit to my fellow physicians for providing increasingly sophisticated support for these tough decisions that you'd never get in Vegas.

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This post first appeared on Common Sense Family Doctor on January 6, 2015.

Monday, April 24, 2017

Safety net doesn't protect patients from low-value care

During my residency training and for parts of my career, I practiced in several "safety net" clinics, defined as clinics that serve a patient population where at least 25% have no health insurance or are insured with Medicaid. As family physicians who work in these settings well know, resources are often limited, and arranging for patients to receive necessary care at an affordable price can be a major challenge.

While on telephone hold one day for the umpteenth prior authorization request for a medication my patient had been taking for years, I remember consoling myself that at least these maddening financial constraints provided protection against low-value care. Unlike the concierge practice on the other side of town, I couldn't get patients with acute low back pain into a magnetic resonance imaging (MRI) scanner the next day or order huge panels of unnecessary laboratory tests at health maintenance exams.

As it turned out, my perception was more myth than reality. In a recent cross-sectional analysis of national survey data on nearly 200,000 office visits from 2005 to 2013, Dr. Michael Barnett and colleagues examined performance on quality measures for low- and high-value care among uninsured patients, patients with Medicaid, and privately insured patients. Sample low-value care measures included computed tomography (CT) for sinusitis, screening electrocardiogram during a general medical examination, and CT or MRI for headache. High-value care measures included aspirin, statin, and beta-blocker use in patients with coronary artery disease and tobacco cessation and weight reduction counseling in eligible patients. The authors analyzed the data by insurance type and by physicians classified as practicing in a safety net population. They found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.

This study's findings underline the importance of involving clinicians and patients in underserved practices in the Choosing Wisely campaign against medical overuse. For example, the Connecticut Choosing Wisely Collaborative used a foundation grant to study patient-clinician communication about care experiences and incorporate the Choosing Wisely "5 Questions" at two federally qualified health centers. Lessons learned from these pilot projects included providing patients with context for the "5 Questions" materials and offering ongoing role-specific training and support for everyone on the care team.


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This post first appeared on the AFP Community Blog.

Tuesday, April 11, 2017

The USPSTF takes a step backward on PSA screening

I don't agree with all of the statistics cited in this infographic, particularly the optimistic estimate that 1-2 men out of every 1000 screened with the PSA test avoid death from prostate cancer. I believe that the USPSTF's 2012 estimate of 0-1 men remains more accurate, but even if the new figure is true, I don't think that changing the PSA recommendation from a "D" (benefits no greater than harms, don't do) to a "C" (small net benefit, do selectively) is warranted, given the collateral damage to men's health that screening produces. In an editorial in JAMA, the USPSTF Chair and Vice-Chairs have invited the public to comment on the draft recommendations, which are more consistent with those from the American Cancer Society and American Urological Association than the American Academy of Family Physicians and the American College of Preventive Medicine (which both recommend against PSA-based screening). They will hear from me, and I hope that they will hear from others in primary care about the physical, psychological, and opportunity costs of taking a step backward on PSA screening.