Thursday, April 24, 2014

Does Meaningful Use provide meaningful benefits to patients?

- Kenny Lin, MD, MPH

The ambitious federal effort to improve the quality of patient care in the U.S. by providing up to $30 billion in incentives to physicians who demonstrate "meaningful use" of certified electronic health records (EHRs) has now entered a new stage, aptly described in a recent Family Practice Management article as either a "second wave or a tsunami," depending on one's point of view. Officials at the Centers for Medicare and Medicaid Services believe that meaningful use will ultimately provide meaningful benefits to patients. However, this hypothesis has largely remained untested. In an AFP editorial two years ago, I summed up the state of the science as follows: "the evidence is far from conclusive that EHRs and CDSSs [clinical decision support systems] improve preventive care processes and outcomes in primary care settings."

A research letter published last week in JAMA Internal Medicine examined the association of being a "meaningful user" with performance on 7 quality measures for hypertension, diabetes mellitus, coronary artery disease, asthma, and depression during a 90-day reporting period in the fall of 2012. 540 meaningful users were compared to 318 other outpatient physicians using the same EHR in Brigham and Women's Hospital-affiliated practices. Meaningful users performed slightly better in controlling cholesterol levels and blood pressure, worse in treating asthma and depression, and the same on the 3 remaining measures, compared to non-meaningful users.

Although these preliminary findings are unlikely to affect plans to move ahead with Stages 2 and 3 of meaningful use over the next few years, they remind family physicians of the real goals of practice transformation, and caution us not to conflate meeting meaningful use targets with making patients' lives longer or healthier.

Monday, April 14, 2014

Should we stop dreading the lists patients bring to appointments?

- Jennifer Middleton, MD, MPH

I confess to feeling a little nervous when a patient brings a list to his or her appointment. I admit that it can be helpful at times, but I always get a flutter of irrational fear when I see a patient with one. I'm mostly afraid that the list will be a dozen pages long and/or that this particular patient encounter will be especially lengthy.

A study published in the Journal of Family Practice this month, however, has significantly decreased my anxiety. Researchers at 2 primary care offices in Israel consecutively enrolled patients who had brought a list of concerns and/or issues to their doctor's appointment; for every enrolled patient, the researchers then enrolled a patient who had not brought a list. From their Electronic Health Record (EHR), they obtained basic demographic information on each patient, along with their occupations, disease lists, medication lists, and number of visits to that office in the last year. They also asked patients who had brought a list why they brought it.

They found some differences between the patients who brought a list to their visit and those who did not. For starters, patients who brought a list tended to be older (mean age 63.0 vs 46.7 years) and retired. The patients who brought lists had more chronic medical conditions and had seen their physicians more often in the last year. Women were as likely to bring a list as men, though, and although the list-bringers received more prescriptions for benzodiazepines, the psychiatric histories between the groups was similar; list-bringers were not more likely to suffer from mental illness.

The most common reason patients gave for bringing a list was "a desire to completely satisfy the objectives of the visit." The authors cite a study which showed that lists can improve patient satisfaction without lengthening the visit time. It's not surprising that patients with more complicated medical issues are more likely to use a list. The authors state that patients who bring a list "have no discernible ill intention, and the list serves as a memory aid to help them make the most of the visit."

This study was a small one, though, and may not be generalizable to other countries. The researchers essentially used a convenience sample (whoever showed up to the office that day) and admit that they did not obtain a random sample of the office's patients. I agree with their call for further studies to either refute or confirm their findings. But, despite its limitations, this study still has me rethinking my reaction to the lists patients bring to their appointments. If you'd like to read more, check out the section titled "Improving Practice" in the AFP By Topic on Health Maintenance and Counseling.

What you think of patients who bring a list to their appointments?

Monday, April 7, 2014

Supporting women with incomplete miscarriages

- Jennifer Middleton, MD, MPH

All family physicians, even those not providing full obstetric (OB) care, can have a role in helping women and their partners through the heartbreak of an incomplete miscarriage. Last week's AFP examined a recent Cochrane review titled "Medical Treatments for Incomplete Miscarriage." While we may not all be making this diagnosis and prescribing treatment, understanding the treatment options and recognizing the prevalence of grief and depression after treatment can allow us to provide much-needed caring and support to these women and their families.

An algorithm can help physicians determine if an incomplete miscarriage has taken place; the options for women and their partners, then, fall into three categories: expectant management (waiting for the miscarriage to happen naturally), surgical evacuation, or medical treatment with misoprostol. The AFP reviewers state that most women don't want surgery but also don't want to wait up to 14 days for a natural miscarriage. Medical treatment with misoprostol can offer women and their partners closure while avoiding a surgical procedure.

The Cochrane reviewers looked at 20 studies and found that misoprostol is almost as good as surgical evacuation regarding successful completion of miscarriage. Misoprostol was safe and helped women avoid the need for surgery 95% of the time, though it did result in an average of 2 more days of bleeding compared with surgery and expectant management. Misoprostol is available in several dosing preparations, though the AFP reviewers note that the vaginal route has fewer gastrointestinal side effects compared with oral routes.

The completion of a miscarriage is rarely the end of the story for patients and their loved ones, though. Grief following a miscarriage can be as profound for women and their partners as the loss of a close friend or family member. A study published in JAMA in the late 1990s shows that women are at increased risk of depression following any type of pregnancy loss; more recent studies in the OB/GYN literature and psychiatry literature found similar results. A thoughtful review in an OB nursing journal a few years ago describes several websites that provide excellent support following miscarriage, providing some concrete ways to help these women and their partners.

Although many family physicians do provide full spectrum OB care and are in an excellent position to care for women after a miscarriage, even those family physicians who don't provide OB care have much to offer these grieving women within the context of the doctor-patient relationship. There's an AFP By Topic on prenatal care, with a section on pregnancy loss, if you'd like to read more.

How do you and your office care for women after a miscarriage?

Tuesday, April 1, 2014

Modest programs and big ideas to boost primary care

- Kenny Lin, MD, MPH

The April 1st issue of AFP includes a Graham Center Policy One-Pager that uses historical data to project the effect of the 2010 Primary Care Residency Expansion Program (PCRE). By its conclusion in 2015, the PCRE program will have funded an additional 900 residency trainees in family medicine, general internal medicine, and general pediatrics above the current cap on Medicare-supported residency positions. Based on historical trends, though, only 39 percent of internists will end up practicing primary care, compared to 51 percent of pediatricians and 92 percent of family physicians. As a result, only about two-thirds of these residents are likely to enter the primary care workforce. Of course, 600 new primary care physicians are better than none, but at an estimated $100,000 per year per resident, this well-intentioned federal program will also spend $90 million to train additional internal medicine and pediatric subspecialists that are already in plentiful supply.

In addition to modest programs like PCRE, big ideas are needed to transform U.S. health care to a patient-centered system, grounded in primary care, that delivers the best possible health outcomes for all. AFP assistant medical editor Corey Fogleman, MD and Thomas Gates, MD propose several in a recent article in the Journal of Lancaster General Hospital, including:

1) Making medical school free, and providing residency training stipends only to graduates who choose primary care programs
2) Direct primary care: "eliminating the middle-man of third-party insurance"
3) Single payer systems providing universal insurance coverage on the state level

Of these three big ideas, direct primary care appears to face the fewest political and logistical obstacles. Drs. Fogleman and Gates observe:

Advocates of this approach point out that insurance is meant for large unexpected expenses, while expenses for primary care are relatively modest and predictable. It makes little sense to pay for these through an insurance model, any more than it would make sense to buy auto insurance to protect from the cost of an oil change or new tires. Instead, patients in direct primary care contract directly with a primary care provider for access to a broad range of office-based primary care services, in return for a monthly or annual retainer fee.

Unlike “concierge medicine,” the fee is modest (usually on the order of $500-$1000 per year), and can complement high-deductible or catastrophic insurance (which would cover large and unexpected expenses like hospitalization). An element of competition safeguards consumers: practices that don’t deliver quality and accessible primary care will quickly lose patients.


A collection of articles about direct primary care and membership-based practices is available on the Family Practice Management website.

Monday, March 24, 2014

Azithromycin & levofloxacin safety concerns continue

- Jennifer Middleton, MD, MPH

Safety concerns with azithromycin and levofloxacin seem to be mounting of late, and a new study titled "Azithromycin and Levofloxacin Use and Increased Risk of Cardiac Arrhythmia and Death," just published in the Annals of Family Medicine, adds fuel to the fire.

Rao et al conducted a retrospective cohort study, comparing US veterans who had received azithromycin or levofloxacin to those who had received amoxicillin. The researchers looked at outcomes during the 10 days after starting one of these three antibiotics (first dose of antibiotic = day 1). Participants were excluded if they had been on another antibiotic in the month prior to receiving one of the three antibiotics and/or if they had any current "life-threatening" condition. The researchers then looked through participants' charts and identified which ones had been admitted for a serious cardiac arrythmia (long QT syndrome, ventricular tachycardia, ventricular fibrillation, ventricular flutter, or cardiac arrest), been evaluated in the emergency department with one of those cardiac arrythmias, and/or had died of any cause.

They found that, compared to amoxicillin, treatment with azithromycin and levofloxacin was associated with an increased risk of both death and serious cardiac arrythmia.

During days 1-5, the hazard ratio (HR) for risk of death with azithromycin was 1.48 (95% Confidence Interval 1.05-2.09) and the HR for risk of death with levofloxacin was 2.49 (95% CI 1.70-3.64). In days 6-10, the HR for death in the azithromycin group was no longer statistically significant (1.14 95% CI [0.81-1.62]) but the HR for death in the levofloxacin group still was (1.95 95% CI [1.32-2.88]). The data for cardiac arrythmias follows a similar trend and may be viewed here.

The authors do note that a similarly styled study in Denmark last year was reassuring regarding these risks in a young, healthy cohort, but caring for older men with multiple co-morbidities is a significant portion of my patient panel and, I suspect, is for a significant number of other family docs as well. These men are more likely to have pneumonia, for which I frequently use one of these drugs, and azithromycin and levofloxacin are also recommended for patients with severe COPD exacerbations.

This study's findings warrant attention, even if it is a retrospective study. Although many physicians prefer basing practice change on a prospective study, retrospective studies are better suited than prospective studies to detect rare events. With a prospective study, researchers would need to identify large groups of participants and potentially follow them for a long time before having enough cases to meet statistical rigor. That can take a lot of expense and time to accomplish and can be an understandable turn-off for a potential researcher. So, this retrospective cohort study may be as good as it gets for a while.

As for me, I'll be checking out the AFP By Topics on Pneumonia and COPD to investigate alternative antibiotics to use in my older male patients. How about you - will this retrospective cohort study change how you prescribe azithromycin and/or levofloxacin?

Monday, March 17, 2014

Truth and consequences of antibiotic overuse

- Kenny Lin, MD, MPH

The cover article of AFP's March 15th issue, "Common Questions About Clostridium Difficile Infection," reviews truths about a disease that is a direct consequence of medicine's good intentions: antibiotic use, both appropriate and inappropriate. A recent Vital Signs report from the Centers for Disease Control and Prevention (CDC) addressed the magnitude of the latter by demonstrating that broad-spectrum antibiotics are up to three times as likely to be used in some hospitals compared to others. Additional analyses concluded that 37 percent of prescriptions for intravenous vancomycin and antibiotics for urinary tract infections were not supported by diagnostic testing or documentation of symptoms.

The CDC estimated that reducing the use of broad-spectrum antibiotics by 30 percent could eliminate more than 1 in 4 Clostridium difficile infections. CDC Director Thomas Frieden, MD, MPH outlines seven steps for hospitals to improve accountability and monitoring of antibiotic prescribing in the video below.



Increasingly, Clostridium difficile infections are occurring in outpatient as well as inpatient settings. A study published in Pediatrics revealed that 71% of laboratory-confirmed Clostridium difficile infections identified by a U.S. population-based surveillance system from 2010 to 2011 were community-acquired, with the highest incidence among children 3 years of age or younger.

According to the AFP review article by Dr. Bradford Winslow and colleagues, many Clostridium difficile infections can be prevented by minimizing the frequency and duration of antibiotic prescriptions; practicing hand hygiene and adhering to contact precautions; and prescribing probiotics to patients who are taking antibiotics for infections.