Common Sense Family Doctor

The best recent posts you may have missed

2012-06-01T17:03:00.000-04:00

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from the past few months:

1) How much does it cost to have an appendectomy? (4/24/12)

2) Electronic health records: medical progress, not panacea (5/16/12)

3) My take on state health insurance exchanges (3-part series) (4/16/12)

4) Counterintuitive findings on quality incentives and patient satisfaction (4/20/12)

5) Don't confuse cardiovascular imaging with preventive medicine (3/27/12)

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

Book Review: Between the Lines

2012-05-30T16:14:00.000-04:00

Every year for the past several years, I have served as a faculty group leader for a course in "Evidence-Based Medicine" taught to first and second-year medical students. The course aims to provide students with basic tools to navigate the medical literature that we hope they will retain during their training and use to answer clinical questions long after they enter practice. Unfortunately, the course is a low priority for students in their preclinical years, and many of the epidemiology and statistics concepts we teach are far more advanced than what they will need to know as physicians.

It was a pleasure, then, to read Dr. Marya Zilberberg's Between the Lines: Finding the Truth in Medical Literature, a rare book that bridges the gulf between medical publications and the real world of practicing clinicians. Zilberberg, a physician and noted health services researcher who blogs at Healthcare, etc., distills her expertise from two decades of teaching evidence-based medicine into a concise text that is accessible not only to medical students and other health professionals, but to journalists and educated laypersons who want to look past the latest sensational headlines to uncover what we actually know about sickness and health. The book's conversational tone makes the reader feel as if Zilberberg herself is in the room giving a one-on-one tutoring session.

The book is divided into two parts: "Context" and "Evaluation." The first part was my favorite, containing a collection of short essays with provocative titles such as "Beware of What Seems Too Good to Be True" and "Assume a Spherical Cow." Here Zilberberg exposes the faulty reasoning behind certain health care beliefs shared by much of the general public and a good number of clinicians, as well. For example, a screening test that is touted as being highly sensitive for the condition it detects still may not be worth undergoing, depending on how common (or uncommon) the disease is and how many false positive results it generates.

The second part follows a more standard format for a book on the medical literature, moving logically through a traditional hierarchy of study designs and threats to the interpretation of study results. Zilberberg's writing is clear and straightfoward, and key points are helpfully highlighted in accompanying figures and tables. I recommend this book highly to all students of evidence-based medicine, regardless of occupation or professional degree.

"The best [colorectal cancer screening] test is the one that gets done"

2012-05-21T16:03:00.000-04:00

Last week was a busy one for cancer screening. I could choose to criticize the Centers for Disease Control and Prevention's premature guidelines to screen all baby boomers for hepatitis C (which can lead to cirrhosis and liver cancer) or the less-than-sound recommendations of several major cancer organizations to screen present or former heavy smokers between ages 55 and 74 for lung cancer with CT scans. (As I've pointed out before, there are at least 4 good reasons not to reflexively follow the latter advice.) But instead, I would like to explore the irony that another screening test that has conclusively been shown to result in more health benefits than harms is on the verge of becoming extinct in the U.S. That test is screening for colorectal cancer with flexible sigmoidoscopy.

Flexible sigmoidoscopy is an uncomplicated office procedure that requires no anesthesia and was once commonly taught to, and performed by, thousands of family doctors and general internists in adults over the age of 50. But over the past decade, gastroenterologists have done a magnificent job convincing primary care physicians and the American public that colonoscopy is the "gold standard" for colorectal cancer screening. As a result, a recent national survey found that while 55 percent of respondents reported receiving a screening colonoscopy within the past 10 years, only 1.3 percent of respondents reported being screened recently with flexible sigmoidoscopy.

That's too bad, because not only does screening colonoscopy cost a lot more money, it hasn't ever been shown to be more effective that screening sigmoidoscopy. In fact, screening colonoscopy has never even been tested in a randomized trial, and may never be. In contrast, yesterday the lead researchers of the National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (which previously found that prostate and ovarian cancer screening don't save lives) reported that having a flexible sigmoidoscopy every 3 to 5 years reduced deaths from colorectal cancer by 26 percent, even though nearly half of the control group underwent screening at least once. That's a big deal, since colorectal cancer is the third-leading cause of cancer death among U.S. women, and the second-leading cause of cancer death in men under age 75.

In an accompanying editorial, Dr. John Inadomi urges clinicians to reconsider flexible sigmoidoscopy as a preferred cancer screening strategy for three reasons: 1) it's more evidence-based than screening colonoscopy; 2) patients are more likely to be screened if multiple options are available; 3) screening resources are limited, and efficiency matters. He concludes:

Where does this leave us with regard to screening flexible sigmoidoscopy? First, it should be acknowledged that flexible sigmoidoscopy reduces colorectal-cancer incidence and mortality for the portion of the colon that it is designed to examine. Next, high-quality evidence must show the superiority of colonoscopy over other screening tests before we dismiss the use of flexible sigmoidoscopy and fecal occult-blood testing, both of which have randomized, controlled trials supporting their benefit. Especially critical are data that confirm the ability of colonoscopy to reduce mortality from proximal cancers. Finally, patient preferences for screening tests should be identified and respected — in this case, the best test is the one that gets done.

Electronic health records: medical progress, not panacea

2012-05-16T14:17:00.004-04:00

Yesterday, the family medicine residency program where I serve as a faculty preceptor "went live" with their new electronic health record. They posted a sign at the front desk that read in part: "Pardon Our Progress," as if we were starting a major construction project - which in a way, we were. Instead of wading through stacks of unruly paper charts, my colleagues and I logged on to a sleek online portal via laptop computers to review and sign residents' progress notes. Thanks to months of meticulous preparation and the presence of onsite technical support, the day went relatively smoothly for physicians and patients.

By leaving paper behind, we looked forward to eliminating inconvenience and errors associated with lost charts and illegible or missing documentation. But the most important reason for the switch to an electronic health record was the unspoken presumption that it would allow us to provide better preventive and chronic care for patients. At the end of the afternoon session, I asked the residents how strong the evidence is that practices with electronic health records actually improve their quality of care.

The answer, it turns out, is not very strong at all. In an editorial published in the May 15th issue of American Family Physician, I review the small number of studies that have evaluated the effect of electronic clinical decision support systems (CDSSs) on processes and outcomes of preventive care. Whether the goal was to improve immunization or behavioral counseling rates, electronic health records have had, at best, modest effects:

In summary, the evidence is far from conclusive that EHRs and CDSSs improve preventive care processes and outcomes in primary care settings. The small number of mostly nonrandomized studies makes it hard to determine whether changes in physicians' behaviors were the result of implementing CDSSs, or if other factors were responsible. Also, the most promising studies to date were performed in large practices of employed physicians, rather than in small physician-owned practices. Finally, all but a few studies measured only guideline adherence, rather than patient-oriented health outcomes. To be worth the investment, EHR-enabled CDSSs must ultimately be shown to not only improve processes of preventive care, but also reduce morbidity and mortality and improve quality of life.

Similarly, a study published in this month's issue of the Annals of Family Medicine found that in a group of 42 similar primary care practices in the Northeast, those using EHRs were less likely than those without EHRs to meet three diabetes care quality measures (hemoglobin A1c, LDL cholesterol, and blood pressure), and that the gap did not narrow after 3 years.

So what are the chances that our residency's substantial investment (and the U.S. government's billions of dollars of incentives for physicians and hospitals to install and demonstrate "meaningful use" of electronic health records) will ultimately pay off for patients? The key to success for integrated health systems such as Kaiser Permanente and the Mayo Clinic has been to use the data from EHRs to manage population health. Rather than the traditional model of treating diabetes one patient at a time, for example, "panel managers" (registered nurses or other non-physician health professionals) can reach out to patients outside of the office visit and make sure that they are receiving recommended care. Who will pay these managers outside of the Kaisers and Mayo Clinics remains a largely unanswered question. The bottom line, though, is that it's not enough to just collect electronic data. For EHRs to transform primary care, we need to be able to use the data in new and creative ways, improving the health of large groups of patients - and eventually, entire communities - at the same time.

Effective health care for children with autism spectrum disorders

2012-05-11T09:11:00.001-04:00

A recent report from the Centers for Disease Control and Prevention found that the prevalence of autism spectrum disorders (ASDs), estimated at 1 in 110 children in a 2010 American Family Physician article, may now have risen as high as 1 in 88. Previous AFP Community Blog posts have discussed potential explanations for the continuing increase in autism diagnoses, from the phenomenon of "diagnosis shift" to increased screening for ASDs at well-child visits, a controversial practice.

Although the etiology of ASDs remains unknown, there is evidence to support some treatments for affected children. In the May 1st issue of AFP, Dr. Corey Fogleman launched our "Implementing AHRQ Effective Health Care Reviews" series by summarizing key points from an Agency for Healthcare Research and Quality-sponsored review of the effectiveness, benefits, and harms of therapies for core and associated symptoms of ASDs in children two to 12 years of age. The review found that the antipsychotic drugs risperidone and aripiprazole reduce challenging behaviors in children with ASDs, but are associated with significant adverse effects. Also, intensive one-on-one behavioral interventions appear to improve outcomes if begun before four years of age.

The AHRQ review's conclusion that there is insufficient evidence to assess the benefits and harms of other treatments for ASD-associated repetitive behaviors was supported by a recent study published in Pediatrics. Dr. Melisa Carrasco and colleagues analyzed published and unpublished data on selective serotonin receptor inhibitors (SSRIs) and initially found that SSRIs were modestly helpful in reducing repetitive behaviors in children with ASDs. However, after they adjusted for the effect of publication bias (i.e., the tendency for trials showing a benefit to be published while those showing no benefit are not), the improvement was no longer statistically significant. This study illustrated how difficult it is for even the highest-quality reviews to determine what constitutes effective health care for patients when important data are unavailable for review.

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The above post was first published in the AFP Community Blog.

Job Posting: Primary Care Health Policy Fellow

2012-05-04T08:12:00.000-04:00

The Department of Family Medicine at Georgetown University School of Medicine is currently seeking qualified applicants for its one-year fellowship in Primary Care Health Policy. This is a unique, full-time program that combines experiences in scholarly research, faculty development, and clinical practice. Fellows have the opportunity to interact with local and federal policymakers in Washington, D.C. and pursue original research projects with experienced mentors at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. They will join a dynamic group of faculty (including me) at one of the flagship departments for urban family medicine on the East Coast. Past Health Policy Fellows have gone on to hold leadership positions in federal health agencies, community health organizations, and academia. Applicants should be graduates of an accredited residency program in family medicine or expect to graduate in 2012. Please e-mail me at KWL4@georgetown.edu for additional information.

How much does it cost to have an appendectomy?

2012-04-24T09:08:00.001-04:00

A few years ago, a good friend of mine who holds bachelor's and law degrees from Ivy League schools lost his job and became one of the estimated 50 million medically uninsured persons in the U.S. Over the course of several days, he developed increasingly severe abdominal pain, fever, and vomiting. Though reluctant to seek medical attention, he finally was persuaded to visit his local hospital's emergency department, where he was diagnosed with acute appendicitis. Despite his critical condition and the need for immediate surgery, he refused treatment until the hospital's billing department gave him an estimate of how much an emergency appendectomy would cost. Then, as he was being prepared for the operating room, he somehow managed to bargain with the surgeon to reduce his customary fees.

Sharing this harrowing story weeks later, my friend, until then a strong believer in the power of the market to control rising health care costs, was justifiably proud that his negotiating skills had prevented the hospital bill from completely depleting his savings. On the other hand, he recognized the insanity inherent in trying to practice "consumer driven health care" during a medical emergency, especially given the lack of information about the pricing of health care services. I've written before about how difficult it was for my wife and I to estimate how much it would cost to have a baby (our son, incidentally, is now two months old and doing well). It turns out that variations in pricing for the diagnosis and treatment of acute appendicitis are even larger and less explicable.

A study published yesterday in the Archives of Internal Medicine reported that the hospital charges for patients hospitalized in California for acute uncomplicated appendicitis ranged from $1529 to $182,955, with a median charge of $33,611. Patient age, insurance type, and geographical location explained only about 2/3rds of the observed variations. My friend's experience in a different state confirmed what the authors of this study observed:

A patient with severe abdominal pain is in a poor position to determine whether his or her physician is ordering the appropriate blood work, imaging, or surgical procedure. Price shopping is improbable, if not impossible, because the services are complex, urgently needed, and no definitive diagnosis has yet been made. In our study, even if patients did have the luxury of time and clinical knowledge to "shop around," we found that California hospitals charge patients inconsistently for what should be similar services as defined by our relatively strict definition of uncomplicated appendicitis.

Given better transparency about pricing, perhaps there is a role for comparison shopping for predictable health care expenses, such as elective surgery or labor and delivery. But huge variations in pricing for emergency care illustrate how badly the consumer health care model fails. There are many flaws in the Affordable Care Act that Congress passed in 2010, but extending insurance to millions of currently uninsured Americans is not one of them. As this example shows, it is our country's broken health system, not the health law, that requires urgent repeal and replacement.

Counterintuitive findings on quality incentives and patient satisfaction

2012-04-20T10:28:00.000-04:00

They've been repeated so often that many health care quality gurus take them for granted: 1) paying physicians for performance will improve quality of care; 2) increasing patient satisfaction will reduce care costs and improve outcomes.

Not necessarily, two recent studies suggest.

A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of American Family Physician concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes commentator Elizabeth Salisbury-Afshar, MD, MPH, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.

In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:

Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.

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The above post was first published on the AFP Community Blog.

My take on state health insurance exchanges - Part 3

2012-04-16T09:17:00.000-04:00

Regardless of whether or not the Supreme Court strikes down the individual mandate or the entire 2010 health reform law in June, state-based health insurance exchanges are a good idea and, if established, should benefit many working Americans who are too well-off to qualify for Medicaid but unable to otherwise afford health insurance coverage on their own. This is the last of three posts excerpted from an unpublished paper that I recently authored on this topic. You can read Parts 1 and 2 here and here.

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Exchanges will need to establish procedures for determining 1) citizenship or legal resident status; 2) income eligibility for premium tax credits and cost-sharing reductions; and 3) eligibility for the public insurance programs Medicaid and CHIP. Since the ACA also expands Medicaid eligibility, fluctuations in income over time will force millions of people to repeatedly transition from public insurance coverage to a subsidized exchange plan and vice versa, changing health provider networks and potentially disrupting continuity of care. Exchanges may help to facilitate these transitions by minimizing paper documentation, guaranteeing minimum eligibility periods regardless of interim income changes, and making it possible for at least some insurance plans to be offered under Medicaid and within the exchange (“dual certification”). As one expert advised, since the intent of the ACA was to expand insurance coverage, “Exchanges should see it as their responsibility to ensure the continued enrollment of eligible individuals and families for tax credits and public programs, rather than holding individuals responsible for continually having to work at maintaining their own eligibility.”

The Massachusetts Connector’s experience illustrates the challenges of managing transitions between private and public insurance plans, which often lead to gaps in coverage: “In particular, the dates for enrollment and disenrollment between public and private coverage are not aligned, so that individuals losing Medicaid eligibility early in a month must wait until the first of the following month to enroll in CommCare [exchange for individuals below 300% of the federal poverty line].” Consequently, California anticipated the problem of coordination with public insurance programs in the legislative language enabling its exchange, which requires that the governing board “ensure consistent eligibility and enrollment processes and seamless transitions between coverage.” However, the information technology needed to achieve this goal is still being developed. In December 2011, the Maryland Health Benefit Exchange Board set a goal of ensuring continuity of care between public and private programs by recommending: “The Exchange should require transition of care language in contracts as part of qualified health plan certification and work with Medicaid to promote reciprocal care transition provisions in the managed care organization contracts.”

In drafting the blueprints for their state health insurance exchanges, Maryland and California have largely followed the successful model of the Massachusetts Connector. Other states that are planning to set up their own exchanges will also need to grapple with the questions regarding governance; reducing adverse selection; making plan information available and accessible to consumers; determining eligibility; facilitating transitions between public insurance and subsidized private plans within the exchanges; and a host of other design issues.

Despite the similarities in the structures and functions of the three health insurance exchanges discussed here, characteristics of other state populations, local insurance markets, and existing regulatory institutions will likely lead to a diversity of other approaches. For example, Rhode Island, Utah and Vermont have located their exchanges entirely within state governments, while Hawaii has structured its exchange as an independent nonprofit. Reassuringly, a recent simulation study suggested that state-to-state variations in several critical exchange design elements (e.g., separating versus merging the individual and small-group markets) would have only small effects on overall coverage and cost outcomes nationwide. By establishing some basic requirements but granting states substantial leeway to operate (or not operate) their exchanges in accordance with local resources and preferences, the ACA will hopefully achieve its goal of providing access to affordable health coverage to millions of currently uninsured Americans.

My take on state health insurance exchanges - Part 2

2012-04-14T09:13:00.000-04:00

Regardless of whether or not the Supreme Court strikes down the individual mandate or the entire 2010 health reform law in June, state-based health insurance exchanges are a good idea and, if established, should benefit many working Americans who are too well-off to qualify for Medicaid but unable to otherwise afford health insurance coverage on their own. This is the second of three posts excerpted from an unpublished paper that I recently authored on this topic. You can find my first post here.

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Adverse selection is a phenomenon in which higher-risk (and higher-cost) individuals become more likely to purchase insurance inside the exchanges, leading to premium increases within the exchanges, driving healthier (and lower-cost) individuals to purchase cheaper insurance outside the exchanges, leading to further exchange premium increases, and so on, until the exchange essentially becomes a high-risk pool. Thus, adverse selection is a serious threat to the viability of exchanges. One potential solution is to simply eliminate the market outside of the exchanges, but this option may not be feasible for most states. To reduce the risk of adverse selection, states should have identical rating rules for the markets inside and outside of the exchanges, and require all insurance plans of a certain size to participate in the exchanges. Massachusetts, for example, requires that all insurers with more than 5000 non-group enrollees submit bids to the Connector, and that prices for insurance products be the same inside and outside of it.

California will require insurers inside and outside of its exchange to offer all four tiers of benefit coverage, and in addition, will only permit insurers to offer catastrophic plans if they participate in the exchange. In Maryland, insurers who currently collect more than $10 million in premium revenue from the individual market or more than $20 million in premium revenue from the group market must participate in the exchange, and insurers offering catastrophic plans outside of the exchange must also offer them within the exchange. Maryland’s exchange governing board is empowered to re-examine the participation revenue threshold and adjust it as needed over time to ensure that large insurers remain in the exchange.

In addition to offering subsidized and/or competitive coverage, the exchanges should offer consumers tools to make informed choices between different insurance plans and coverage tiers. To facilitate comparisons, all participating insurers could be required to disclose standard types of benefit information through a common Internet portal, including patient satisfaction scores, if available. Exchanges must strike a balance between ensuring transparency and overwhelming consumers with information, as Jon Kingsdale observes: “Given the (understandable) lack of excitement in the general populace for mastering the details of insurance, the danger of information overload is almost as great as that of knowing too little. Exchanges must learn what information consumers want and need and how best to package and present it – a challenge not unlike that confronted by retailers."

The Massachusetts Connector web site (http://www.mahealthconnector.org) allows consumers to easily compare up to three plans side-by-side on the basis of monthly cost, annual deductible, out of pocket maximum, and other cost variables. Although neither California’s nor Maryland’s benefits exchange portals are yet operational at the time of this writing, California’s current exchange home page (http://www.healthexchange.ca.gov/Pages/Default.aspx) promises that it will “support consumer choice” through a web-based eligibility portal, website that provides standardized plan comparison information, a cost-comparison calculator, and a toll-free assistance hotline.

My take on state health insurance exchanges - Part 1

2012-04-12T09:50:00.000-04:00

Regardless of whether or not the Supreme Court strikes down the individual mandate or the entire 2010 health reform law in June, state-based health insurance exchanges are a good idea and, if established, should benefit many working Americans who are too well-off to qualify for Medicaid but unable to otherwise afford health insurance coverage on their own. This post and two to follow over the next week are excerpts from an unpublished paper that I recently authored on this topic.

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One of the key elements of the insurance coverage expansion contained in the Affordable Care Act (ACA) is the establishment of health benefits exchanges operated by individual states, groups of states, or the federal government, by January 1, 2014. These exchanges will offer competitive and/or subsidized insurance options for individuals whose employers do not provide insurance, as well as offer plans to small businesses (up to 100 employees) at reasonable rates. Prior to the ACA, Massachusetts and Utah had both operated state insurance exchanges with varying degrees of success. By outlining only basic requirements for the functions of the exchanges, the ACA left many important questions regarding their design unanswered. Some states appear to be pursuing a “wait and see” strategy, hoping that the U.S. Supreme Court will strike down the ACA prior to the January 2013 deadline for showing sufficient progress toward establishing an exchange or ceding control to the federal government. Others are at various stages of the planning process; as of January 2012, 13 states had formally established their exchanges through legislation or executive orders. Maryland and California are at the vanguard of this group.

The ACA mandated the creation of state-based exchanges for individuals (American Health Benefit Exchanges) and businesses with up to 100 employees (Small Business Health Options Program [SHOP] Exchanges), which may be separate markets or merged into a single exchange. Beginning in 2017, states may allow businesses with more than 100 employees to purchase coverage through the exchanges. Only U.S. citizens and legal immigrants will be permitted access to coverage through the exchanges. Individual and small group plans will include four tiers of coverage: bronze (60% of benefit costs), silver (70% of benefit costs), gold (80% of benefit costs), and platinum (90% of benefit costs). A catastrophic plan will be available for individuals up to age 30 and other persons who are financially exempt from the insurance purchase mandate. Carriers must guarantee insurance issue and only vary ratings based on age, premium rating area, family
composition, and tobacco use. Exchanges will be responsible for establishing enrollment procedures and determining eligibility for tax credits.

States may decide to locate exchanges within a government agency, in a quasi-governmental body, or an independent nonprofit organization. Although greater government control probably makes it easier for the exchanges to respond to the policy needs of their states (especially in exchanges that are designed as “active purchasers” of insurance rather than simple clearinghouses for any insurer that wants to participate), it also increases the risk of political interference favoring particular insurers. To date, most states have chosen the quasi-governmental model. For example, although it is governed by an 11-member Board of Directors that includes several state health officials, the Massachusetts Connector is by statute outside of the control of the executive branch of government.

California established a 5-member independent governing board for its exchange, consisting of its Secretary of Health and Human Services and four members appointed by the Governor and the state legislature. To avoid conflicts of interest, board members may not be health care providers or employees of health care facilities or insurance companies. To improve its responsiveness to the market, the exchange is exempted from most state administrative regulations on personnel and contracting. Similarly, Maryland’s quasi-governmental exchange is supervised by a 9-member board, including 3 state health officials and 6 appointed members. Conflict-of-interest provisions are similar to California’s.

The FDA fails to stop deceptive dementia drug advertising

2012-04-09T15:13:00.001-04:00

In the March 15, 2011 issue of American Family Physician, Drs. Mark Graber, Robert Dachs, and Andrea Darby-Stewart analyzed an industry-funded trial that compared the effects of two daily doses of the Alzheimer's disease drug donepezil (Aricept): a new 23 mg version and the existing 10 mg version that would soon lose its patent protection. Despite the trial authors' finding that the higher dose of donepezil slightly improved cognitive outcomes, AFP Journal Club commentators determined that this difference was clinically unimportant, and was greatly outweighed by the higher frequency of adverse effects in patients using the higher dose:

First, the authors did four comparisons. Three were negative and only one was positive. And the one that was positive was only two points different on a 100-point scale. So, although this is statistically significant, it is clinically meaningless. There is no discernible benefit for the patient or caregivers. ... Also, the drop-out rate in this study was an astounding 30 percent in the higher-dose group and 18 percent in the lower-dose group.

Adverse effects of donepezil include bradycardia, falls, nausea, diarrhea, and anorexia. In fact, a recent study demonstrated that community-dwelling older persons with dementia who are taking currently available cholinesterase inhibitors have higher rates of hospitalization for syncope, bradycardia, pacemaker insertion, and hip fractures compared with similar patients with Alzheimer disease who are not taking these medications. So, the idea of increasing the dose to 23 mg, potentially resulting in more serious adverse events while achieving no clinical gain, is ill-conceived at best.

Nonetheless, based on this study, the U.S. Food and Drug Administration eventually approved the 23 mg dose of donepezil against the advice of its own medical reviewers. One year later, though, the Journal Club on donepezil has proved to be prescient. Last month, in a scathing editorial published in BMJ, noted physician-researchers Lisa Schwartz and Steven Woloshin echoed AFP's earlier critique. They also rebuked the FDA for allowing Eisai, the manufacturer of donepezil, to include a false statement on the drug label and physician advertisements that touted "important clinical benefits" on measures of cognition (which, as noted, were clinically meaningless) and global function (which were not even statistically significant). Schwartz and Woloshin concluded by calling on the FDA to exercise greater oversight of such ethically questionable practices:

Alzheimer's is an awful disease. Sadly, the available drugs don't work well. But that is no excuse for emotionally manipulating vulnerable patients, desperate family members, and their doctors to use a product that is more likely to add harm than benefit. Nowhere - not in the direct to consumer or the physician advertisements, nor even in the FDA approved label - are the great uncertainties about this drug explained. ... That it is so easy to send doctors and patients incomplete and distorted messages about drugs is depressing. To make good decisions about drugs, doctors and patients need the evidence. The FDA should not forget to give it to them.

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The above post originally appeared in the AFP Community Blog.

The best recent posts you may have missed

2012-03-29T13:38:00.000-04:00

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from the past few months:

1) How much does it cost to have a baby? (1/20/12)

2) Rethinking shared decisions in prostate cancer screening (2/28/12)

3) The reality behind "death panel" rhetoric (3/14/12)

4) Screening-illiterate physicians may do more harm than good (3/5/12)

5) Curbing overuse of CT scans (1/18/12)

If you have a personal favorite that isn't on this list, please let me know. See you on the other side of Spring Break!

Don't confuse cardiovascular imaging with preventive medicine

2012-03-27T17:24:00.000-04:00

Despite the existence of well-established guidelines for clinicians on applying effective smoking cessation interventions in practice, one in five adults in the U.S. continues to smoke. This fact has led researchers to explore other ways to motivate smokers to quit, such as using imaging technology to show them the personal consequences of tobacco use. In a randomized trial recently published in the Archives of Internal Medicine, researchers tested the "pictures are worth a thousand words" theory by comparing cessation rates between smokers who received standard therapy plus carotid plaque ultrasonographic screening to smokers receiving standard therapy alone. The results were uniformly disappointing. Even though 58 percent of smokers in the intervention group were found to have carotid plaques, there was no statistical difference in cessation rates between the groups after one year, and patients with plaques were not more likely to quit smoking than those with normal ultrasound results.

In an accompanying editorial, Dr. Patrick O'Malley called for a renewed emphasis on developing communication skills throughout medical training:

We rely too much on technology and testing that are misapplied to problems that really should be addressed with cognitive, emotion handling, and relationship-centered skills. We need a paradigm shift in priorities and incentives to shift from excessive reliance on technologies, a terribly wasteful practice, to training and cultivation of communication- and relationship-based skills that are likely much more effective in the psychosocial domains of care.

Here are my two take-home points for physicians and patients:

1) To help smokers quit, talking trumps technology.
2) Don't confuse cardiovascular imaging with preventive medicine.

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Part of the above post was originally published on the AFP Community Blog.

Essential readings on health reform

2012-03-22T09:31:00.000-04:00

Can't get a Supreme Court-side seat for next week's six hours of oral arguments on the constitutionality of the Affordable Care Act? Want to understand how the United States reached the point where the fate of a mostly yet-to-be-implemented 2010 federal law that extends health insurance coverage to nearly all of its citizens may rest on the Justices' interpretations of the Constitution's Commerce and Taxing and Spending clauses? You would do better to spend those six hours reading two essential books that shed a great deal of light on the legislative history and contemporary health policy issues that have shaped the current debate: Paul Starr's Remedy and Reaction and Douglas Kamerow's Dissecting American Health Care.

The authors of these two books have a wealth of experience as observers and participants in health reform efforts: Starr as a Princeton historian and sometime Democratic health policy advisor, and Kamerow as a former Assistant Surgeon General and Public Health Service officer. Both published in the last year, the books are complementary: while Starr's provides an overarching narrative history of health reform efforts from the 1920s through the present, Kamerow's is a collection of insightful short commentaries written for National Public Radio and BMJ starting in 2007. (Full disclosure: I have known and admired Doug Kamerow for several years in my capacity as a fellow adjunct faculty member in Georgetown University's Department of Family Medicine.)

Below are quotations from two excellent reviews of each of the books:

From JAMA (Remedy and Reaction):

By removing the elderly and much of the working population from the uninsured, Medicare and the tax exclusion also removed much of the impetus for extending coverage to those still lacking it. The direct cost of Medicare and employer-provided coverage of beneficiaries is obvious, supporting the sense that beneficiaries' benefits are earned, while the heavy government subsidies involved are all but invisible. Extending similar benefits to others thus not only threatens a tax increase for those already covered but also can readily be understood or characterized as “welfare” and incompatible with US political ideals. The piecemeal approach to health insurance coverage did little to address problems in health care delivery, but it increased vested interests in maintaining the status quo.

Over time, reform proposals tended to leave more and more of the enormously complicated web of health care subsystems in place. One result is the great complexity of the Affordable Care Act, which provides yet another reason for objecting to it. None of the numerous other histories of US health care policy develops these themes in such an illuminating fashion.

- Samuel Y. Sessions, MD

From Family Medicine (Dissecting American Health Care):

Finally, there are quite a few essays throughout the book commenting or reflecting on recent developments in U.S. health care reform - made all the more interesting by the author's inclusion of essays in which his predictions about the course of health care reform turned out to be incorrect. ... This is a short, portable, and easily readable volume. All the essays are brief, so the book is perfectly suited for keeping on hand for those times when a few minutes are available to sneak in some reading. This book would also be suited to use in teaching on medicine and politics or medicine and society - the essays would provide interesting discussion starters for student or resident discussion groups.

- William E. Cayley Jr., MD

Guest Post: PSA screening: does it or doesn't it?

2012-03-19T09:56:00.000-04:00

Marya Zilberberg, MD, MPH is an independent physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is also a Professor of Epidemiology at the University of Massachusetts, Amherst. The following post was first published on her blog, Healthcare, etc.

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A study in the NEJM reports that after 11 years of follow up in a very large cohort of men randomized either to PSA screening every 4 years (~73,000 subjects) or to no screening (~89,000 subjects) there was both a reduction in death and no mortality advantage. How confusing can things get? Here is a screenshot of the headlines about it from Google News:

How can the same test cut prostate cancer deaths and at the same time not save lives? This is counter-intuitive. Yet I hope that a regular reader of this blog is not surprised at all. For the rest of you, here is a clue to the answer: competing risks.

What's competing risks? It is a mental model of life and death that states that there are multiple causes competing to claim your life. If you are an obese smoker, you may die of a heart attack or diabetes complications or a cancer, or something altogether different. So, if I put you on a statin and get you to lose weight, but you continue to smoke, I may save you from dying from a heart attack, but not from cancer. One major feature of the competing risks model that confounds the public and students of epidemiology alike is that these risks can actually add up to over 100% for an individual. How is this possible? Well, the person I describe may have (and I am pulling these numbers out of thin air) a 50% risk of dying from a heart attack, 30% from lung cancer, 20% from head and neck cancer, and 30% from complications of diabetes. This adds up to 130%; how can this be? In an imaginary world of risk prediction anything is possible. The point is that he will likely die of one thing, and that is his 100% cause of death.

Before I get to translating this to the PSA data, I want to say that I find the second paragraph in the Results section quite problematic. It tells me how many of the PSA tests were positive, how many screenings on average each man underwent, what percentage of those with a positive test underwent a biopsy, and how many of those biopsies turned up cancer. What I cannot tell from this is precisely how many of the men had a false positive test and still had to undergo a biopsy -- the denominators in this paragraph shape-shift from tests to men. The best I can do is estimate: 136,689 screening tests, of which 16.6% (15,856) were positive. Dividing this by 2.27 average tests per subject yields 6,985 men with a positive PSA screen, of whom 6,963 had a biopsy-proven prostate cancer. And here is what's most unsettling: at the cut-off for PSA level of 4.0 or higher, the specificity of this test for cancer is only 60-70%. What this means is that at this cut-off value, a positive PSA would be a false positive (positive test in the absence of disease) 30-40% of the time. But if my calculations are anywhere in the ballpark of correct, the false positive rate in this trial was only 0.3%. This makes me think that either I am reading this paragraph incorrectly, or there is some mistake. I am especially concerned since the PSA cut-off used in the current study was 3.0, which would result in a rise in the sensitivity with a concurrent decrease in specificity and therefore even more false positives. So this is indeed bothersome, but I am willing to write it off to poor reporting of the data.

Let's get to mortality. The authors state that the death rates from prostate cancer were 0.39 in the screening group and 0.50 in the control group per 1,000 patient-years. Recall from my meat post that patient-years are roughly a product of the number of subjects observed by the number of years of observation. So, again, to put the numbers in perspective, the absolute risk reduction here for an individual over 10 years is from 0.5% to 0.39%, again microscopic. Nevertheless, the relative risk reduction was a significant 21%. But of course we are only talking about deaths from prostate cancer, not from all other competitors. And this is the crux of the matter: a man in the screening group was just as likely to die as a similar man in the non-screening group, only causes other than prostate cancer were more likely to claim his life.

The authors go through the motions of calculating the number needed to invite for screening (NNI) in order to avoid a single prostate cancer death, and it turns out to be 1,055. But really this number is only meaningful if we decide to get into death design in a something like "I don't want to die of this, but that other cause is OK" kind of a choice. And although I don't doubt that there may be takers for such a plan, I am pretty sure that my tax dollars should not pay for it. And thus I cast my vote for "doesn't."

Addressing gaps in end-of-life planning

2012-03-15T11:11:00.000-04:00

A recent article by family physician Ken Murray in the Wall Street Journal, titled "Why Doctors Die Differently," observed that doctors are more likely than other people to decline end-of-life interventions that have little likelihood of benefit:

It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.

Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).

In a published survey of older physicians cited in the article, 64 percent of physicians had created an advanced directive, which Dr. Murray argues is essential to planning for end-of-life care: "Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements."

In the March 1st issue of American Family Physician, Drs. G. David Spoelhof and Barbara Elliott review strategies for implementing advance directives in office practice. The authors recommend that physicians have interactive discussions with patients regarding their end-of-life care preferences over multiple office visits, and they provide guidance for overcoming common patient- and physician-related barriers to completion of advance directives. A suggested approach for physicians is to bring up the topic of advance directives at routine visits for patients age 50 years or older and intensify discussions upon the diagnosis of a chronic and progressive illness such as cancer, heart failure, or dementia:

Following a realistic discussion of the patient's prognosis, the physician initiates a more in-depth discussion, including the proxy and family members as desired, that centers on the patient's care goals. Adding a values history to the advance directive may be helpful. After the discussion, the advance directive is updated and made as specific as possible. These issues should be readdressed periodically and as circumstances change. The last phase occurs with the onset of frailty or the need for long-term care. The discussion, centered on the patient's care goals, may result in consistent and specific physician orders regarding life-sustaining interventions.

To ensure that patients' end-of-life wishes are respected, advance directives should avoid vague language (e.g., "no heroics"), be shared with proxy decision-makers, and be made accessible in the medical record so that they are easily transferable to multiple levels of care.

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The above post was originally published on the AFP Community Blog.

The reality behind "death panel" rhetoric

2012-03-14T10:43:00.000-04:00

In a moving piece recently published in the Annals of Internal Medicine, surgeon Mark Vierra describes his emergency room encounter with a man dying from colorectal cancer. Called to discuss possible surgery for a perforated bowel, Dr. Vierra sadly observes that despite the patient's grim prognosis, he and his wife "had not discussed limits on his care, how far to carry things, what to do when the treatment stopped working, or when the end was in sight." They had not had any of these discussions with their primary care physician or either of his oncologists. After Dr. Vierra reviews the options and the patient's wife chooses hospice care, he reflects on the wide gulf between the reality of end-of-life decision-making and the damaging political rhetoric of "death panels":

I should not have been called to see this patient. Decisions like the one we had to make that day should have been made among friends and family or in the company of his family physician or oncologist, at a time when he was awake and at his best, when he was not in pain, and he could remember who he was and he could explain to those he would leave behind how he wanted to be remembered. To have to make such decisions the way we did that day—counseled by a stranger in the sterile alcove of a busy emergency room—is not what any of us would want. That it turned out the way it did, I believe, was fortunate. It would have been so easy for the powerful momentum of modern medicine to have carried his broken body into the operating room and from there to the ICU, where he would be nurtured by the finest medical technology and the clinical compassion of strangers.

Recently, we have been warned that government “death panels” would knock us off. The provision in the new health care legislation, which said that private, end-of-life discussions between a patient and his or her physician would be reimbursable every 5 years, somehow became a sinister governmental strategy to kill us quickly and save resources. It disappeared from the President's health care legislation, was quietly added back as a Medicare provision, but disappeared again when the new Medicare guidelines came out. Can this sensible, thoughtful proposal really be so objectionable? ... Every one of my patients is going to die one day. Like it or not, I should have these conversations earlier, more often, and more comfortably. If that makes me part of a death panel, well, I suppose I can live with that.

Amen.

What's in your doctor's health care shopping cart?

2012-03-08T09:16:00.000-05:00

A few years ago, the medical journal I edit received a letter from a reader who complained that the approximate prices of drugs we provided were often quite different from the prices he found online or in his local drugstore. This letter ultimately led to a re-evaluation of our rationale and process for estimating drug costs, as editor Jay Siwek, MD explained in this editorial:

Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.

Although having information about the costs of drugs can be helpful, physicians are often unaware of the costs of common tests, procedures, and referrals. A recent commentary in JAMA argues that electronic medical records should incorporate such cost information to make clinicians aware of the overall costs generated by office visits and other health care encounters:

What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.

The American Academy of Family Physicians recently partnered with the American Board of Internal Medicine and several other physician and consumer groups in the Choosing Wisely campaign, an initiative to promote more efficient use of limited health care resources. Although this campaign focuses on reducing use of tests or procedures that have no clinical benefits (e.g., imaging for uncomplicated low back pain, antibiotics for upper respiratory infections), it raises the question of whether physicians should take some responsibility for controlling costs of health care beyond simply eliminating "waste." For example, should your physician's virtual "shopping carts" drive more selective use of health services that have high costs and marginal benefits (e.g., coronary CT scans, cancer screening in patients over age 75 years)? Or is this type of thinking unjustified and unethical rationing? What's your view?

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The above post was first published on the AFP Community Blog.

Screening-illiterate physicians may do more harm than good

2012-03-05T17:12:00.000-05:00

On the first day of the clinical preventive medicine course that I teach every spring, I review the concept of lead-time bias and its potential to make a screening test look more effective than it really is (or, effective when it's not). Frugal Family Doctor recently explained how lead-time bias deceptively improves 5-year survival statistics. If you are unfamiliar with this concept, I recommend reading his post, but the basic idea is that by advancing the time in the disease course that cancer (or some other condition) is detected, screening will always increase the percentage of patients who survive for 5 years or more, even if it doesn't do anything to reduce mortality. This concept is as basic to the appropriate use of screening tests as vital signs are to the practice of medicine. In my opinion, any physicians who don't understand lead-time bias ought to have their test-ordering privileges suspended until they do.

Unfortunately, a study published today in the Annals of Internal Medicine concluded that a whole lot of clinicians require remedial education regarding lead-time bias. A national sample of more than 400 primary care physicians were provided scenarios about the effects of two hypothetical screening tests. The first test improved 5-year survival from 68 to 99 percent, and the second reduced the mortality rate from 2 deaths per 1000 to 1.6 deaths per 1000. 95 percent of surveyed physicians said that they would "definitely" or "probably" recommend the test that improved 5-year survival, even though this information (which is based on lead-time statistics associated with screening for prostate cancer) provides absolutely no evidence that the test improves patient outcomes. In contrast, considerably fewer physicians were enthusiastic about the test that actually lowered the mortality rate, perhaps because the absolute risk reduction seemed unimpressive by comparison.

Another disappointing finding was that almost half of surveyed physicians believed that a screening test "saves lives" if more cancers are detected in screened than in unscreened populations. The truth is, finding more cancers is a poor assurance of better outcomes. For example, a randomized trial of screening for ovarian cancer found no difference in mortality rates between women assigned to annual screening versus those receiving usual care despite 21% more cancers being detected in the screening group. This study confirmed what most medical organizations had suspected for years in recommending against ovarian cancer screening in asymptomatic women. Unfortunately, another survey published recently in Annals found that one-third of a nationally representative sample of family physicians, general internists, and obstetricians nonetheless believe that ovarian cancer screening is effective.

The Institute of Medicine has identified low levels of health literacy in the general population as a major obstacle to ensuring optimal health and quality of care. But how can physicians expect our patients to make informed decisions regarding screening tests when large numbers of us are functionally illiterate regarding basic screening concepts? As a medical educator, I took home this message from these studies: medical schools, residency programs, and certifying boards must devote more time and effort to improving physicians' literacy regarding screening, lest misleading survival statistics continue to fuel overuse of ineffective tests and expose countless patients to potential harm.

Public Speaking Update

2012-03-01T21:12:00.000-05:00

Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.com, Care and Cost, The Health Care Blog, and Gary Schwitzer's HealthNewsReview, as well as the websites of major national newspapers such as the New York Times, the Wall Street Journal, USA Today, and the Boston Globe. I also wrote the consumer health blog Healthcare Headaches for U.S. News and World Report from August 2010 through September 2011.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.

Upcoming events:

Why You Should Stop Screening Patients for Prostate Cancer
Ephrata Community Hospital (PA)
- May 1, 2012

Screening Mammography for Women in their 40s: Exploring the Controversy
Spanish Catholic Center of Catholic Charities of Washington DC
- April 19, 2012

Identifying and Using Good Practice Guidelines
36th Semi-Annual Family Practice Review Course
Temple University School of Medicine / Lancaster General Hospital
- March 12, 2012

A list of selected talks that I've given over the past few years is available here.

Rethinking shared decisions in prostate cancer screening

2012-02-28T09:43:00.003-05:00

Last October, the U.S. Preventive Services Task Force provisionally recommended against screening for prostate cancer using the prostate-specific antigen (PSA) test, eliciting a variety of reactions from medical and patient advocacy groups. The New England Journal of Medicine published one of the most thoughtful responses by Mary McNaughton-Collins and Michael Barry, two physicians who have done a great deal of research on the psychological and physical harms related to false-positive tests, an all-too-common occurrence in men who receive periodic PSA testing. They respectfully disagreed with the USPSTF's "D" (don't do) rating for this preventive service, arguing that the rating should have instead been a "C" (don't do routinely):

A grade C recommendation would allow the patient to be involved in the decision to skip or choose a PSA screening test, after a discussion with a primary care provider about the magnitude of the known harms and the potential for some benefit. The patient could then provide his perspective on how he views the trade-off. Weighing the pros and cons to make a decision about PSA screening is an individual process, and different well-informed men will make different decisions. A grade D recommendation removes the patient from the equation and puts the physician in the central position of discouraging use of the test. Uncertainty in medicine is more common than we usually let on, and the way to address uncertainty is to allow patients the central position in decision making. ... We do not believe that anyone but the patient should decide whether the small and uncertain benefits of PSA screening are worth it.

In 2010, the American Cancer Society took a similar stance, recommending that men age 50 years or older make "informed choices" about whether or not to receive the PSA test after being provided with detailed information about the risks and benefits and tools to help them make the decision. On the surface, both of these recommendations seem more reasonable that the USPSTF's. Rather than making a unilateral decision for every patient based on imperfect population-level evidence, why not let each patient make the choice for himself?

The answer is that primary care physicians have already been trying this approach for many years, and it does not work. Numerous studies have shown that no matter how much information men are given in any format, the vast majority still choose to receive the test, and most of them end up worse off because of that decision. In fact, as a new study concludes in the Archives of Internal Medicine, once prostate cancer is diagnosed via PSA testing, the men most likely to receive aggressive ("curative") treatments are those who are least likely to need it - men who would have been better off not getting the test in the first place.

A case in point: in the same issue of the journal, an academic oncologist who exclusively cares for prostate cancer patients tells the story of his own concerning PSA test, prostate biopsy, and subsequent decision to undergo radical prostatectomy at age 56. Five years later, he is cancer-free, but has permanent right-sided weakness as the result of the surgery, which was in retrospect unnecessary given the limited spread and good prognosis of his tumor. He laments: "Even the most informed patient (me in this case) has difficulty making a truly informed decision." And if a physician who spent decades caring for patients with prostate cancer has trouble making the right call, what hope is there for the rest of us?

Physician-researcher H. Gilbert Welch (author of Overdiagnosed, previously reviewed on this blog) recently challenged the consensus that informed decision-making is the best approach to PSA testing:

I worry that excessive fealty to informed decision-making in cancer screening may distract us from more important issues—like what is bothering patients right now. It may also lead physicians to abdicate our role as advisor—physicians simply transfer responsibility to their patients. And the problem appears to be asymmetric: we seem less inclined to recommend against than to recommend for. ... Why are we so reluctant to make value judgments about things not to do to patients? Is it because we are so fearful of potential litigation? Is it that we have become so financially conflicted? Or is it that we fear being accused of caring about cost? Maybe clinicians need the Task Force to make the call for us. And, for PSA testing, they did. If I was pressed to get off the fence, it's the call I would have made.

I couldn't agree more. Shared decision-making in PSA screening is an attractive concept that in practice leads to more harm than good. The Task Force was right to recommend that it stop, and that we instead advise patients not to get the test.

Cutting Prevention Fund to pay for 10 month "doc fix" is medical #Linsanity

2012-02-22T09:41:00.003-05:00

Like millions of basketball fans around the world, I've been transfixed by the story of Jeremy Lin, the undrafted Taiwanese American point guard from Harvard who has taken the NBA by storm this month as the new superstar of the New York Knicks. It doesn't hurt that we share a last name, ethnic background (both of my parents immigrated from Taiwan), and Crimson alma mater. But otherwise, the title of this blog post and the below YouTube video of Lin's latest athletic exploit (a steal and dunk en route to 28 points and a win over the defending champion Dallas Mavericks) is a shameless ploy to get you to read about a current health issue that's just as #Linsane in its own way.

Last week, Congress agreed to extend Social Security payroll tax cuts and delay by ten months a 30 percent cut to physicians' Medicare payments (also known as the "doc fix") in part by raiding the Prevention and Public Health Fund, created by the 2010 Affordable Care Act to meet critical clinical and community needs such as childhood immunizations, tobacco cessation, and obesity and diabetes prevention. The Fund was initially allocated $21 billion over ten years; this number was cut to $16 billion in President Obama's FY 2012-13 budget proposal and slashed to $11 billion by the latest Congressional action. $11 billion still sounds like a lot, but it's a paltry fraction of the estimated $2,600,000 billion that the U.S. spends on health care each year, and now nearly all of the Fund will merely offset draconian cuts to state public health programs due to the recession, rather than paying for new or expanded prevention initiatives. (If you have any doubts that we need to do much more as a nation to fight obesity, see these graphics on state obesity trends from the Centers for Disease Control and Prevention.) And of course there's no guarantee that the remaining funds will be protected when Congress looks to extend the doc fix at year's end.

Journalist Merrill Goozner tartly observed that cutting 10 years of prevention funds to pay doctors for 10 months is like "selling your home's storm doors to pay for this winter's heating bills." Alas, this penny-wise, pound-foolish decision was predictable. As Yale Prevention Research Center Director David Katz, MD argues, public health programs are chronically vulnerable to budget cuts because "prevention at its best is as dull as watching paint dry":

Let's face it -- a heart attack that doesn't happen lacks drama. The bout of influenza someone doesn't get lacks flare. When prevention and public health work well, you see just about none of what you get. You get a lot, and see ... nothing. When we talk about what prevention could do -- eliminate 80 percent of all heart disease, 90 percent of all diabetes, up to 60 percent of cancer and so on -- it is all in terms of some anonymous public. We are hard-wired to shrug our shoulders about that, and carry on. In contrast, Whitney Houston had a name and face and voice we all knew -- and for the loss of that, we readily feel passion and shed tears.

But consider for a moment the people you love who have been touched by heart disease, cancer, stroke or diabetes. Recall the visit to the hospital, the dreaded phone call. Now consider that prevention funds, used wisely, could make that experience go away fully eight times in 10. Prevention funds, used wisely, could help us give our children a world in which those horrible phone calls and anxious trips to the ER and ICU are mostly gone.

It's all too easy for the prevention fund to be about a public with no face and no name. But when we part the veil of statistical anonymity, the faces looking back at us are the faces of people we love. Those in Congress swinging the [budget] axe simply didn't pause to part the veil.

Life and career transitions

2012-02-10T11:28:00.001-05:00

As I wrote about in a previous post, my wife and I are expecting our third child to be born any day now. Along with this joyful transition in my family life, I'm looking forward to an upcoming career transition as well. In mid-April, I will re-join the full-time faculty in the Georgetown University Department of Family Medicine, where my responsibilities will include directing the Primary Care Health Policy Fellowship, seeing patients in a model family medicine practice, teaching medical students and residents, and continuing my editing work with the American Family Physician journal. I'm excited about working more closely with family physician colleagues (many of whom I've known for several years or more) in this dynamic and productive department. I will continue blogging on Common Sense Family Doctor, of course, but it's possible that you may be reading more posts about medical education than in years past.

How many physician referrals is too many?

2012-02-07T15:06:00.000-05:00

Most clinical review articles about health conditions that may require co-management of specialist physicians contain a short section or Table titled "Indications for Referral." For example, a recent article on prevention and care of outpatient burns includes a list of criteria from the American Burn Association for considering the transfer of a patient to a burn center. This and other lists generally represent expert consensus on appropriate reasons to refer a patient in a typical primary care setting; obviously, availability and accessibility of specialists has a large influence on a family physician's practice with regard to management of "referable" conditions. Clinicians' training and expertise also affect their comfort levels in caring for patients with complex problems and, as previous studies have shown, these factors lead to variations in referral rates.

Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago.

What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?

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The above post was first published on the AFP Community Blog.