Several months ago, I wrote in this blog about the precipitous decline of vaginal births after Cesarean (VBAC) in the U.S., which I attributed in part to the the internalization by obstetric specialists of the medical maxim "hearing hoofbeats, thinking zebras":
Objective data support the notion that labor managed by family physicians and professional midwives is considerably more likely to result in a vaginal birth than labor managed by an Ob/Gyn, even controlling for factors such as maternal age and risk status. It isn't difficult to understand why. If an Ob/Gyn is feeling uncertain about how well a patient's labor is progressing and has an inflated estimate of the probability that something might go wrong (the zebra), it's very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically, then and there. On the other hand, if the surgeon is at least a phone call away, the family physician or nurse midwife might be more patient with the hoofbeats, betting they're hearing a horse.
In preparation for a consensus development conference on VBAC held in March at the National Institutes of Health, a team of evidence reviewers from Oregon Health and Science University prepared a comprehensive report on the factors associated with successful VBAC delivery and the benefits and harms to the mother and infant from a trial of labor. I summarize this report in the Nov. 15th issue of American Family Physician. Here are the main results:
The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). Most studies found no differences in neonatal intensive care unit admission rates.
Bottom line: "most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant." In July, the American College of Obstetricians and Gynecologists slightly relaxed their previous restrictions on access to VBAC by issuing an updated guideline. Will this guideline change and fresh re-examination of the evidence supporting a trial of labor in patients with a previous Cesarean be enough for VBAC to make a comeback in the U.S.?
Wednesday, 30 April 2014
Moneyball and health care quality statistics - Part 2 of 2
The Society of Thoracic Surgeons recently allowed Consumer Reports to use its national database of information about heart bypass surgeries to rate surgical groups on patient survival rates, surgical complications, and medication management. But this ranking, too, has its limitations: While about 90 percent of the approximately 1,100 cardiac surgical groups in the U.S. participate in the society's database, just 22 percent of these groups opted to include themselves in the Consumer Reports rankings. That's because they didn't want their performance data to become public. And none would allow individual surgeons to be named.
Many health insurers have begun sending confidential "report cards" to family doctors that give them feedback on their performance in managing chronic conditions such as heart failure and diabetes. These evaluations, too, have been criticized for ignoring differences in patient populations; younger patients with high-paying jobs, for example, are less likely to stop taking medications for financial reasons than older patients on fixed incomes. So a doctor with a poorer patient population might get poorer grades than one with a richer population. Still, the evaluations might be helpful in comparing two doctors who practice in the same neighborhood, if practices eventually make this information public to prospective and current patients.
In the next few years, more information should become available on the quality of care provided to patients. The government is working to compile national numbers on hospital complication rates, which would add to patient safety data already being collected such as how often incisions reopen after surgery. The new data that will soon be offered on the Hospital Compare tool will, in my opinion, be a game changer. First and foremost, it will include information on infection rates. Nearly 90,000 U.S. patients die every year from hospital-acquired infections, and about a third of those deaths are due to preventable bloodstream infections caused by the insertion of a catheter, according to the Centers for Disease Control and Prevention.
It would be nice to know how often the hospital you pick for surgery takes precautions proven to prevent these infections, like covering patients with sterile drapes and swabbing their skin with an antiseptic before a catheter is inserted and making sure doctors who do the insertion wash their hands and wear a sterile mask, hat, gown and gloves. Hospital Compare will also provide data on surgical mistakes due to foreign objects left in the body; severe pressure ulcers from not turning bed-ridden patients, falls and other accidents that occur in the hospital; blood transfusions with the wrong blood type; and signs of diabetes mismanagement.
As more reliable statistics about the quality of care provided by doctors and hospitals become available, it's important to consider what factors matter most to you as a patient. For example, clean bathrooms are nice, but most people would place a higher value on surviving the hospitalization and not needing to return after being discharged. A heart surgeon's brusque bedside manner may not matter nearly as much to you as the percentage of her patients who develop postoperative infections. And family doctors who are willing to share their numbers—and work to improve them—are likely to go the extra mile to manage your chronic condition appropriately.
**
The above post (continued from a previous post) first appeared on my Healthcare Headaches blog at USNews.com.
Many health insurers have begun sending confidential "report cards" to family doctors that give them feedback on their performance in managing chronic conditions such as heart failure and diabetes. These evaluations, too, have been criticized for ignoring differences in patient populations; younger patients with high-paying jobs, for example, are less likely to stop taking medications for financial reasons than older patients on fixed incomes. So a doctor with a poorer patient population might get poorer grades than one with a richer population. Still, the evaluations might be helpful in comparing two doctors who practice in the same neighborhood, if practices eventually make this information public to prospective and current patients.
In the next few years, more information should become available on the quality of care provided to patients. The government is working to compile national numbers on hospital complication rates, which would add to patient safety data already being collected such as how often incisions reopen after surgery. The new data that will soon be offered on the Hospital Compare tool will, in my opinion, be a game changer. First and foremost, it will include information on infection rates. Nearly 90,000 U.S. patients die every year from hospital-acquired infections, and about a third of those deaths are due to preventable bloodstream infections caused by the insertion of a catheter, according to the Centers for Disease Control and Prevention.
It would be nice to know how often the hospital you pick for surgery takes precautions proven to prevent these infections, like covering patients with sterile drapes and swabbing their skin with an antiseptic before a catheter is inserted and making sure doctors who do the insertion wash their hands and wear a sterile mask, hat, gown and gloves. Hospital Compare will also provide data on surgical mistakes due to foreign objects left in the body; severe pressure ulcers from not turning bed-ridden patients, falls and other accidents that occur in the hospital; blood transfusions with the wrong blood type; and signs of diabetes mismanagement.
As more reliable statistics about the quality of care provided by doctors and hospitals become available, it's important to consider what factors matter most to you as a patient. For example, clean bathrooms are nice, but most people would place a higher value on surviving the hospitalization and not needing to return after being discharged. A heart surgeon's brusque bedside manner may not matter nearly as much to you as the percentage of her patients who develop postoperative infections. And family doctors who are willing to share their numbers—and work to improve them—are likely to go the extra mile to manage your chronic condition appropriately.
**
The above post (continued from a previous post) first appeared on my Healthcare Headaches blog at USNews.com.
Moneyball and health care quality statistics - Part 1 of 2
At a recent conference, Harvard surgeon and best-selling author Atul Gawande told the audience of health professionals and policy makers that he always assigns his medical students a book about baseball called Moneyball: The Art of Winning an Unfair Game. It's the story of how the 2002 Oakland Athletics, which had one of the lowest payrolls in professional baseball, were able to consistently out-compete better financed teams due to their general manager's unrivaled ability to evaluate and appropriately value players. Oakland took advantage of the tendency of other teams to overvalue players based on word-of-mouth assessments of talent or commonly measured statistics—such as batting averages and number of stolen bases—that had little relationship to winning games.
Gawande's point was that many of the Moneyball lessons can be applied to medical care when it comes to evaluating the performance of doctors and hospitals. Since I have a policy of not accepting close friends and family members as patients, I refer them to doctors with whom I've worked in the past or have met through medical conferences. My loved ones may be reassured by my recommendation, and I assume I'm pointing them to a good doctor.
But I also have a nagging worry that my gut instincts about a doctor I'm acquainted with may not correlate with the quality of care that doctor provides. I have no way of knowing if my friends and family members will get better or worse care from my referral than if they had randomly selected a name from a list. In fact, a recent study published in the journal Archives of Internal Medicine found that publicly available data on physicians such as medical school attended, malpractice lawsuit history, and specialty board certification are poor predictors of their adherence to accepted standards of medical care such as checking cholesterol levels in patients with diabetes and performing Pap smears in adult women at least every 3 years.
Take the well-known U.S. News & World Report "Best Hospital" Rankings. Whether a hospital is ranked in a particular specialty depends on its score, almost a third of which comes from its reputation with specialists. There may be a good argument for doing that, but to me it's too much like my physician recommendations. The website of the federal Centers for Medicare and Medicaid Services features a Hospital Compare tool that allows patients to search for and compare up to three hospitals at a time based on statistics such as the percentage of patients with heart failure who receive appropriate discharge instructions, medications, and smoking cessation counseling. It tells you if readmission and death rates for patients with heart attacks, heart failure, or pneumonia are better, the same as, or worse than the national average. (Higher rates of readmission could indicate that the hospital didn't do a good job of treating the patient in the first place or provided inadequate instructions for follow-up care.) It also provides subjective measures like patient surveys about the responsiveness of nurses and doctors, the cleanliness of rooms and bathrooms, and how well pain was controlled.
**
The above post (to be continued in a few days) originally appeared on my Healthcare Headaches blog at USNews.com.
Gawande's point was that many of the Moneyball lessons can be applied to medical care when it comes to evaluating the performance of doctors and hospitals. Since I have a policy of not accepting close friends and family members as patients, I refer them to doctors with whom I've worked in the past or have met through medical conferences. My loved ones may be reassured by my recommendation, and I assume I'm pointing them to a good doctor.
But I also have a nagging worry that my gut instincts about a doctor I'm acquainted with may not correlate with the quality of care that doctor provides. I have no way of knowing if my friends and family members will get better or worse care from my referral than if they had randomly selected a name from a list. In fact, a recent study published in the journal Archives of Internal Medicine found that publicly available data on physicians such as medical school attended, malpractice lawsuit history, and specialty board certification are poor predictors of their adherence to accepted standards of medical care such as checking cholesterol levels in patients with diabetes and performing Pap smears in adult women at least every 3 years.
Take the well-known U.S. News & World Report "Best Hospital" Rankings. Whether a hospital is ranked in a particular specialty depends on its score, almost a third of which comes from its reputation with specialists. There may be a good argument for doing that, but to me it's too much like my physician recommendations. The website of the federal Centers for Medicare and Medicaid Services features a Hospital Compare tool that allows patients to search for and compare up to three hospitals at a time based on statistics such as the percentage of patients with heart failure who receive appropriate discharge instructions, medications, and smoking cessation counseling. It tells you if readmission and death rates for patients with heart attacks, heart failure, or pneumonia are better, the same as, or worse than the national average. (Higher rates of readmission could indicate that the hospital didn't do a good job of treating the patient in the first place or provided inadequate instructions for follow-up care.) It also provides subjective measures like patient surveys about the responsiveness of nurses and doctors, the cleanliness of rooms and bathrooms, and how well pain was controlled.
**
The above post (to be continued in a few days) originally appeared on my Healthcare Headaches blog at USNews.com.
Guest Blog: The IOM report on the future of nursing
Stephen Ferrara, NP is a family nurse practitioner at Montefiore Medical Center in New York City. The following post originally appeared in his blog, A Nurse Practitioner's View.
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The big news this week in the world of nurse practitioners and health care was the release of the Institute of Medicine's (IOM) Report, "The Future of Nursing: Leading Change, Advancing Health." It's a logical read and echoes what NPs, patients, and some other professions have been saying for years: let NPs do the work they are already educated and trained to do without arbitrary and archaic state and/or federal barriers. This is not a "scope of practice" issue; it is allowing us to practice to the full extent of our educations.
For example, when I reflect back on my NP education, there was no course entitled, "How to sort of take care of chronic conditions but when you get in over your head, make sure you have your collaborating physician's number on speed dial." We were taught to function as primary care providers that included acquiring the knowledge base to evaluate, diagnose and treat our patients and their conditions using the skill sets and tools needed to care for our patients. NPs don't practice witchcraft or voodoo - we are providing high-quality, cost-effective and culturally congruent care.
Predictably, organized medicine is playing the "patient safety" and "quality of care" card. Bad outcomes occur when there are breakdowns in communication and from care that is uncoordinated - not usually because the clinician is incompetent.
The bottom line is (at least in New York where I practice), without a collaborating physician on record, the 14,000 or so NPs are unemployed and can't legally do anything that we were trained or educated to do. It is time to remove these non-evidence based barriers and retrospective reviews and allow us to function as true partners on the health care team. Collaboration among providers would still continue to happen, and I promise pigs wouldn't start to fly. Fourteen states have already transitioned to to an autonomous model of practice model for NPs. Lawmakers must not cave to special interests and, instead, make the tough decisions that will enable greater access to care.
**
The big news this week in the world of nurse practitioners and health care was the release of the Institute of Medicine's (IOM) Report, "The Future of Nursing: Leading Change, Advancing Health." It's a logical read and echoes what NPs, patients, and some other professions have been saying for years: let NPs do the work they are already educated and trained to do without arbitrary and archaic state and/or federal barriers. This is not a "scope of practice" issue; it is allowing us to practice to the full extent of our educations.
For example, when I reflect back on my NP education, there was no course entitled, "How to sort of take care of chronic conditions but when you get in over your head, make sure you have your collaborating physician's number on speed dial." We were taught to function as primary care providers that included acquiring the knowledge base to evaluate, diagnose and treat our patients and their conditions using the skill sets and tools needed to care for our patients. NPs don't practice witchcraft or voodoo - we are providing high-quality, cost-effective and culturally congruent care.
Predictably, organized medicine is playing the "patient safety" and "quality of care" card. Bad outcomes occur when there are breakdowns in communication and from care that is uncoordinated - not usually because the clinician is incompetent.
The bottom line is (at least in New York where I practice), without a collaborating physician on record, the 14,000 or so NPs are unemployed and can't legally do anything that we were trained or educated to do. It is time to remove these non-evidence based barriers and retrospective reviews and allow us to function as true partners on the health care team. Collaboration among providers would still continue to happen, and I promise pigs wouldn't start to fly. Fourteen states have already transitioned to to an autonomous model of practice model for NPs. Lawmakers must not cave to special interests and, instead, make the tough decisions that will enable greater access to care.
Telemedicine: more than what the doctor ordered
Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure had risen dangerously. I'd adjust blood pressure medications only to find her short of breath with swollen legs—a sign of worsening heart failure—at her follow-up appointment. The trouble was, I had no idea how well she followed my instructions in between visits which occurred every month or two. Had her blood pressure been soaring at home for the past few weeks or only during the hour she was in my office? I had no way of knowing.
Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.
Given this unacceptable situation, family doctors need to adopt a new model of care that includes more frequent contacts with patients and adjustment of medications based on blood pressure monitoring at home, stress the authors of the AJMC paper who are affiliated with the University of California at San Francisco. They suggest that hypertensive patients receive home monitors to check their blood pressure on a daily basis and record the readings in a paper or electronic log. Nurses, medical assistants, or other "health coaches" should call patients every two weeks in between office visits to check on their blood pressure readings and provide counseling on lifestyle changes, such as starting an exercise program or reducing dietary sodium. If a patient's home blood pressure readings are too high, a medication dose can be increased using standard protocols that are pre-approved by the doctor. This model is supported by research: A 2008 study published in the Journal of the American Medical Association found that patients who received home blood pressure monitors and regular contacts from a pharmacist through a secure Web site were significantly more likely to achieve blood pressure control after one year compared to patients who weren't monitoring themselves.
Of course, remote monitoring or telemedicine for chronic health conditions has applications beyond blood pressure management. Remote devices can send the results of blood sugar readings or body weight measurements, in addition to blood pressure readings, from your home directly to your doctor's office. Studies conducted by the Veterans Health Administration have demonstrated that daily body weight measurements on scales remotely linked to doctor's offices can help reduce re-admission rates for heart failure patients, a major factor in reducing ballooning health care costs. In fact, 12 states now require that health insurance plans cover telemedicine services, and 25 states reimburse doctors for telemedicine services through their Medicaid programs.
Even in states that don't mandate coverage for home health monitoring, many health insurers are introducing pilot programs that provide free equipment to selected patients, provided that their doctors show they're utilizing the data to improve care. If you have high blood pressure or another chronic health condition that might benefit from monitoring in between office visits, it's worth checking with your doctor and insurance provider about options that could be available to you at little or no cost.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.
Given this unacceptable situation, family doctors need to adopt a new model of care that includes more frequent contacts with patients and adjustment of medications based on blood pressure monitoring at home, stress the authors of the AJMC paper who are affiliated with the University of California at San Francisco. They suggest that hypertensive patients receive home monitors to check their blood pressure on a daily basis and record the readings in a paper or electronic log. Nurses, medical assistants, or other "health coaches" should call patients every two weeks in between office visits to check on their blood pressure readings and provide counseling on lifestyle changes, such as starting an exercise program or reducing dietary sodium. If a patient's home blood pressure readings are too high, a medication dose can be increased using standard protocols that are pre-approved by the doctor. This model is supported by research: A 2008 study published in the Journal of the American Medical Association found that patients who received home blood pressure monitors and regular contacts from a pharmacist through a secure Web site were significantly more likely to achieve blood pressure control after one year compared to patients who weren't monitoring themselves.
Of course, remote monitoring or telemedicine for chronic health conditions has applications beyond blood pressure management. Remote devices can send the results of blood sugar readings or body weight measurements, in addition to blood pressure readings, from your home directly to your doctor's office. Studies conducted by the Veterans Health Administration have demonstrated that daily body weight measurements on scales remotely linked to doctor's offices can help reduce re-admission rates for heart failure patients, a major factor in reducing ballooning health care costs. In fact, 12 states now require that health insurance plans cover telemedicine services, and 25 states reimburse doctors for telemedicine services through their Medicaid programs.
Even in states that don't mandate coverage for home health monitoring, many health insurers are introducing pilot programs that provide free equipment to selected patients, provided that their doctors show they're utilizing the data to improve care. If you have high blood pressure or another chronic health condition that might benefit from monitoring in between office visits, it's worth checking with your doctor and insurance provider about options that could be available to you at little or no cost.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
Tuesday, 29 April 2014
The meeting that wasn't, and a surprise announcement
Although I normally arrive at work around 9 AM on Mondays, today would have been an important exception. This was to be the first day of the third U.S. Preventive Services Task Force meeting of 2010, and about now, outgoing Task Force Chairman Ned Calonge would be calling the meeting to order and asking every person in the room, including staff, observers, and the medical transcriptionist, to introduce themselves by name, position, and one interesting personal fact that changed from meeting to meeting. One meeting it was birthplaces; another meeting it was our favorite vacation spots; another, our favorite quotations. Even though this process often consumed half an hour or more, Dr. Calonge believed that getting to know each other a little bit better was crucial to the success of dissecting volumes of scientific evidence and making recommendations that would affect primary care clinicians and patients throughout the United States, if not the world.
As reported in this article in the Wall Street Journal's Health Blog, however, there is no USPSTF meeting today. And while the question of why the meeting was cancelled is perhaps easily answered by looking at the calendar, in my mind it is much less apparent how to repair the damage that this setback did to the Task Force, medicine, and the fragile public trust.
This leads me to an announcement that may come as a surprise to some: in less than three weeks, I will be leaving the support team of the USPSTF and resigning from the Agency for Healthcare Research and Quality. I am looking forward to having more time to spend writing this blog and Healthcare Headaches, as well as expanding my medical editing roles at American Family Physician and returning to patient care. But I will miss my colleagues at AHRQ and the Task Force very much. To borrow a line from a farewell message I sent to many of them last week, they deserve all our thanks for everything they do (and will continue to do) to make the U.S. health care "system" a little bit more rational, despite the many obstacles and challenges. Politics trumped science this time, as it has in the past, and may at times in the future. On the bright side, though, in a few more weeks the growing force of private sector allies of the USPSTF and evidence-based medicine will have one more member, and I'm ready and willing to speak my mind.
As reported in this article in the Wall Street Journal's Health Blog, however, there is no USPSTF meeting today. And while the question of why the meeting was cancelled is perhaps easily answered by looking at the calendar, in my mind it is much less apparent how to repair the damage that this setback did to the Task Force, medicine, and the fragile public trust.
This leads me to an announcement that may come as a surprise to some: in less than three weeks, I will be leaving the support team of the USPSTF and resigning from the Agency for Healthcare Research and Quality. I am looking forward to having more time to spend writing this blog and Healthcare Headaches, as well as expanding my medical editing roles at American Family Physician and returning to patient care. But I will miss my colleagues at AHRQ and the Task Force very much. To borrow a line from a farewell message I sent to many of them last week, they deserve all our thanks for everything they do (and will continue to do) to make the U.S. health care "system" a little bit more rational, despite the many obstacles and challenges. Politics trumped science this time, as it has in the past, and may at times in the future. On the bright side, though, in a few more weeks the growing force of private sector allies of the USPSTF and evidence-based medicine will have one more member, and I'm ready and willing to speak my mind.
No Common Sense Family Doctor post this week
I will be busy preparing a presentation on blogging and using social media tools for the Family Medicine Education Consortium's Northeast Region Meeting in Hershey, PA and also laying the groundwork for a big announcement early next week (how's that for a teaser)? If you can't wait that long to get your blog fix, there will be a new post on my Healthcare Headaches blog on USNews.com tomorrow or Wednesday. See you all in November!
Improving care with electronic health records
For most of my career, I kept track of my patients' health histories by scribbling hand-written notes in a paper chart. For a healthy child, I'd include dates when vaccines were given; for an adult with, say, diabetes, I'd make sure to jot down a recommended schedule of blood and urine tests as well as foot and eye exams. A majority of primary care physicians, in fact, still use this kind of tracking system—despite research suggesting that these handwritten flowsheets aren't just inefficient, but extremely vulnerable to errors. Some say the solution lies in simply switching to electronic medical records.
After all, paper charts don't automatically update themselves when, say, the Centers for Disease Control and Prevention makes a new vaccine recommendation. An electronic medical record system can do that and can also allow test results to be emailed or transferred automatically into a patient's chart; paper charts rely on office administrators to input them by hand, which can lead to mistakes. I, myself, have occasionally forgotten to record that a vaccine was administered during the chaos of a busy work day. Nor did I have any systematic way of knowing how many of my patients were actually receiving the preventive and chronic care they needed.
But the latest research suggests that electronic health records don't necessarily improve care unless they include interactive features: They should make it easier for doctors to implement proven guidelines for good care, providing the necessary shots and screenings, follow-up exams and treatments to help patients live longer with chronic diseases or to prevent these diseases altogether. Ideally, these records should include a software tool that periodically culls through patients' records looking for gaps in care such as who is overdue for a cholesterol screening or flu vaccine. The system would then send out reminders to patients to come in for a test or appointment.
Kaiser Permanente added such a tool to their electronic medical record system several years ago and found that it works to improve care. A study published last month in the American Journal of Managed Care found that the support tool brought more diabetes and heart disease patients in for health screenings, vaccinations and medication adjustments. After three years, for patients with diabetes, the percentage of care recommendations met every month increased from 68 percent to 73 percent; for heart disease patients, the percentage rose from 64 percent to 71 percent. Another study found that the tool helped more healthy patients get recommended screening and exams for preventive care. Bottom line: This support tool lowers the rate of skipped appointments and gaps in care.
This is great news if you use Kaiser Permanente for medical care, but what if you don't? Well, you can probably expect to see some significant changes at your doctor's office over the next three to five years. Physicians who take advantage of government financial incentives to set up electronic medical record systems must prove they're making "meaningful use" of the data from the health records, meaning that they've improved patient care as a result.
But now is a good time to ask your doctor about how your records will be handled in the future. Will a fail-safe system be implemented to ensure that you don't miss crucial office visits or screenings? If you see more than one doctor on a regular basis, find out if your primary care clinician—the one responsible for coordinating all of your care—uses a system that's compatible with the systems your specialists use. This will make it far easier to transfer test results and updates to prescriptions back and forth between various offices. Otherwise, the responsibility for keeping your medical chart up to date will fall on your shoulders. If you're not satisfied that your doctor is staying abreast of all these technological changes, you might want to consider switching to another practice.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
After all, paper charts don't automatically update themselves when, say, the Centers for Disease Control and Prevention makes a new vaccine recommendation. An electronic medical record system can do that and can also allow test results to be emailed or transferred automatically into a patient's chart; paper charts rely on office administrators to input them by hand, which can lead to mistakes. I, myself, have occasionally forgotten to record that a vaccine was administered during the chaos of a busy work day. Nor did I have any systematic way of knowing how many of my patients were actually receiving the preventive and chronic care they needed.
But the latest research suggests that electronic health records don't necessarily improve care unless they include interactive features: They should make it easier for doctors to implement proven guidelines for good care, providing the necessary shots and screenings, follow-up exams and treatments to help patients live longer with chronic diseases or to prevent these diseases altogether. Ideally, these records should include a software tool that periodically culls through patients' records looking for gaps in care such as who is overdue for a cholesterol screening or flu vaccine. The system would then send out reminders to patients to come in for a test or appointment.
Kaiser Permanente added such a tool to their electronic medical record system several years ago and found that it works to improve care. A study published last month in the American Journal of Managed Care found that the support tool brought more diabetes and heart disease patients in for health screenings, vaccinations and medication adjustments. After three years, for patients with diabetes, the percentage of care recommendations met every month increased from 68 percent to 73 percent; for heart disease patients, the percentage rose from 64 percent to 71 percent. Another study found that the tool helped more healthy patients get recommended screening and exams for preventive care. Bottom line: This support tool lowers the rate of skipped appointments and gaps in care.
This is great news if you use Kaiser Permanente for medical care, but what if you don't? Well, you can probably expect to see some significant changes at your doctor's office over the next three to five years. Physicians who take advantage of government financial incentives to set up electronic medical record systems must prove they're making "meaningful use" of the data from the health records, meaning that they've improved patient care as a result.
But now is a good time to ask your doctor about how your records will be handled in the future. Will a fail-safe system be implemented to ensure that you don't miss crucial office visits or screenings? If you see more than one doctor on a regular basis, find out if your primary care clinician—the one responsible for coordinating all of your care—uses a system that's compatible with the systems your specialists use. This will make it far easier to transfer test results and updates to prescriptions back and forth between various offices. Otherwise, the responsibility for keeping your medical chart up to date will fall on your shoulders. If you're not satisfied that your doctor is staying abreast of all these technological changes, you might want to consider switching to another practice.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
Family medicine leadership
A recent commentary in the New England Journal of Medicine by family physicians Thomas Bodenheimer and David West examines how the city of Grand Junction, Colorado has managed to provide above-average quality health care with Medicare costs that are 24% lower than the national average. The explanation that Grand Junction residents are simply healthier that residents of other U.S. jurisdictions doesn't hold water. So what differences in the health care system of this community can be credited for its remarkable results - and applied to other communities across the country? Bodenheimer and West answer:
We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adapted elsewhere. These are
leadership by the primary care community;
a payment system involving risk sharing by physicians;
equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients;
regionalization of services into an orderly system of primary, secondary, and tertiary care;
limits on the supply of expensive resources, including specialists, beds, and equipment;
payment of primary care physicians for hospital visits; and
robust end-of-life care.
Although these innovations are mostly common sense, the perverse financial and political incentives that drive the U.S. health system (before and after the implementation of this year's reforms) present obstacles to many of them, from equalization of physician payment (requiring fresh infusions of dollars from tight state and federal budgets) to the appallingly inaccurate portrayal of end-of-life care as "death panels" (see my previous posts here and here).
We're just two weeks away from a midterm election that will likely alter the national political landscape, but no matter which party ends up with a legislative majority, patients and physicians can't look to the parties for sensible health policy solutions. To improve population health in this country, the professionals who care for the "folks" - family physicians and other primary care clinicians - need to lead the way by advocating for changes that will give every community a fighting chance to replicate the successes of Grand Junction.
We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adapted elsewhere. These are
leadership by the primary care community;
a payment system involving risk sharing by physicians;
equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients;
regionalization of services into an orderly system of primary, secondary, and tertiary care;
limits on the supply of expensive resources, including specialists, beds, and equipment;
payment of primary care physicians for hospital visits; and
robust end-of-life care.
Although these innovations are mostly common sense, the perverse financial and political incentives that drive the U.S. health system (before and after the implementation of this year's reforms) present obstacles to many of them, from equalization of physician payment (requiring fresh infusions of dollars from tight state and federal budgets) to the appallingly inaccurate portrayal of end-of-life care as "death panels" (see my previous posts here and here).
We're just two weeks away from a midterm election that will likely alter the national political landscape, but no matter which party ends up with a legislative majority, patients and physicians can't look to the parties for sensible health policy solutions. To improve population health in this country, the professionals who care for the "folks" - family physicians and other primary care clinicians - need to lead the way by advocating for changes that will give every community a fighting chance to replicate the successes of Grand Junction.
Guest Blog: Advocating for change at community health centers
Dr. Keisa Bennett is a family physician in Lexington, Kentucky who previously saw patients at a community health center in Washington, DC while completing a fellowship in primary care health policy. The following piece was originally posted on her blog, Ruminations of a Family Doctor.
**
I had a bright spot listening to the head of DC Primary Care Association criticize community health centers, the very entities her organization exists to support (in a way). Sharon Baskerville's beef with the CHC model (and she makes it well known, so I'm not "outing" her here), is its arrogance and self-righteousness. "We're doing good things for poor people," we say, but what we mean is: "We're doing better than nothing for people no one else cares about." We who reject a "cush" job in the 'burbs with a well-educated, well-insured patient population are sure we're saints. And to be sure, many people who work in CHC's have indeed made great personal sacrifices to work with and advocate for their patients.
The danger in this arrogance, however, is the "better-than-nothing" mindset. It makes us work hard and feel justified, even if our patients wait for hours to see us only to be turned away or told they need to go to the emergency room. Even if our clinic looks dingy and has folding chairs and no toys or magazines during those waits. Even if we skimp on using phone translation because it's so darn slow and seeing more patients must mean we're doing "better".
We get so caught up in doing better care for the indigent, we excuse the fact that we don't question why medical indigence even exists. We doctors don't want to admit that a few trained community health workers could do at least half of the services we're doing more efficiently. No one wants to ask the patients what they really want because we already know the answer. They want what we want, and we wouldn't want to travel by bus and by foot for 30 minutes just to sit in a dingy waiting room all day only to be told that our baby's horrible, scary cough doesn't need any treatment and then be scolded for not using the thermometer correctly.
We would want a trusted person or persons we could call on when we were afraid of a symptom or unsure whether to go to the doctor. Someone who would gather community members together to help everyone figure out how to make the whole environment healthier. When we did need a doctor, we would want to go to a warm, welcoming place where the staff greeted us as a friend and enjoyed serving us and we were happy to pay for their care in one way or another. We want a relationship with at least one person in this office who we can trust to be our advocate. We want these people to communicate well with any higher-level or specialty care we might need.
And if some of us deserve this, all of us deserve it. Shouldn't we all work for it? We would have to give up a system of "better than..." The trouble with trying to make things good for everyone is that a lot of better than disappears. Martyrdom and crusades have to be let go of, given up. We crusaders don't think we are holding up change, but as long as we work for CHCs existing in their present form, we are part of the inertia.
- Keisa Bennett
**
I had a bright spot listening to the head of DC Primary Care Association criticize community health centers, the very entities her organization exists to support (in a way). Sharon Baskerville's beef with the CHC model (and she makes it well known, so I'm not "outing" her here), is its arrogance and self-righteousness. "We're doing good things for poor people," we say, but what we mean is: "We're doing better than nothing for people no one else cares about." We who reject a "cush" job in the 'burbs with a well-educated, well-insured patient population are sure we're saints. And to be sure, many people who work in CHC's have indeed made great personal sacrifices to work with and advocate for their patients.
The danger in this arrogance, however, is the "better-than-nothing" mindset. It makes us work hard and feel justified, even if our patients wait for hours to see us only to be turned away or told they need to go to the emergency room. Even if our clinic looks dingy and has folding chairs and no toys or magazines during those waits. Even if we skimp on using phone translation because it's so darn slow and seeing more patients must mean we're doing "better".
We get so caught up in doing better care for the indigent, we excuse the fact that we don't question why medical indigence even exists. We doctors don't want to admit that a few trained community health workers could do at least half of the services we're doing more efficiently. No one wants to ask the patients what they really want because we already know the answer. They want what we want, and we wouldn't want to travel by bus and by foot for 30 minutes just to sit in a dingy waiting room all day only to be told that our baby's horrible, scary cough doesn't need any treatment and then be scolded for not using the thermometer correctly.
We would want a trusted person or persons we could call on when we were afraid of a symptom or unsure whether to go to the doctor. Someone who would gather community members together to help everyone figure out how to make the whole environment healthier. When we did need a doctor, we would want to go to a warm, welcoming place where the staff greeted us as a friend and enjoyed serving us and we were happy to pay for their care in one way or another. We want a relationship with at least one person in this office who we can trust to be our advocate. We want these people to communicate well with any higher-level or specialty care we might need.
And if some of us deserve this, all of us deserve it. Shouldn't we all work for it? We would have to give up a system of "better than..." The trouble with trying to make things good for everyone is that a lot of better than disappears. Martyrdom and crusades have to be let go of, given up. We crusaders don't think we are holding up change, but as long as we work for CHCs existing in their present form, we are part of the inertia.
- Keisa Bennett
Monday, 28 April 2014
Challenging conventional clinical wisdom
Over the past few years, I've been invited to speak twice at Lancaster General Hospital (PA) about studies of the effects of screening for colorectal and prostate cancer. Recognizing the need to further explore the controversies surrounding the evidence for these tests, Dr. Larry Bonchek kindly asked me to write a scientific commentary about these topics for the Journal of Lancaster General Hospital, which he edits. The result was the article "Challenging the Conventional Wisdom on Colorectal and Prostate Cancer Screening," just published in the journal's Fall 2010 issue. You are more than welcome to read the full article online, but here are my bottom-line conclusions for clinicians and patients:
The decision to perform screening for colorectal or prostate cancer can be complex, and should take in account evidence-based recommendations, the implications of recent studies, and patient preferences. In order to give patients accurate information on the benefits and limitations of cancer screening tests, physicians should discard “conventional wisdom” that has not been supported by scientific evidence. To briefly review:
1) Collecting a fecal occult blood sample for screening during the digital rectal examination is not “better than nothing at all.”
2) FOBT and flexible sigmoidoscopy have comparable benefits and fewer harms than screening colonoscopy.
3) Benefits of PSA screening on mortality are likely small to none.
4) Overdiagnosis and overtreatment of PSA-detected prostate cancers cause substantial harms.
The decision to perform screening for colorectal or prostate cancer can be complex, and should take in account evidence-based recommendations, the implications of recent studies, and patient preferences. In order to give patients accurate information on the benefits and limitations of cancer screening tests, physicians should discard “conventional wisdom” that has not been supported by scientific evidence. To briefly review:
1) Collecting a fecal occult blood sample for screening during the digital rectal examination is not “better than nothing at all.”
2) FOBT and flexible sigmoidoscopy have comparable benefits and fewer harms than screening colonoscopy.
3) Benefits of PSA screening on mortality are likely small to none.
4) Overdiagnosis and overtreatment of PSA-detected prostate cancers cause substantial harms.
Recent evidence on low-carbohydrate diets
I first heard of the Atkins diet back in medical school 12 years ago when one of my classmates abruptly began eating steak without potatoes and hamburgers without the bun. I was skeptical that this odd regimen would work, but his experience and subsequent research has shown that low-carbohydrate diets are as effective as traditional low-calorie, low-fat diets for losing weight.
A more important question is whether a low-carbohydrate diet, which includes higher amounts of protein and fat than the typical higher-carb diet, is as good for your heart in the long run. Two recent studies published in the journal Annals of Internal Medicine seem to provide conflicting answers. In the first study, researchers randomly assigned 307 overweight adults to a low-carbohydrate or a low-fat diet, in addition to exercise counseling. After 2 years, participants in both groups had lost an average of about 15 pounds, but the low-carbohydrate group had a significantly greater increase in HDL "good" cholesterol.
The second study, though, found that all low-carbohydrate diets aren't created equal. This one followed 100,000 male and female health professionals over a period of 20 years or more to see whether the amount of carbohydrates, fat and protein they ingested had any impact on their health. Participants whose diets were classified as the lowest in carbohydrates were 12 percent more likely to die during the study than those who consumed the highest amount of carbohydrates. But it was the low-carb, meat-loving folks who had the highest risk of death from heart disease and cancer compared to low-carb dieters whose protein sources were mostly vegetables.
So which study should you believe? Unfortunately, neither provides a definitive answer about whether low-carb diets are good or bad in the long run. Although the first study confirms that low-carb diets lead to weight loss and an increase in HDL cholesterol, that doesn't mean followers of these diets will wind up with less heart disease down the road. Also, participants in the first study had access to trained health counselors who met with them 37 times over two years to make sure that they rigorously adhered to the diet and exercise plan—a valuable resource that most people can't afford. While the second study provides more long-term data on low-carb diets, the researchers couldn't control for every factor that might affect a person's risk of dying such as, for example, exposure to air pollution. Rural folks might be more likely to eat more plant proteins like soybeans, while also having less exposure to air pollution than urban folks who might gravitate towards meat-based meals. So the type of protein people ate may not have been completely responsible for the difference in death risk.
If you're thinking of trying a high-protein, low-carb diet to lose weight or improve your health, consider the following factors based on the latest research.
1) You have a good chance of losing weight if you follow the diet faithfully, and you will most likely find it easier to stick with than a low-fat diet.
2) In order to keep off any weight you lose, you need to increase your physical activity. Aerobic exercise (walking, jogging, swimming) produces better results for weight maintenance than strength-building exercises (pushups, lifting weights), though a combination of both types may offer additional health benefits, such as prevention of injuries.
3) Although low-carb diets have been shown to improve cholesterol in some people, we don't know if they protect against heart problems in the long run. One thing I do know: If a diet sounds too good to be true, it probably is. In this case, current research is consistent with common sense. Replacing carbs with tofu and steamed vegetables is likely to be better for your health than baby-back ribs and pork loins.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
A more important question is whether a low-carbohydrate diet, which includes higher amounts of protein and fat than the typical higher-carb diet, is as good for your heart in the long run. Two recent studies published in the journal Annals of Internal Medicine seem to provide conflicting answers. In the first study, researchers randomly assigned 307 overweight adults to a low-carbohydrate or a low-fat diet, in addition to exercise counseling. After 2 years, participants in both groups had lost an average of about 15 pounds, but the low-carbohydrate group had a significantly greater increase in HDL "good" cholesterol.
The second study, though, found that all low-carbohydrate diets aren't created equal. This one followed 100,000 male and female health professionals over a period of 20 years or more to see whether the amount of carbohydrates, fat and protein they ingested had any impact on their health. Participants whose diets were classified as the lowest in carbohydrates were 12 percent more likely to die during the study than those who consumed the highest amount of carbohydrates. But it was the low-carb, meat-loving folks who had the highest risk of death from heart disease and cancer compared to low-carb dieters whose protein sources were mostly vegetables.
So which study should you believe? Unfortunately, neither provides a definitive answer about whether low-carb diets are good or bad in the long run. Although the first study confirms that low-carb diets lead to weight loss and an increase in HDL cholesterol, that doesn't mean followers of these diets will wind up with less heart disease down the road. Also, participants in the first study had access to trained health counselors who met with them 37 times over two years to make sure that they rigorously adhered to the diet and exercise plan—a valuable resource that most people can't afford. While the second study provides more long-term data on low-carb diets, the researchers couldn't control for every factor that might affect a person's risk of dying such as, for example, exposure to air pollution. Rural folks might be more likely to eat more plant proteins like soybeans, while also having less exposure to air pollution than urban folks who might gravitate towards meat-based meals. So the type of protein people ate may not have been completely responsible for the difference in death risk.
If you're thinking of trying a high-protein, low-carb diet to lose weight or improve your health, consider the following factors based on the latest research.
1) You have a good chance of losing weight if you follow the diet faithfully, and you will most likely find it easier to stick with than a low-fat diet.
2) In order to keep off any weight you lose, you need to increase your physical activity. Aerobic exercise (walking, jogging, swimming) produces better results for weight maintenance than strength-building exercises (pushups, lifting weights), though a combination of both types may offer additional health benefits, such as prevention of injuries.
3) Although low-carb diets have been shown to improve cholesterol in some people, we don't know if they protect against heart problems in the long run. One thing I do know: If a diet sounds too good to be true, it probably is. In this case, current research is consistent with common sense. Replacing carbs with tofu and steamed vegetables is likely to be better for your health than baby-back ribs and pork loins.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
A different perspective on screening for breast cancer
A nurse practitioner and writer living in Washington, DC, Veneta Masson contributed a guest post to Common Sense Family Doctor earlier this year. This month, she published a thought-provoking piece in the journal Health Affairs, titled "Why I Don't Get Mammograms." Explaining her decision to stop receiving yearly mammograms after age 56, she eloquently articulates her perspective as a patient informed by clinical experience and syntheses of scientific evidence regarding the benefits and harms of screening for breast cancer. In doing so, she challenges the public and medical consensus that routine mammography is an unqualified societal good. Ms. Masson concludes:
I accept that sooner or later, I’ll die of something. It could be breast cancer. It’s also possible that I’ll die with cancerous changes in my breast (or some other location) that never progressed enough to cause harm. ... It’s been ten years since my last mammogram. I don’t have to wonder whether this will be the year for a false alarm, false reassurance, or discovery of a cancer that might or might not require treatment. I accept the fact that life is uncertain.
I’m grateful for the gift of good health, recognizing that that’s what it is: a gift. I will always mourn my sister’s untimely death, which took place three years after her [breast cancer] diagnosis despite state-of-the-art treatment. If it were in my power, I’d honor her by redirecting the $5 billion this country spends each year on screening mammography to other purposes. I’d direct those sums instead to the study of how breast cancer starts, and what we can do to treat it more effectively.
This piece is especially timely in light of a recent study in the New England Journal of Medicine that suggested that nearly two-thirds of the reduction in breast cancer mortality observed after the implementation of routine screening mammography in Norway was actually the result of advances in treatment, rather than earlier detection. Both articles are must-reads for clinicians and patients who want to better understand the limitations and tradeoffs associated with breast cancer screening and screening for cancer in general.
I accept that sooner or later, I’ll die of something. It could be breast cancer. It’s also possible that I’ll die with cancerous changes in my breast (or some other location) that never progressed enough to cause harm. ... It’s been ten years since my last mammogram. I don’t have to wonder whether this will be the year for a false alarm, false reassurance, or discovery of a cancer that might or might not require treatment. I accept the fact that life is uncertain.
I’m grateful for the gift of good health, recognizing that that’s what it is: a gift. I will always mourn my sister’s untimely death, which took place three years after her [breast cancer] diagnosis despite state-of-the-art treatment. If it were in my power, I’d honor her by redirecting the $5 billion this country spends each year on screening mammography to other purposes. I’d direct those sums instead to the study of how breast cancer starts, and what we can do to treat it more effectively.
This piece is especially timely in light of a recent study in the New England Journal of Medicine that suggested that nearly two-thirds of the reduction in breast cancer mortality observed after the implementation of routine screening mammography in Norway was actually the result of advances in treatment, rather than earlier detection. Both articles are must-reads for clinicians and patients who want to better understand the limitations and tradeoffs associated with breast cancer screening and screening for cancer in general.
Complexities of cardiac risk assessment
One of the most powerful patient education tools I've used in practice is the Framingham Heart Study's coronary risk calculator, which estimates the 10-year risk of having a heart attack using age, sex, smoking status, cholesterol and blood pressure levels. I've frequently used this calculator to illustrate that quitting smoking is far more effective at lowering one's heart attack risk than taking drugs to lower cholesterol and blood pressure to recommended levels.
It turns out, though, that not all risk calculators are created equal. A recent study published in the Journal of General Internal Medicine found that many online heart risk calculators, including the one on the American Heart Association's website, use a simplified algorithm (a point-based tool, rather than an equation) that ends up estimating an artifically high risk for 10% of adults and an artificially low risk for 5%. Worse, using the faulty calculator, 39% of patients with high cholesterol would have met criteria for more intensive therapy (either a higher drug dose or the addition of a new drug) than necessary. Since most doctors are unaware of differences between the calculators, it's possible that millions of patients might be misclassified and subjected to more treatment than they really need.
While the solution to this problem is fairly obvious - toss the point-based tool, which was created to help docs do pen-and-paper calculations in the days before widespread Internet access - the solution to another problem of estimating cardiac risk is much less clear. As it is with many other health conditions, socioeconomic status (i.e., being poor) is an independent risk factor for heart attacks that isn't counted by the Framingham calculator.
But it's clearly impractical (and ethically questionable) to practice primary prevention of heart disease on the basis of an individual patient's family income. So a group of researchers publishing in the current issue of Annals of Family Medicine suggested a somewhat more workable alternative: substituting individual incomes with residential income quartiles derived from census areas, since people of similar income levels tend to live in the same neighborhoods. They suggest that electronic health records might be programmed to automatically incorporate the patient's street address into the coronary risk calculation, or conversely, lower the risk thresholds for cholesterol-lowering treatments.
I was attracted to family medicine partly out of a desire to reduce health disparities, but I honestly hadn't imagined that doing so would potentially involve prescribing more cholesterol-lowering drugs to people just because they happened to live in poor neighborhoods. On the other hand, it seems unethical to expose poorer patients to higher heart attack risks just because I feel uneasy about differentiating patients based on socioeconomic status. I'd very much enjoy hearing other clinician and patient perspectives on this issue.
It turns out, though, that not all risk calculators are created equal. A recent study published in the Journal of General Internal Medicine found that many online heart risk calculators, including the one on the American Heart Association's website, use a simplified algorithm (a point-based tool, rather than an equation) that ends up estimating an artifically high risk for 10% of adults and an artificially low risk for 5%. Worse, using the faulty calculator, 39% of patients with high cholesterol would have met criteria for more intensive therapy (either a higher drug dose or the addition of a new drug) than necessary. Since most doctors are unaware of differences between the calculators, it's possible that millions of patients might be misclassified and subjected to more treatment than they really need.
While the solution to this problem is fairly obvious - toss the point-based tool, which was created to help docs do pen-and-paper calculations in the days before widespread Internet access - the solution to another problem of estimating cardiac risk is much less clear. As it is with many other health conditions, socioeconomic status (i.e., being poor) is an independent risk factor for heart attacks that isn't counted by the Framingham calculator.
But it's clearly impractical (and ethically questionable) to practice primary prevention of heart disease on the basis of an individual patient's family income. So a group of researchers publishing in the current issue of Annals of Family Medicine suggested a somewhat more workable alternative: substituting individual incomes with residential income quartiles derived from census areas, since people of similar income levels tend to live in the same neighborhoods. They suggest that electronic health records might be programmed to automatically incorporate the patient's street address into the coronary risk calculation, or conversely, lower the risk thresholds for cholesterol-lowering treatments.
I was attracted to family medicine partly out of a desire to reduce health disparities, but I honestly hadn't imagined that doing so would potentially involve prescribing more cholesterol-lowering drugs to people just because they happened to live in poor neighborhoods. On the other hand, it seems unethical to expose poorer patients to higher heart attack risks just because I feel uneasy about differentiating patients based on socioeconomic status. I'd very much enjoy hearing other clinician and patient perspectives on this issue.
Self-management support doesn't help in heart failure
Heart failure is the most common reason seniors wind up in the hospital, and many patients are hospitalized again and again. They find it's just too difficult to properly manage their condition with its complex drug regimens, dietary restrictions, and frequent monitoring—all of which have been shown in studies to reduce their risk of severe disability and even death. As a family doctor, I've always had a hard time getting my patients to adhere to my advice on managing their heart failure and assumed that any additional one-on-one counseling would be beneficial. Turns out, though, that may not be the case. A study published in a recent issue of JAMA finds that patients with heart failure who receive customized support are no less likely to suffer from disabling symptoms, be hospitalized, or die prematurely than patients receiving standard educational materials.
Self-management support has been shown to improve blood sugar control and quality of life in patients with diabetes. It differs from traditional patient education in that it enables patients to better monitor their own conditions, set personal goals, and overcome any physical or psychological impediments that prevent them from controlling their disease. Rather than, say, simply handing a patient a brochure about the disease and its treatments, a doctor would help patients implement problem-solving strategies and tap into community resources. For example, clinicians might help patients sketch out exercise plans or help them join a local YMCA or neighborhood walking group. They would also check in with patients every week or two to see if those exercise promises were being kept.
The researchers in the JAMA study, which included more than 900 patients with mild to moderate heart failure, randomly assigned participants to either receive face-to-face counseling with educational materials or just the materials without any counseling. Those who received counseling attended two-hour meetings 18 times over the duration of a year to learn skills in monitoring their condition, reducing stress, altering their diets and calling on family and friends for support with their changes. Unfortunately, the study found that these intensive efforts were no better than basic educational materials.
I prefer, though, to look at this from a positive perspective. Those patients in the study who received just the educational materials were actually quite successful at reducing their sodium intake and reported less depression and improved confidence in their ability to manage their disease. These patients had 18 tip sheets mailed to them over a year and received followup phone calls to make sure they'd received each one; the caller also answered any questions patients had about the sheets. This type of support that the control group received, frankly, goes above and beyond the normal standard of care for most heart failure patients. What's more, it was just as good as 36 hours of face-to-face meetings—and far less expensive.
For me, the take-home message of this study is that if you have heart failure, you should learn as much as you can about things you can do to manage your condition, and the way you get that information doesn't seem to matter. Perhaps face-to-face counseling with a doctor or nurse works best for you. Maybe you'd rather take home some handouts to read on your own or look up information online from reputable health sites run by the government or university health centers. Or you may choose to turn to social networking tools such as blogs, Twitter or smart phone apps that have supportive and educational messages. While these technologies weren't included in the JAMA study, I'd be surprised if they don't turn out to be effective too.
**
The above post is excerpted from "Heart Failure Treatment: Counseling Not Necessary," first published on my Healthcare Headaches blog on USNews.com. (By the way, I don't write the headlines. In this case I would not have chosen those words. Counseling is necessary and good - but more counseling may not be better.)
Self-management support has been shown to improve blood sugar control and quality of life in patients with diabetes. It differs from traditional patient education in that it enables patients to better monitor their own conditions, set personal goals, and overcome any physical or psychological impediments that prevent them from controlling their disease. Rather than, say, simply handing a patient a brochure about the disease and its treatments, a doctor would help patients implement problem-solving strategies and tap into community resources. For example, clinicians might help patients sketch out exercise plans or help them join a local YMCA or neighborhood walking group. They would also check in with patients every week or two to see if those exercise promises were being kept.
The researchers in the JAMA study, which included more than 900 patients with mild to moderate heart failure, randomly assigned participants to either receive face-to-face counseling with educational materials or just the materials without any counseling. Those who received counseling attended two-hour meetings 18 times over the duration of a year to learn skills in monitoring their condition, reducing stress, altering their diets and calling on family and friends for support with their changes. Unfortunately, the study found that these intensive efforts were no better than basic educational materials.
I prefer, though, to look at this from a positive perspective. Those patients in the study who received just the educational materials were actually quite successful at reducing their sodium intake and reported less depression and improved confidence in their ability to manage their disease. These patients had 18 tip sheets mailed to them over a year and received followup phone calls to make sure they'd received each one; the caller also answered any questions patients had about the sheets. This type of support that the control group received, frankly, goes above and beyond the normal standard of care for most heart failure patients. What's more, it was just as good as 36 hours of face-to-face meetings—and far less expensive.
For me, the take-home message of this study is that if you have heart failure, you should learn as much as you can about things you can do to manage your condition, and the way you get that information doesn't seem to matter. Perhaps face-to-face counseling with a doctor or nurse works best for you. Maybe you'd rather take home some handouts to read on your own or look up information online from reputable health sites run by the government or university health centers. Or you may choose to turn to social networking tools such as blogs, Twitter or smart phone apps that have supportive and educational messages. While these technologies weren't included in the JAMA study, I'd be surprised if they don't turn out to be effective too.
**
The above post is excerpted from "Heart Failure Treatment: Counseling Not Necessary," first published on my Healthcare Headaches blog on USNews.com. (By the way, I don't write the headlines. In this case I would not have chosen those words. Counseling is necessary and good - but more counseling may not be better.)
Sunday, 27 April 2014
One month until the FMEC NorthEast Region meeting
For those of you who are family physicians or teach family physicians-in-training, I want to make sure you're aware of the Family Medicine Education Consortium (FMEC) and their upcoming Northeast Region meeting ("Family Medicine Innovations: Blueprints for Redesigning Health Care") in Hershey, PA at the end of October. Along with accepting an award for creative nonfiction, I will also be participating in a panel discussion on the uses of social media for personal and professional purposes. Plenary speakers will include Paul Grundy, President of the Patient-Centered Primary Care Collaborative; and Roland Goertz, President-Elect of the American Academy of Family Physicians. You can learn more about this exciting conference by checking out its unofficial blog or watching the professionally produced YouTube video below.
The best recent posts you may have missed
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 August and September:
1) Spain: an unlikely primary care model for the U.S. (8/14/10)
2) Air, space, and primary care checklists (8/23/10)
3) Primary care and health disparities (9/16/10)
4) Care management for chronic health conditions (8/28/10)
5) Quality assessment in primary care: an imperfect science (9/6/10)
If you have a personal favorite that isn't on this list, please let me know. As always, thank you for reading!
1) Spain: an unlikely primary care model for the U.S. (8/14/10)
2) Air, space, and primary care checklists (8/23/10)
3) Primary care and health disparities (9/16/10)
4) Care management for chronic health conditions (8/28/10)
5) Quality assessment in primary care: an imperfect science (9/6/10)
If you have a personal favorite that isn't on this list, please let me know. As always, thank you for reading!
Money-saving medication tips
When you purchase a new item of clothing, television set, or a car, as a general rule you can assume that the higher-quality items are the newest and/or those with the highest price tags, even if you know little about the products themselves. But this approach is often a poor guide to purchasing medications, where the newest and most costly drugs are often no better than, and occasionally inferior to, older and less expensive ones.
Most family practices have a "sample closet" stocked with free samples of brand-name prescription drugs for common conditions. When I was in training, I often gave financially needy patients who were starting a new medication a one month supply of samples instead of a prescription. Although it seemed like a money-saving idea at the time, it wasn't long before the samples ran out, and my patients were left with the choice of paying for an unnecessarily expensive medication or switching to a less expensive drug that they hadn’t tried before. In fact, a 2006 study in the Journal of the American Board of Family Medicine found that practices that distributed free drug samples actually cost their patients an average of $7 more per prescription per month than practices that did not give out samples.
This added cost might have been worth it if patients were paying for higher-quality medications, but most new drugs offer no clinical advantages. The Food and Drug Adminstration requires only that new drugs be superior when compared to a placebo, not to the best drug already on the market. Also, in order to maintain patent protection and prevent competitors from offering cheaper versions, pharmaceutical companies often develop “new” drugs with trivial differences from the originals. For example, prescription Clarinex for seasonal allergies is more expensive, but no more effective than, over-the-counter Claritin, and prescription Nexium for acid reflux is more expensive, but no more effective than, generic omeprazole.
Even worse, a few drugs that are commonly stocked in sample closets turn out to be downright dangerous to your health, since rare and potentially fatal side effects often don't become evident until a drug has been on the market for several years. I remember (and regret) giving out countless samples of Vioxx instead of over-the-counter ibuprofen to patients with arthritis pain; this drug was withdrawn from the market in 2004 after studies showed that it increased the risk of heart attacks and strokes. Avandia, an expensive diabetes drug that has been a fixture in sample closets for years, is the subject of an ongoing FDA safety review about its potential to increase the risk of heart attacks and heart failure.
There are a few easy things that you can do to avoid paying too much for your medications. When your doctor suggests that you need a new medication, ask if it’s possible to prescribe a less costly or generic alternative. Many pharmacies and discount chains offer one month supplies of generic medications for $4 or 90-day supplies for $10. If you are taking more than one medication for a condition (high blood pressure, for example), generic pills may be available that combine two drugs in one. If you don’t have insurance coverage for prescription drugs, some pharmaceutical companies and local and state government agencies often offer sizeable discounts on frequently prescribed drugs for people who meet certain financial requirements. (Here are more details on the Together Rx Access program offered by drug companies.)
Finally, after you have been on a stable dose of a medication for three months or more, consider buying several months’ supply in bulk via mail order. The Pharmacy Checker website provides a useful tool for comparing drug prices among reputable online pharmacies. I have usually advised patients to check with me before doing this, in case I anticipate making a change in their dose or frequency.
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The above post is adapted from "Drug Discount: 5 Ways to Save at the Pharmacy," first published on my Healthcare Headaches blog on USNews.com.
Most family practices have a "sample closet" stocked with free samples of brand-name prescription drugs for common conditions. When I was in training, I often gave financially needy patients who were starting a new medication a one month supply of samples instead of a prescription. Although it seemed like a money-saving idea at the time, it wasn't long before the samples ran out, and my patients were left with the choice of paying for an unnecessarily expensive medication or switching to a less expensive drug that they hadn’t tried before. In fact, a 2006 study in the Journal of the American Board of Family Medicine found that practices that distributed free drug samples actually cost their patients an average of $7 more per prescription per month than practices that did not give out samples.
This added cost might have been worth it if patients were paying for higher-quality medications, but most new drugs offer no clinical advantages. The Food and Drug Adminstration requires only that new drugs be superior when compared to a placebo, not to the best drug already on the market. Also, in order to maintain patent protection and prevent competitors from offering cheaper versions, pharmaceutical companies often develop “new” drugs with trivial differences from the originals. For example, prescription Clarinex for seasonal allergies is more expensive, but no more effective than, over-the-counter Claritin, and prescription Nexium for acid reflux is more expensive, but no more effective than, generic omeprazole.
Even worse, a few drugs that are commonly stocked in sample closets turn out to be downright dangerous to your health, since rare and potentially fatal side effects often don't become evident until a drug has been on the market for several years. I remember (and regret) giving out countless samples of Vioxx instead of over-the-counter ibuprofen to patients with arthritis pain; this drug was withdrawn from the market in 2004 after studies showed that it increased the risk of heart attacks and strokes. Avandia, an expensive diabetes drug that has been a fixture in sample closets for years, is the subject of an ongoing FDA safety review about its potential to increase the risk of heart attacks and heart failure.
There are a few easy things that you can do to avoid paying too much for your medications. When your doctor suggests that you need a new medication, ask if it’s possible to prescribe a less costly or generic alternative. Many pharmacies and discount chains offer one month supplies of generic medications for $4 or 90-day supplies for $10. If you are taking more than one medication for a condition (high blood pressure, for example), generic pills may be available that combine two drugs in one. If you don’t have insurance coverage for prescription drugs, some pharmaceutical companies and local and state government agencies often offer sizeable discounts on frequently prescribed drugs for people who meet certain financial requirements. (Here are more details on the Together Rx Access program offered by drug companies.)
Finally, after you have been on a stable dose of a medication for three months or more, consider buying several months’ supply in bulk via mail order. The Pharmacy Checker website provides a useful tool for comparing drug prices among reputable online pharmacies. I have usually advised patients to check with me before doing this, in case I anticipate making a change in their dose or frequency.
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The above post is adapted from "Drug Discount: 5 Ways to Save at the Pharmacy," first published on my Healthcare Headaches blog on USNews.com.
Patient-centered primary care: easier said than done
Two months ago, surgeon and New York Times columnist Pauline Chen observed that primary care demonstration projects have spent most of their efforts building components of the "medical home" - such as proactive, team-based care and health information technology - without necessarily making it "patient-centered":
Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.
It's welcome news, then, that a pair of insightful, accessible analyses of the potential and challenges of the patient-centered medical home model were published last week. The first article, a Health Policy Brief from the Robert Wood Johnson Foundation, succinctly explains the key elements of the medical home, provisions in U.S. health reform legislation designed to spread its adoption in primary care, and remaining questions, including:
1) What does it mean to be a patient-centered medical home?
2) How will we know whether they work?
3) Are patients and physicians ready?
4) Are they for everybody?
5) Do we have the necessary political and financial resources?
The second article on the PCMH, published in the September issue of Family Practice Management, bears the appropriate subtitle "Still a Work in Progress." It describes the variety of pilot projects that are ongoing across the nation, involving "over 14,000 physicians in nearly 5,000 practices caring for nearly 5 million patients."
For these projects to be successful, those 5 million patients need to experience being at the center of their primary care. What does that mean, exactly? In the August issue of Health Affairs, several prominent family medicine researchers defined a patient-centered approach as one that "fosters interactions in which clinicians and patients engage in two-way sharing of information; explore patients' values and preferences; help patients and their families make clinical decisions; facilitate access to appropriate care; and enable patients to follow through with often difficult behavioral changes needed to maintain or improve health."
It's hard for me as a family physician to read those words and not think that patient-centered primary care is stuck in a sort of chicken-and-the egg scenario. In order to "earn" more time per patient visit, we've been asked to prove to insurers, payers, and government officials that the patient-centered medical home provides additional value beyond traditional primary care. But in order to do all of the things that constitute patient-centered care, we first need to be able to spend more time with patients. Therefore the subtitle of this post: easier said than done.
Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.
It's welcome news, then, that a pair of insightful, accessible analyses of the potential and challenges of the patient-centered medical home model were published last week. The first article, a Health Policy Brief from the Robert Wood Johnson Foundation, succinctly explains the key elements of the medical home, provisions in U.S. health reform legislation designed to spread its adoption in primary care, and remaining questions, including:
1) What does it mean to be a patient-centered medical home?
2) How will we know whether they work?
3) Are patients and physicians ready?
4) Are they for everybody?
5) Do we have the necessary political and financial resources?
The second article on the PCMH, published in the September issue of Family Practice Management, bears the appropriate subtitle "Still a Work in Progress." It describes the variety of pilot projects that are ongoing across the nation, involving "over 14,000 physicians in nearly 5,000 practices caring for nearly 5 million patients."
For these projects to be successful, those 5 million patients need to experience being at the center of their primary care. What does that mean, exactly? In the August issue of Health Affairs, several prominent family medicine researchers defined a patient-centered approach as one that "fosters interactions in which clinicians and patients engage in two-way sharing of information; explore patients' values and preferences; help patients and their families make clinical decisions; facilitate access to appropriate care; and enable patients to follow through with often difficult behavioral changes needed to maintain or improve health."
It's hard for me as a family physician to read those words and not think that patient-centered primary care is stuck in a sort of chicken-and-the egg scenario. In order to "earn" more time per patient visit, we've been asked to prove to insurers, payers, and government officials that the patient-centered medical home provides additional value beyond traditional primary care. But in order to do all of the things that constitute patient-centered care, we first need to be able to spend more time with patients. Therefore the subtitle of this post: easier said than done.
Primary care and health disparities
One of the ugliest incidents in my career occurred during my faculty development fellowship year, when I spent two days each week seeing patients at several federally qualified community health centers in inner city Washington, DC. Midway through the year, I was transferred from a health center that served an African-American population to one serving a mostly Spanish-speaking clientele. Nearly all of the permanent primary care clinicians at this health center spoke fluent Spanish, and I saw it as a sign of the center's desperate need for clinicians that they willingly accepted a family physician who had never managed to learn enough Spanish to ask any questions more complex than "where does it hurt?"
The plan had been for me to be paired with a Spanish-speaking medical assistant who could also function as an interpreter, but due to staffing changes and the reality that medical assistants have many responsibilities, that never worked out. So I found myself spending hours using awkward telephone translation services, pressing patients' relatives and children into service as translators (a big no-no), or as a last resort, deliberately avoiding picking up the medical charts of patients who knew no English.
None of these actions endeared me to the other clinicians, but one in particular, a short-tempered Latino family doctor who had worked at the health center for many years, seemed offended by my presence from the outset. After weeks of giving me the silent treatment, one day he literally exploded and told me in no uncertain terms that I had absolutely no business seeing patients there (especially "his" patients) when I couldn't speak the language, and that the constant influx of temporary physicians from academic medical centers like me who moved on to other things was what gave health centers for the underserved a reputation for poor quality.
Several years removed from that professionally and personally distressing incident, I came across a study in the Archives of Internal Medicine that examined the relationship between proportions of minority patients served by 96 U.S. primary care clinics and elements of their workplace and organizational environments. Consistent with my experience, clinics that served at least a 30% minority population reported that their patients often spoke little or no English, had lower health literacy, and had more complex and chronic medical problems such as depression, pain syndromes, and substance abuse. To address these challenges, these clinics had access to fewer resources (medical supplies, referral specialists, pharmacy services, and examination rooms) and were more likely to have "chaotic" work environments and low job satisfaction than clinics serving less than 30% minorities. The authors concluded that primary health care for minority populations in this country is both "separate and unequal," and suggested that health disparities may be due as much to disadvantages built into the provision of care as to patient-centered factors.
And last week, JAMA published an important analysis of Health Plan Employer and Data Information Set (HEDIS) performance measures of 162 primary care physicians in a practice-based research network in eastern Massachusetts. The authors concluded: "Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary care physicians."
My hat is off to family physicians and other primary care clinicians who care for underserved patients. Every day, you make do with less, manage more challenging clinical problems, and to add insult to injury, apparently are now getting dinged on the quality of care you provide. There is no excuse for the way I was treated in that clinic many years ago, but I have come to understand my antagonist's "us versus them" mentality as a coping mechanism. Making a real dent in health disparities will require more than expanding Medicaid coverage and building new community health centers. Creative programs are also needed to attract top-flight family physicians to practices for the underserved and keep them there by providing the necessary support for them to thrive, professionally and emotionally.
The plan had been for me to be paired with a Spanish-speaking medical assistant who could also function as an interpreter, but due to staffing changes and the reality that medical assistants have many responsibilities, that never worked out. So I found myself spending hours using awkward telephone translation services, pressing patients' relatives and children into service as translators (a big no-no), or as a last resort, deliberately avoiding picking up the medical charts of patients who knew no English.
None of these actions endeared me to the other clinicians, but one in particular, a short-tempered Latino family doctor who had worked at the health center for many years, seemed offended by my presence from the outset. After weeks of giving me the silent treatment, one day he literally exploded and told me in no uncertain terms that I had absolutely no business seeing patients there (especially "his" patients) when I couldn't speak the language, and that the constant influx of temporary physicians from academic medical centers like me who moved on to other things was what gave health centers for the underserved a reputation for poor quality.
Several years removed from that professionally and personally distressing incident, I came across a study in the Archives of Internal Medicine that examined the relationship between proportions of minority patients served by 96 U.S. primary care clinics and elements of their workplace and organizational environments. Consistent with my experience, clinics that served at least a 30% minority population reported that their patients often spoke little or no English, had lower health literacy, and had more complex and chronic medical problems such as depression, pain syndromes, and substance abuse. To address these challenges, these clinics had access to fewer resources (medical supplies, referral specialists, pharmacy services, and examination rooms) and were more likely to have "chaotic" work environments and low job satisfaction than clinics serving less than 30% minorities. The authors concluded that primary health care for minority populations in this country is both "separate and unequal," and suggested that health disparities may be due as much to disadvantages built into the provision of care as to patient-centered factors.
And last week, JAMA published an important analysis of Health Plan Employer and Data Information Set (HEDIS) performance measures of 162 primary care physicians in a practice-based research network in eastern Massachusetts. The authors concluded: "Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary care physicians."
My hat is off to family physicians and other primary care clinicians who care for underserved patients. Every day, you make do with less, manage more challenging clinical problems, and to add insult to injury, apparently are now getting dinged on the quality of care you provide. There is no excuse for the way I was treated in that clinic many years ago, but I have come to understand my antagonist's "us versus them" mentality as a coping mechanism. Making a real dent in health disparities will require more than expanding Medicaid coverage and building new community health centers. Creative programs are also needed to attract top-flight family physicians to practices for the underserved and keep them there by providing the necessary support for them to thrive, professionally and emotionally.
Saturday, 26 April 2014
Guest Blog: Prescription report cards
Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog, DrPullen.com.
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Twice a year, each of the major health insurance plans sends me a report card showing how I compare to my peers on prescribing generic medications, formulary medications, and overall cost of medications. For a few years, I always felt good about these reports. I consistently look favorable when compared to my peers. I figured I was doing my part to control the cost of health care. I don’t believe that having good insurance and being able to afford the higher tier co-payments for brand name expensive meds is a good enough reason to skip less expensive generics when I have reason to believe the less expensive meds will be more efficacious. I try to be both informed and conscientious in attempting to manage the costs of prescriptions for my patients. Probably as a result I always look pretty good on the comparison graphs.
Diabetes is one of the conditions where use of only generic medications simply will not get many patients to the goals we are encouraged to pursue. I am proud to be a Diabetes NCQA and Bridges to Excellence Diabetes Recognized Provider, but am certain this would not be the case if I didn’t prescribe the medications I’m encouraged to find alternatives for on these report cards. I’m also encouraged to substitute an ACE inhibitor for any patients I have on an angiotensin receptor blocker (ARB). I know that I rarely prescribe an ARB to patients who have not had unacceptable side effects, usually refractory cough, from an ACE inhibitor. I am reminded of the minority of my patients who are on trade name SSRIs or SNRIs for depression, and non-generic statins. Most of these have been prescribed by their psychiatrists or their cardiologists, and it is difficult for the primary physician to get these substituted if the patient is at goal for their LDL numbers, or is doing well from a mental health standpoint.
Overall, now I look at these reports as what I believe they really are, marketing propaganda insurers use to show prospective large company buyers of their product what they are doing to keep the costs of medical care low. What I’d really like to see is more helpful information from insurers, like which of my consultants spends more money than others in treatment of various conditions. Then I can use the information insurers are the best at collecting to refer patients to specialists whom I believe provide quality care (which I am better positioned to judge than the insurers), and who are cost-conscious as well.
I’d also like to have insurance companies contact my patients directly to get them to have their preventive services done. Rather than scold me for not having all my female patients between the ages of 50 and 65 up-to-date on their mammograms, why not notify them and ask them to see me for an examination and referral? I am already working hard on my patients' health and disease management. Third party payers could make better use of their data than merely sending me report cards on costs of my prescriptions. They could be encouraging patients to get their preventive and disease management care done, too.
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Twice a year, each of the major health insurance plans sends me a report card showing how I compare to my peers on prescribing generic medications, formulary medications, and overall cost of medications. For a few years, I always felt good about these reports. I consistently look favorable when compared to my peers. I figured I was doing my part to control the cost of health care. I don’t believe that having good insurance and being able to afford the higher tier co-payments for brand name expensive meds is a good enough reason to skip less expensive generics when I have reason to believe the less expensive meds will be more efficacious. I try to be both informed and conscientious in attempting to manage the costs of prescriptions for my patients. Probably as a result I always look pretty good on the comparison graphs.
Diabetes is one of the conditions where use of only generic medications simply will not get many patients to the goals we are encouraged to pursue. I am proud to be a Diabetes NCQA and Bridges to Excellence Diabetes Recognized Provider, but am certain this would not be the case if I didn’t prescribe the medications I’m encouraged to find alternatives for on these report cards. I’m also encouraged to substitute an ACE inhibitor for any patients I have on an angiotensin receptor blocker (ARB). I know that I rarely prescribe an ARB to patients who have not had unacceptable side effects, usually refractory cough, from an ACE inhibitor. I am reminded of the minority of my patients who are on trade name SSRIs or SNRIs for depression, and non-generic statins. Most of these have been prescribed by their psychiatrists or their cardiologists, and it is difficult for the primary physician to get these substituted if the patient is at goal for their LDL numbers, or is doing well from a mental health standpoint.
Overall, now I look at these reports as what I believe they really are, marketing propaganda insurers use to show prospective large company buyers of their product what they are doing to keep the costs of medical care low. What I’d really like to see is more helpful information from insurers, like which of my consultants spends more money than others in treatment of various conditions. Then I can use the information insurers are the best at collecting to refer patients to specialists whom I believe provide quality care (which I am better positioned to judge than the insurers), and who are cost-conscious as well.
I’d also like to have insurance companies contact my patients directly to get them to have their preventive services done. Rather than scold me for not having all my female patients between the ages of 50 and 65 up-to-date on their mammograms, why not notify them and ask them to see me for an examination and referral? I am already working hard on my patients' health and disease management. Third party payers could make better use of their data than merely sending me report cards on costs of my prescriptions. They could be encouraging patients to get their preventive and disease management care done, too.
Required reading
"Lessons from the Mammography Wars" is a terrific commentary by physicians Kerianne Quanstrum and Rodney Hayward that appears in today's New England Journal of Medicine. After recapitulating the now-familiar controversy that ensued last November when the U.S. Preventive Services Task Force determined that the decision to begin breast cancer screening for a woman in her 40s should be an individual choice rather than a mandatory requirement, the authors succinctly explore the concept of "gray areas" in the assessment of the net benefit of a health intervention and suggest that a policy of separating self-interest from guideline creation (which does not occur when breast imaging societies make guidelines regarding mammography) would be most likely to benefit patients. Here are two of my favorite passages:
Recent proposals to increase spending on comparative-effectiveness research are certainly laudable, but it is unrealistic to think that an investment in research alone will have a sizable effect on the practice of medicine without a concomitant investment in a credible process for vetting medical evidence and clinical care guidelines.
If there is overutilization in health care, we can be sure that it will continue unabated as long as those with a vested interest are allowed to win the public-relations wars by shouting about "rationing" or "death panels" whenever anyone suggests that more health care, in fact, may not be better.
The entire article, in fact, should be required reading for health policy makers, clinicians, and informed patients.
Recent proposals to increase spending on comparative-effectiveness research are certainly laudable, but it is unrealistic to think that an investment in research alone will have a sizable effect on the practice of medicine without a concomitant investment in a credible process for vetting medical evidence and clinical care guidelines.
If there is overutilization in health care, we can be sure that it will continue unabated as long as those with a vested interest are allowed to win the public-relations wars by shouting about "rationing" or "death panels" whenever anyone suggests that more health care, in fact, may not be better.
The entire article, in fact, should be required reading for health policy makers, clinicians, and informed patients.
Quality assessment in primary care: an imperfect science
Several years ago, when I was a very junior faculty member at a well-regarded medical school, I was asked to give a lecture to first-year students about, among other things, medical licensure and specialty board certification. I considered this task to be unenviable because these processes 1) are boring; and 2) don't happen until after medical school graduation, and thus are probably the last things on the minds of first-years who are spending most of their waking hours memorizing anatomical and biochemical trivia.
So, to get them interested, I began the lecture with a question: how does society assure that medical schools like their own produce "good" doctors who are worthy of the trust that patients have traditionally placed in them? More to the point, how do processes such as licensure and board certification assure the quality of practicing physicians? As it turns out, not well at all. Only the worst offenders (doctors who abuse or divert prescription painkillers, for example) are typically disciplined by state medical boards, and there was no publicly available information then or now that would allow an average citizen to determine how his or her doctor measured up against others.
More recently, in an attempt to provide feedback about their performance, some institutions have started giving primary care (and other) physicians "report cards" that summarize their performance on objective measures of care quality; for example, what percentage of patients with a hypertension diagnosis met blood pressure goals at their most recent visits. In theory, this type of reporting should motivate physicians who receive lower scores than their peers to improve their practices, and, therefore, the quality of care they provide their patients.
A few weeks ago, general internist Danielle Ofri, MD, PhD (a frequent guest contributor to Common Sense Family Doctor) wrote a commentary in the New England Journal of Medicine that portrayed current methods for assessing quality in individual primary care physicians as inadequate and potentially misleading. Ofri writes:
Quantitative analysts ... will see it as a sign of medical arrogance that physicians insist that everyone simply trust us to do the right thing because we are such smart and noble people. I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables - experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective - that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care.
Notwithstanding the firestorm of blog responses that Dr. Ofri's editorial provoked (most of whom misunderstood her as arguing for discarding quality measurement in general, rather than the crude tools being used to measure it in primary care), she has a point. Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.
This doesn't mean that we should throw up our hands and stop trying. Not at all - in fact, I think it's critical for family physicians to be open to novel methods of quality measurement to in order to support our role in the changes that will be taking place in the U.S. health system over the coming years and decades. As I've said in this blog again and again, there will be no real health reform without meaningful investment in good primary care. To that statement I now add this corollary: there will be no meaningful investment in good primary care until we develop much better tools to measure what, exactly, good primary care is.
So, to get them interested, I began the lecture with a question: how does society assure that medical schools like their own produce "good" doctors who are worthy of the trust that patients have traditionally placed in them? More to the point, how do processes such as licensure and board certification assure the quality of practicing physicians? As it turns out, not well at all. Only the worst offenders (doctors who abuse or divert prescription painkillers, for example) are typically disciplined by state medical boards, and there was no publicly available information then or now that would allow an average citizen to determine how his or her doctor measured up against others.
More recently, in an attempt to provide feedback about their performance, some institutions have started giving primary care (and other) physicians "report cards" that summarize their performance on objective measures of care quality; for example, what percentage of patients with a hypertension diagnosis met blood pressure goals at their most recent visits. In theory, this type of reporting should motivate physicians who receive lower scores than their peers to improve their practices, and, therefore, the quality of care they provide their patients.
A few weeks ago, general internist Danielle Ofri, MD, PhD (a frequent guest contributor to Common Sense Family Doctor) wrote a commentary in the New England Journal of Medicine that portrayed current methods for assessing quality in individual primary care physicians as inadequate and potentially misleading. Ofri writes:
Quantitative analysts ... will see it as a sign of medical arrogance that physicians insist that everyone simply trust us to do the right thing because we are such smart and noble people. I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables - experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective - that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care.
Notwithstanding the firestorm of blog responses that Dr. Ofri's editorial provoked (most of whom misunderstood her as arguing for discarding quality measurement in general, rather than the crude tools being used to measure it in primary care), she has a point. Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.
This doesn't mean that we should throw up our hands and stop trying. Not at all - in fact, I think it's critical for family physicians to be open to novel methods of quality measurement to in order to support our role in the changes that will be taking place in the U.S. health system over the coming years and decades. As I've said in this blog again and again, there will be no real health reform without meaningful investment in good primary care. To that statement I now add this corollary: there will be no meaningful investment in good primary care until we develop much better tools to measure what, exactly, good primary care is.
Writing awards
I've mentioned previously that Common Sense Family Doctor started as the result of a science writing workshop taught by David Taylor at The Writer's Center in Bethesda, Maryland in the summer of 2009.
Earlier in the same year, I took a workshop in prose writing, taught by novelist Nancy Lemann. During this workshop, I wrote a piece titled "Failure to Progress" that chronicled the true story of my son's birth and the somewhat fictionalized impact of that experience on my career as a family physician and writer. I learned today that a revised version of "Failure to Progress" has won 3rd place in the Prose category of the 2010 Family Medicine Education Consortium (FMEC) Creative Writing Awards. Pretty exciting stuff, since the last time I won an award for non-scientific writing was in high school!
After this piece is officially published at the FMEC Northeast Region Meeting at the end of October, I plan to post it on this blog.
Earlier in the same year, I took a workshop in prose writing, taught by novelist Nancy Lemann. During this workshop, I wrote a piece titled "Failure to Progress" that chronicled the true story of my son's birth and the somewhat fictionalized impact of that experience on my career as a family physician and writer. I learned today that a revised version of "Failure to Progress" has won 3rd place in the Prose category of the 2010 Family Medicine Education Consortium (FMEC) Creative Writing Awards. Pretty exciting stuff, since the last time I won an award for non-scientific writing was in high school!
After this piece is officially published at the FMEC Northeast Region Meeting at the end of October, I plan to post it on this blog.
Care management for chronic health conditions
When my three-year old son began having recurrent coughing fits and shortness of breath after exercise, my wife and I knew the probable diagnosis. We made an appointment with our family doctor who confirmed that our son, indeed, had asthma. After prescribing medications to prevent and manage the symptoms, our doctor would have—had we not been medical professionals—taken just 10 or 15 minutes to explain how to administer the medications and avoid triggers like tobacco smoke, mold, pollen, and hairy pets. She would have also had to cram in lessons on recognizing the early warning signs of an asthma attack, what actions to take to treat it, and when to call the office or go straight to the emergency room.
Our son's doctor didn't have go into detail about any of those things and, given her crowded waiting room, I suspect she was grateful. But what about the 7 million other parents whose children are diagnosed with asthma? Or those who live with chronic conditions like diabetes and heart disease who don't have the benefit of medical school training?
One solution that's becoming more widespread: care management or disease management programs now offered by many health insurance plans and some large employers like IBM to help patients manage their care between doctor's visits. Basic programs generally offer round-the-clock telephone or e-mail access to health educators and informational brochures. More intensive programs may include home visits by nurses and/or remote monitoring of pharmacy usage to keep track of prescriptions written by multiple physicians. Employers and health insurance companies hope to benefit in the long run by keeping employees on the job and defraying costs of multiple hospitalizations for poorly managed conditions.
Patients at Johns Hopkins Hospital in Baltimore can, as outpatients, enroll in the hospital's ambitious Guided Care program. A specially trained nurse in each primary care practice affiliated with Hopkins coordinates care from various specialists—for those with multiple health problems—making sense of various, sometimes contradictory, care instructions. The nurse also provides individualized counseling on diet, exercise and medications, and links the patient to nutritionists and physical activity programs. Recent studies have shown that the Guided Care program improves patients' perceived quality of health care and their satisfaction; it isn't yet known, however, whether it results in fewer emergency room visits and hospitalizations.
Unfortunately, most care management programs haven't been subjected to the same degree of scientific scrutiny, so it's not clear which components help patients most. In order for you or your loved one to get the most out of a care management program, I recommend that you do the following:
1) Make sure to tell your doctor that you've enrolled in a program and provide the name and contact information. Insurance companies and employers who provide care management programs don't necessarily keep patients' individual physicians in the loop.
2) Find out from your doctor what's unique about your condition and relay that to your care manager. Chances are you deviate somewhat from the "typical" patient with your condition. Everyone has a different mix of symptoms, concurrent health problems, and medical history, so find out where you deviate from the norm.
3) Check with your doctor about the accuracy of any educational materials you receive. Such materials are usually generic and not meant to cover every conceivable situation.
4) Peruse your local library. You'd be amazed how many health books are out there for every conceivable condition. Becoming more informed about your chronic health conditions not only helps you manage them better but also gives you the freedom to worry less about day to day complications, allowing you to live each day more fully.
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The above post is an excerpt from "Multiple Health Problems? Try Care Management," first published on my Healthcare Headaches blog on USNews.com.
Our son's doctor didn't have go into detail about any of those things and, given her crowded waiting room, I suspect she was grateful. But what about the 7 million other parents whose children are diagnosed with asthma? Or those who live with chronic conditions like diabetes and heart disease who don't have the benefit of medical school training?
One solution that's becoming more widespread: care management or disease management programs now offered by many health insurance plans and some large employers like IBM to help patients manage their care between doctor's visits. Basic programs generally offer round-the-clock telephone or e-mail access to health educators and informational brochures. More intensive programs may include home visits by nurses and/or remote monitoring of pharmacy usage to keep track of prescriptions written by multiple physicians. Employers and health insurance companies hope to benefit in the long run by keeping employees on the job and defraying costs of multiple hospitalizations for poorly managed conditions.
Patients at Johns Hopkins Hospital in Baltimore can, as outpatients, enroll in the hospital's ambitious Guided Care program. A specially trained nurse in each primary care practice affiliated with Hopkins coordinates care from various specialists—for those with multiple health problems—making sense of various, sometimes contradictory, care instructions. The nurse also provides individualized counseling on diet, exercise and medications, and links the patient to nutritionists and physical activity programs. Recent studies have shown that the Guided Care program improves patients' perceived quality of health care and their satisfaction; it isn't yet known, however, whether it results in fewer emergency room visits and hospitalizations.
Unfortunately, most care management programs haven't been subjected to the same degree of scientific scrutiny, so it's not clear which components help patients most. In order for you or your loved one to get the most out of a care management program, I recommend that you do the following:
1) Make sure to tell your doctor that you've enrolled in a program and provide the name and contact information. Insurance companies and employers who provide care management programs don't necessarily keep patients' individual physicians in the loop.
2) Find out from your doctor what's unique about your condition and relay that to your care manager. Chances are you deviate somewhat from the "typical" patient with your condition. Everyone has a different mix of symptoms, concurrent health problems, and medical history, so find out where you deviate from the norm.
3) Check with your doctor about the accuracy of any educational materials you receive. Such materials are usually generic and not meant to cover every conceivable situation.
4) Peruse your local library. You'd be amazed how many health books are out there for every conceivable condition. Becoming more informed about your chronic health conditions not only helps you manage them better but also gives you the freedom to worry less about day to day complications, allowing you to live each day more fully.
**
The above post is an excerpt from "Multiple Health Problems? Try Care Management," first published on my Healthcare Headaches blog on USNews.com.
Friday, 25 April 2014
Air, space, and primary care checklists
There is a mesmerizing - some would say hypnotic - air traffic control display at the National Air and Space Museum in Washington, DC that shows the flight paths of every airplane over the United States during a 24-hour period in 2006. At any given moment, up to 6,000 planes were in the air, and the total number of flights numbered in the many tens of thousands. Immediately after the 9/11 terrorist attacks, air traffic controllers were instructed to land every one of them at once. And miraculously, they were able to do so without a single runway collision or plane running out of fuel.
After reading Harvard surgeon Atul Gawande's bestselling book The Checklist Manifesto several months ago, I learned that a feat that seemed miraculous to an outsider really wasn't. Since the early days of aviation, when planes became too complex for even the most experienced pilots to control without making an occasional devastating error of judgment or omission, pilots have depended upon checklists to manage both routine tasks and once-in-a-lifetime emergencies, such as last year's "Miracle on the Hudson" landing of a crippled US Airways jet in the Hudson River in which every passenger was rescued. Gawande's book goes on to describe how checklists have revolutionized industries as far apart as skyscraper construction and his own studies of safety in surgery.
Since reading Gawande's book, I've thought about how checklists might be applied to improve the performance and efficiency of primary care. On one hand, we already have many checklist-type procedures in family medicine: obtaining vital signs (which can include smoking status and body mass index in addition to height, weight, temperature, and blood pressure), paper or electronic applications that help family physicians to remember recommended immunizations, screening tests, checklists for diabetes care, and so forth. And through trial and error while developing the patient-centered medical home, we've found that regular practice meetings called "huddles" can serve much the same purpose as a surgical team organizing itself for a major operation.
On the other hand, primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so? I'd love to hear your ideas.
After reading Harvard surgeon Atul Gawande's bestselling book The Checklist Manifesto several months ago, I learned that a feat that seemed miraculous to an outsider really wasn't. Since the early days of aviation, when planes became too complex for even the most experienced pilots to control without making an occasional devastating error of judgment or omission, pilots have depended upon checklists to manage both routine tasks and once-in-a-lifetime emergencies, such as last year's "Miracle on the Hudson" landing of a crippled US Airways jet in the Hudson River in which every passenger was rescued. Gawande's book goes on to describe how checklists have revolutionized industries as far apart as skyscraper construction and his own studies of safety in surgery.
Since reading Gawande's book, I've thought about how checklists might be applied to improve the performance and efficiency of primary care. On one hand, we already have many checklist-type procedures in family medicine: obtaining vital signs (which can include smoking status and body mass index in addition to height, weight, temperature, and blood pressure), paper or electronic applications that help family physicians to remember recommended immunizations, screening tests, checklists for diabetes care, and so forth. And through trial and error while developing the patient-centered medical home, we've found that regular practice meetings called "huddles" can serve much the same purpose as a surgical team organizing itself for a major operation.
On the other hand, primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so? I'd love to hear your ideas.
Welcome to the blogosphere, American Family Physician
In addition to blogging for Common Sense Family Doctor and Healthcare Headaches, starting today I will also be writing and moderating a new blog for the journal American Family Physician (where I am an associate medical editor). The AFP Community Blog will be a weekly forum for exchanging thoughts and opinions about clinical topics published in the journal and other important issues relevant to the practice of family medicine. Please visit this blog to see what it has to offer.
Does your doctor understand your health beliefs?
As a family physician, I've found that patients' individual health beliefs often play a big role in important decisions such as starting a new medication or undergoing an invasive test or procedure. Some patients were more willing to endure potentially risky procedures in order to learn their diagnosis quicker, for example, while others preferred "watchful waiting," or monitoring symptoms that were unlikely to be a sign of anything serious. Unfortunately, in a typical 15-minute office visit, I barely had enough time to establish a friendly rapport with my patients, much less probe them deeply about their beliefs. As a result, I'd often find myself making assumptions about the care they preferred.
Unfortunately, it turns out my assumptions, and those of other doctors, were more likely to be wrong than right. In a recent study published in the Journal of General Internal Medicine, researchers found that physicians' and patients' beliefs about conditions and treatments often diverge. Patients typically assume that they're somehow to blame for a disease, like diabetes or heart failure, and that the disease can be managed with non-pharmaceutical treatments; they also assume that they'll partner with their doctors in making treatment decisions. Doctors, on the other hand, often see the conditions they diagnose as unavoidable and requiring a prescription to treat with little input necessary from the patient.
The study's surprising finding was that when physicians were asked to fill out surveys expressing their own beliefs and what they thought their patients' beliefs were, they gave pretty much the same answers. In other words, doctors thought that their patients' beliefs were basically the same as their own.
So how can you, as a patient, avoid misunderstandings with your doctor? Here are three communication tactics I try with my doctor when I'm the one being examined.
1. Speak up. The authors of the study found that doctors were more likely to be aware of their patients' individual health beliefs when their patients "asked questions, expressed concerns, and stated their opinions." I might start a conversation by saying something like "let me make sure I understand correctly what you're recommending…" because I know when I hear these words from my own patients, it's a clue for me to step back and make sure that I understand the patient's point of view. The aim is to be polite but persistent in making sure your doctor understands your personal preferences.
2. Don't be afraid to disagree. If your doctor seems to be shrugging off your symptoms as "all in your head" or suggesting what seems to be an unreasonable course of action, make sure you fully explain why you disagree. Perhaps this pain feels different or lasts longer than the usual aches, or perhaps you can't comprehend how your doctor reached a particular diagnosis based on your medical history. Sometimes challenging your doctor can reveal mistakes. And doctors, like everyone else, make them from time to time.
3. Write out your questions in advance. It's common to forget what you wanted to discuss while you're undergoing a quick exam. If possible, try to write out some questions before your appointment concerning your preferences for follow-up and treatment. If you don't know what kinds of questions to ask or how to ask them, check out the Agency for Healthcare Research and Quality's website. The bottom line: While your doctor's knowledge of medicine may trump yours, you have a vaster knowledge of your own beliefs and preferences—and satisfying care requires a knowledge of both.
**
The above post is an excerpt from "3 Ways to Get Your Doctor To Take Your Pain Seriously," first published on my Healthcare Headaches blog on USNews.com.
Unfortunately, it turns out my assumptions, and those of other doctors, were more likely to be wrong than right. In a recent study published in the Journal of General Internal Medicine, researchers found that physicians' and patients' beliefs about conditions and treatments often diverge. Patients typically assume that they're somehow to blame for a disease, like diabetes or heart failure, and that the disease can be managed with non-pharmaceutical treatments; they also assume that they'll partner with their doctors in making treatment decisions. Doctors, on the other hand, often see the conditions they diagnose as unavoidable and requiring a prescription to treat with little input necessary from the patient.
The study's surprising finding was that when physicians were asked to fill out surveys expressing their own beliefs and what they thought their patients' beliefs were, they gave pretty much the same answers. In other words, doctors thought that their patients' beliefs were basically the same as their own.
So how can you, as a patient, avoid misunderstandings with your doctor? Here are three communication tactics I try with my doctor when I'm the one being examined.
1. Speak up. The authors of the study found that doctors were more likely to be aware of their patients' individual health beliefs when their patients "asked questions, expressed concerns, and stated their opinions." I might start a conversation by saying something like "let me make sure I understand correctly what you're recommending…" because I know when I hear these words from my own patients, it's a clue for me to step back and make sure that I understand the patient's point of view. The aim is to be polite but persistent in making sure your doctor understands your personal preferences.
2. Don't be afraid to disagree. If your doctor seems to be shrugging off your symptoms as "all in your head" or suggesting what seems to be an unreasonable course of action, make sure you fully explain why you disagree. Perhaps this pain feels different or lasts longer than the usual aches, or perhaps you can't comprehend how your doctor reached a particular diagnosis based on your medical history. Sometimes challenging your doctor can reveal mistakes. And doctors, like everyone else, make them from time to time.
3. Write out your questions in advance. It's common to forget what you wanted to discuss while you're undergoing a quick exam. If possible, try to write out some questions before your appointment concerning your preferences for follow-up and treatment. If you don't know what kinds of questions to ask or how to ask them, check out the Agency for Healthcare Research and Quality's website. The bottom line: While your doctor's knowledge of medicine may trump yours, you have a vaster knowledge of your own beliefs and preferences—and satisfying care requires a knowledge of both.
**
The above post is an excerpt from "3 Ways to Get Your Doctor To Take Your Pain Seriously," first published on my Healthcare Headaches blog on USNews.com.
Spain: an unlikely primary care model for the U.S.
When U.S. health reformers were looking abroad last year, the health systems of Canada and the United Kingdom were the most commonly mentioned. In this blog, I've also compared our primary care to better-functioning systems in more out-of-the-way places: the former Soviet republic of Kazakhstan and the tiny island nation of Taiwan.
An article in the August issue of the journal Health Affairs took a closer look at the reform of the primary care system in Spain that began in the mid-1970s. Following the end of the Franco dictatorship, Spain moved rapidly to reorganize the way it provided health care to its citizens. Not only did it formally recognize family medicine as a distinctive medical specialty, Spain's central government dedicated public funds to guarantee primary care access within "Basic Health Zones" that were "organized around a single primary care team ... [to] coordinate prevention, promotion, treatment, and community care activities." They set a goal to establish a primary care center within a 15-minute drive of any residence in the country, and in 2007, 97 percent of all primary care visits were recorded on electronic health records.
The resulting health gains were impressive. Spain's life expectancy in 2007 was 84.3 years for women and 77.8 years for men, both considerably better than the U.S.'s 80.7 years for women at 75.4 years for men. And like other nations that have organized their health systems around primary care, Spain spends a much smaller fraction of its gross domestic product on health care than does the U.S.: just 8.5 percent compared to 16 percent.
Can lessons learned from the transformation of Spain's primary care system be applied to the U.S.? My answer is yes and no. We have made some recent, though comparatively modest, investments in strengthening the training of primary care physicians, and there are new incentives for physicians to accelerate their adoption of health information technology. In terms of access, it may always be difficult to recruit and retain talented physicians in rural underserved areas, as a recent Washington Post story illustrates. But improving the health of the country certainly won't happen if political leaders don't make universal primary care access - distinct from universal insurance coverage - a high priority over the coming decades.
An article in the August issue of the journal Health Affairs took a closer look at the reform of the primary care system in Spain that began in the mid-1970s. Following the end of the Franco dictatorship, Spain moved rapidly to reorganize the way it provided health care to its citizens. Not only did it formally recognize family medicine as a distinctive medical specialty, Spain's central government dedicated public funds to guarantee primary care access within "Basic Health Zones" that were "organized around a single primary care team ... [to] coordinate prevention, promotion, treatment, and community care activities." They set a goal to establish a primary care center within a 15-minute drive of any residence in the country, and in 2007, 97 percent of all primary care visits were recorded on electronic health records.
The resulting health gains were impressive. Spain's life expectancy in 2007 was 84.3 years for women and 77.8 years for men, both considerably better than the U.S.'s 80.7 years for women at 75.4 years for men. And like other nations that have organized their health systems around primary care, Spain spends a much smaller fraction of its gross domestic product on health care than does the U.S.: just 8.5 percent compared to 16 percent.
Can lessons learned from the transformation of Spain's primary care system be applied to the U.S.? My answer is yes and no. We have made some recent, though comparatively modest, investments in strengthening the training of primary care physicians, and there are new incentives for physicians to accelerate their adoption of health information technology. In terms of access, it may always be difficult to recruit and retain talented physicians in rural underserved areas, as a recent Washington Post story illustrates. But improving the health of the country certainly won't happen if political leaders don't make universal primary care access - distinct from universal insurance coverage - a high priority over the coming decades.
Guest Blog: What primary care can learn from oncology - Part 2 of 2
This is the second of two guest posts by Shantanu Nundy, MD. You can find the first part of this piece here.
**
Perhaps the best evidence in support of the care we provided our leukemia patients came from my most startling observation: nearing the end of my 4-week rotation, I have yet to admit a single patient from the emergency room. In general medicine, by contrast, well over 90% of admissions come from the ER.
ER admissions are undesirable for a number of reasons. For one, everything in the ER costs more. Though I have never verified this myself, it is rumored that ERs routinely charge $200 for a single dose of aspirin. Furthermore, because ER doctors are trained to address the worst-case scenario and often know little about the patients besides what is written in the medical record, patients often get unnecessary and expensive tests and procedures in the emergency room. Finally, because leukemia is so super-specialized, leukemic patients are also at risk for substandard care from ER physicians who are generalists by nature.
How are inconvenient, costly, and potentially suboptimal ER stays avoided in leukemia? At diagnosis and frequently thereafter, patients with leukemia are educated about the signs and symptoms of serious complications such as infection. When fever or another acute issue arises, they have a clear care plan. They know who to call and can often reach their primary oncologist directly. Physicians that receive the call triage patients over the phone. If the patient needs to be admitted, he or she will be told to come into the hospital directly, where an inpatient bed will have already been arranged and where the resident on call (e.g., me) will have already been made aware of the oncologist’s concerns and given an initial plan and workup. Patients who need to be seen urgently but not necessarily admitted will be scheduled for a same day or next day appointment. Because every doctor in the group knows each patient (thanks to the weekly leukemia conference), even if the patient’s provider does not have a clinic spot available, the patient can be seen by another provider.
So why do my primary care patients not get as good care as my patients on leukemia? It’s not that primary care doctors are bad and leukemia doctors are good. Clearly it’s not that simple. Reimbursement in oncology is higher than in primary care, and in general oncology has a higher proportion of commercially insured rather than publicly insured patients. This gives oncologists resources primary care physicians can only dream of – outpatient laboratory services, IV infusion suites, advanced practice nurses, and dedicated case managers. Oncology also receives greater NIH funding, which supports research of new and existing treatments, and funding from philanthropic institutions and charities (think “Live Strong” and breast cancer awareness). It is also a more narrow field that requires fellowship training, compared to primary care which spans three different specialities (internal medicine, pediatrics, and family medicine) and includes general and subspecialty trainees.
But some of it is cultural as well. When I asked one of my leukemia attendings to explain why there were so few ER admissions, his answer was that leukemia specialists viewed inpatient and outpatient care as part of the same continuum of care and took responsibility for patients over the full cycle of care. Comparatively, in general medicine, outpatient and inpatient care are treated quite separately, a reality that has been formalized by the growing hospitalist movement, in which patients admitted to the hospital are taken care of by a group of physicians wholly separate from their outpatient providers.
Primary care doctors often argue that we need more resources, better compensation, and greater reimbursement. I agree on all fronts, and in fact many of my observations above only support this notion. But I think even with the resources at hand, there is much we can improve upon. We must become more scientific in our methods, more integrated in our care, and more patient-centric in our approach. We need not wait for change in Washington, DC to get started. We can begin by taking a closer look at our peers and learning from their successes, starting (at least at my institution) with leukemia. This will provide useful answers to the important question of why the care of oncology patients seems to be better than that of general medicine patients.
As I leave the world of oncology and return to general medicine, I can’t help but ask myself another question: what would happen if my primary care patients benefited from the same systems of care as my patients in oncology? How much better off would they be? I’m not sure of the answer, but given what I observed this past month, I would love to find out.
- Shantanu Nundy, MD
**
Perhaps the best evidence in support of the care we provided our leukemia patients came from my most startling observation: nearing the end of my 4-week rotation, I have yet to admit a single patient from the emergency room. In general medicine, by contrast, well over 90% of admissions come from the ER.
ER admissions are undesirable for a number of reasons. For one, everything in the ER costs more. Though I have never verified this myself, it is rumored that ERs routinely charge $200 for a single dose of aspirin. Furthermore, because ER doctors are trained to address the worst-case scenario and often know little about the patients besides what is written in the medical record, patients often get unnecessary and expensive tests and procedures in the emergency room. Finally, because leukemia is so super-specialized, leukemic patients are also at risk for substandard care from ER physicians who are generalists by nature.
How are inconvenient, costly, and potentially suboptimal ER stays avoided in leukemia? At diagnosis and frequently thereafter, patients with leukemia are educated about the signs and symptoms of serious complications such as infection. When fever or another acute issue arises, they have a clear care plan. They know who to call and can often reach their primary oncologist directly. Physicians that receive the call triage patients over the phone. If the patient needs to be admitted, he or she will be told to come into the hospital directly, where an inpatient bed will have already been arranged and where the resident on call (e.g., me) will have already been made aware of the oncologist’s concerns and given an initial plan and workup. Patients who need to be seen urgently but not necessarily admitted will be scheduled for a same day or next day appointment. Because every doctor in the group knows each patient (thanks to the weekly leukemia conference), even if the patient’s provider does not have a clinic spot available, the patient can be seen by another provider.
So why do my primary care patients not get as good care as my patients on leukemia? It’s not that primary care doctors are bad and leukemia doctors are good. Clearly it’s not that simple. Reimbursement in oncology is higher than in primary care, and in general oncology has a higher proportion of commercially insured rather than publicly insured patients. This gives oncologists resources primary care physicians can only dream of – outpatient laboratory services, IV infusion suites, advanced practice nurses, and dedicated case managers. Oncology also receives greater NIH funding, which supports research of new and existing treatments, and funding from philanthropic institutions and charities (think “Live Strong” and breast cancer awareness). It is also a more narrow field that requires fellowship training, compared to primary care which spans three different specialities (internal medicine, pediatrics, and family medicine) and includes general and subspecialty trainees.
But some of it is cultural as well. When I asked one of my leukemia attendings to explain why there were so few ER admissions, his answer was that leukemia specialists viewed inpatient and outpatient care as part of the same continuum of care and took responsibility for patients over the full cycle of care. Comparatively, in general medicine, outpatient and inpatient care are treated quite separately, a reality that has been formalized by the growing hospitalist movement, in which patients admitted to the hospital are taken care of by a group of physicians wholly separate from their outpatient providers.
Primary care doctors often argue that we need more resources, better compensation, and greater reimbursement. I agree on all fronts, and in fact many of my observations above only support this notion. But I think even with the resources at hand, there is much we can improve upon. We must become more scientific in our methods, more integrated in our care, and more patient-centric in our approach. We need not wait for change in Washington, DC to get started. We can begin by taking a closer look at our peers and learning from their successes, starting (at least at my institution) with leukemia. This will provide useful answers to the important question of why the care of oncology patients seems to be better than that of general medicine patients.
As I leave the world of oncology and return to general medicine, I can’t help but ask myself another question: what would happen if my primary care patients benefited from the same systems of care as my patients in oncology? How much better off would they be? I’m not sure of the answer, but given what I observed this past month, I would love to find out.
- Shantanu Nundy, MD
Thursday, 24 April 2014
Healthcare headaches
I'm pleased to announce that I have started writing a weekly blog on the website of US News and World Report, Healthcare Headaches. This blog will aim to inform patients about current health issues and how to navigate the health system to get the care they need. The first entry, 3 Ways to Get Your Doctor to Take Your Pain Seriously, discusses a recent study in the Journal of General Internal Medicine about doctors' misperceptions of patients' health beliefs and provides practical tips to patients on how to communicate their needs to clinicians.
US News has given me permission to excerpt or re-post Healthcare Headaches content on Common Sense Family Doctor one week after an entry goes live on their website, which I will do if it makes sense to do so (e.g. involves a primary care theme). In the meantime, please feel free to tell your friends, colleagues, and patients about my new blog. Thank you!
US News has given me permission to excerpt or re-post Healthcare Headaches content on Common Sense Family Doctor one week after an entry goes live on their website, which I will do if it makes sense to do so (e.g. involves a primary care theme). In the meantime, please feel free to tell your friends, colleagues, and patients about my new blog. Thank you!
Guest Blog: What primary care can learn from oncology - Part 1 of 2
Shantanu Nundy, MD is an internal medicine physician at the University of Chicago and the author of Stay Healthy at Every Age: What Your Doctor Wants You to Know. The following piece was originally posted on his blog, BeyondApples.org.
**
Why do my patients with cancer get better care than my patients in primary care?
As the senior resident on my hospital’s inpatient leukemia service this past month, this question troubled and intrigued me daily. Despite the sheer complexity of treating leukemia (administration of chemotherapy, bone marrow biopsies, stem cell transplantation), the resources required (transplantation routinely costs $1 million), and the severity of the illness (patients with little to no functional immune system), I couldn’t help but marvel at how coordinated, integrated, and patient-centric the care was.
From the first day I saw that things in leukemia worked differently. Most inpatient ward teams consist of an attending, a senior medical resident, one or two interns, and medical students. Each member of the team is “on service” for 2-4 weeks after which they rotate to different parts of the hospital or to the outpatient or research setting. As a result, a patient admitted to general medicine today is taken care of by a completely different team than took care of her 3 months earlier when she came in for the same problem.
On leukemia, our medical team included an advanced practice nurse (APN) who did not rotate off and on service. Being on the inpatient leukemia team was her primary responsibility 365 days a year. When I wondered if a patient admitted for chemotherapy needed an interval CT scan, she would remind me that the patient had just received one a month earlier. When the patient later developed a rash that I considered getting a biopsy of, she reassured me that the rash looked no different than the one the patient had developed the last time she received chemotherapy. And when I was trying to determine which prophylactic antibiotics to discharge the patient on, she contacted the primary oncologist to get his opinion and, if necessary, arranged prior authorization for medications that her insurance company might otherwise deny coverage for. Perhaps most importantly, our APN was a constant presence for patients fighting a disease that wrecked havoc on their bodies and their lives.
Often when the medical team finished examining a patient, the patient would ask to speak to our APN privately, no doubt to receive additional emotional and psychosocial support, something that is terribly lacking in many patients with chronic disease, yet serves to reduce treatment breaks and improve adherence and identify co morbid conditions such as depression that are common but often go unnoticed.
Then there was the weekly leukemia conference I was reminded to attend. Thinking I was walking into another research lecture, I was surprised to learn that this meeting was really a “tumor board” in which new and active patients were discussed. Sitting around the expansive conference table were leukemia attendings and fellows, advanced practice nurses, social workers, case managers, and the inpatient leukemia team. We began by discussing the admitted patients with my team providing the updates and the outpatient oncologist providing context and overall direction. ... We then discussed the new patients — while multiple leukemia specialists went back and forth formulating the diagnostic plan and initial chemotherapy, the case managers and social workers figured out how to best coordinate the dozens of steps required to place a central line, draw routine blood tests at home, and schedule chemotherapy and follow up visits. Finally, everyone was encouraged to bring up concerns about any patient on the roster.
In general medicine, doctors are often left to deal with complex medical and social issues with little input from others. Though I’m in a large group practice of over 100 primary care physicians, we have no clear and formal mechanisms for asking and receiving advice from each other on individual patients. In addition, despite the fact that many of the day-to-day challenges of primary care center around not the medical but rather the socioeconomic determinants of health, I do not have access to dedicated social work and case management services.
At the conference we each received a roster of all the patients the group was actively managing. Each line of the roster included the patient’s name, date of birth, type of leukemia, and treatment plan – nothing surprising. But in addition, it included the name of any clinical trial or research protocol the patient was on. Flipping through the roster, I was stunned to see that virtually every patient was enrolled in a research study of one sort or another. Those who were not in a study of a new experimental chemotherapy or drug (Phase I or Phase II trial) were instead on a study to collect and track patient responses to an established leukemia treatment.
General medicine is no less cutting-edge than leukemia; many of our treatments have no good data supporting their use and new drugs come out each year. And yet, to my knowledge, I don’t have a single patient in my practice on a research protocol. Worse still, we don’t even analyze our own data. If you asked me what the average HbA1c is for my patients with diabetes, I couldn’t tell you. In comparison, the oncologists at my hospital can report their institutional survival rates for specific types of leukemia by age of diagnosis, gender, and ethnicity.
This dedication to building evidence was matched by a commitment to use the available evidence. At times it almost seemed as if they were speaking another language. Sentences often were punctuated by phrases such as “per the CALBG 10580 protocol” and frequently, recommendations were accompanied by specific citations from the oncology literature. In primary care, most of our recommendations are based on experience or habit; seldomly we may refer to a consensus guideline. It’s no wonder, then, that studies show it takes 7-10 years after a new guideline or seminal study is released for practice patterns to change. It’s not that such data doesn’t exist — it’s that often we just aren’t using it.
(to be continued later this week)
**
Why do my patients with cancer get better care than my patients in primary care?
As the senior resident on my hospital’s inpatient leukemia service this past month, this question troubled and intrigued me daily. Despite the sheer complexity of treating leukemia (administration of chemotherapy, bone marrow biopsies, stem cell transplantation), the resources required (transplantation routinely costs $1 million), and the severity of the illness (patients with little to no functional immune system), I couldn’t help but marvel at how coordinated, integrated, and patient-centric the care was.
From the first day I saw that things in leukemia worked differently. Most inpatient ward teams consist of an attending, a senior medical resident, one or two interns, and medical students. Each member of the team is “on service” for 2-4 weeks after which they rotate to different parts of the hospital or to the outpatient or research setting. As a result, a patient admitted to general medicine today is taken care of by a completely different team than took care of her 3 months earlier when she came in for the same problem.
On leukemia, our medical team included an advanced practice nurse (APN) who did not rotate off and on service. Being on the inpatient leukemia team was her primary responsibility 365 days a year. When I wondered if a patient admitted for chemotherapy needed an interval CT scan, she would remind me that the patient had just received one a month earlier. When the patient later developed a rash that I considered getting a biopsy of, she reassured me that the rash looked no different than the one the patient had developed the last time she received chemotherapy. And when I was trying to determine which prophylactic antibiotics to discharge the patient on, she contacted the primary oncologist to get his opinion and, if necessary, arranged prior authorization for medications that her insurance company might otherwise deny coverage for. Perhaps most importantly, our APN was a constant presence for patients fighting a disease that wrecked havoc on their bodies and their lives.
Often when the medical team finished examining a patient, the patient would ask to speak to our APN privately, no doubt to receive additional emotional and psychosocial support, something that is terribly lacking in many patients with chronic disease, yet serves to reduce treatment breaks and improve adherence and identify co morbid conditions such as depression that are common but often go unnoticed.
Then there was the weekly leukemia conference I was reminded to attend. Thinking I was walking into another research lecture, I was surprised to learn that this meeting was really a “tumor board” in which new and active patients were discussed. Sitting around the expansive conference table were leukemia attendings and fellows, advanced practice nurses, social workers, case managers, and the inpatient leukemia team. We began by discussing the admitted patients with my team providing the updates and the outpatient oncologist providing context and overall direction. ... We then discussed the new patients — while multiple leukemia specialists went back and forth formulating the diagnostic plan and initial chemotherapy, the case managers and social workers figured out how to best coordinate the dozens of steps required to place a central line, draw routine blood tests at home, and schedule chemotherapy and follow up visits. Finally, everyone was encouraged to bring up concerns about any patient on the roster.
In general medicine, doctors are often left to deal with complex medical and social issues with little input from others. Though I’m in a large group practice of over 100 primary care physicians, we have no clear and formal mechanisms for asking and receiving advice from each other on individual patients. In addition, despite the fact that many of the day-to-day challenges of primary care center around not the medical but rather the socioeconomic determinants of health, I do not have access to dedicated social work and case management services.
At the conference we each received a roster of all the patients the group was actively managing. Each line of the roster included the patient’s name, date of birth, type of leukemia, and treatment plan – nothing surprising. But in addition, it included the name of any clinical trial or research protocol the patient was on. Flipping through the roster, I was stunned to see that virtually every patient was enrolled in a research study of one sort or another. Those who were not in a study of a new experimental chemotherapy or drug (Phase I or Phase II trial) were instead on a study to collect and track patient responses to an established leukemia treatment.
General medicine is no less cutting-edge than leukemia; many of our treatments have no good data supporting their use and new drugs come out each year. And yet, to my knowledge, I don’t have a single patient in my practice on a research protocol. Worse still, we don’t even analyze our own data. If you asked me what the average HbA1c is for my patients with diabetes, I couldn’t tell you. In comparison, the oncologists at my hospital can report their institutional survival rates for specific types of leukemia by age of diagnosis, gender, and ethnicity.
This dedication to building evidence was matched by a commitment to use the available evidence. At times it almost seemed as if they were speaking another language. Sentences often were punctuated by phrases such as “per the CALBG 10580 protocol” and frequently, recommendations were accompanied by specific citations from the oncology literature. In primary care, most of our recommendations are based on experience or habit; seldomly we may refer to a consensus guideline. It’s no wonder, then, that studies show it takes 7-10 years after a new guideline or seminal study is released for practice patterns to change. It’s not that such data doesn’t exist — it’s that often we just aren’t using it.
(to be continued later this week)
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