Tuesday, March 21, 2017

The influence of residency training on high-value care

- Kenny Lin, MD, MPH

The American Academy of Family Physicians last week celebrated the results of the 2017 Match, which saw a record 3,237 medical students and graduates fill first-year positions in family medicine residency programs. Although there is ample evidence that providing primary care improves population health, it is less clear how residency training specialty or location influences future health care quality and spending.

As Dr. Jennifer Middleton and I mentioned in prior posts, the AAFP was an early adopter of the American Board of Internal Medicine Foundation's Choosing Wisely campaign against questionable or unnecessary medical interventions, but so far, studies have shown limited effects of the campaign in primary care. Since an estimated 30 percent of health care spending is wasted on unnecessary services, and a recent case study in JAMA suggested that "excessive resource utilization" may be considered an adverse event, it is worth studying if residency training spending patterns persist in clinical practice.

In a research paper in this month's Annals of Family Medicine, Dr. Robert L. Phillips, Jr. and colleagues at the American Board of Family Medicine and the Robert Graham Center analyzed spending patterns of a nationally representative sample of 3,075 family physicians and general internists who graduated from residency between 1992 and 2010 and who cared for a total of more than 500,000 Medicare patients. The physicians' residency program locations were matched with Hospital Service Areas (HSAs) and categorized by spending per patient into low-, average-, and high-cost groups. The researchers found that the "imprint" of residency training spending patterns persisted regardless of where physicians ended up providing primary care:

Physicians trained in high-cost HSAs spent significantly more per patient than those trained in low-cost HSAs, no matter what the spending category of the practice HSA. Averaged across all practice HSAs, this difference was $1,644. ... This relationship held true for family physicians and general internists in our multivariable analysis; general internists, however, made up two-thirds of sample physicians trained in high-cost HSAs, and family physicians made up two-thirds of those trained in low-cost HSAs. [Residency] graduates were significantly more likely to be low-cost physicians if their sponsoring institution produced fewer total physicians, more rural physicians, or more primary care physicians.


The researchers found no relationship between spending patterns and diabetes quality measures, suggesting that lower spending did not lead to worse health outcomes. And it is important to note that family physicians who trained in high-cost HSAs were as likely to be big health care spenders as general internists from high-cost programs; in other words, there did not appear to be anything inherent in family medicine training that caused graduates to spend less. However, more general internists provided costlier care by virtue of having trained in high-cost areas - most likely, those with tertiary academic medical centers. I agree with Dr. Phillips and colleagues' conclusion that their study "supports efforts to test interventions in residency training that may bend imprinting toward teaching and modeling behaviors that improve value in health care." One intervention has borne fruit for the past 8 years in a row: attracting more medical students to the specialty of family medicine.

Monday, March 13, 2017

Supporting our LGBT adolescents

- Jennifer Middleton, MD

Well care at all stages of life is an important part of many family physicians' practices, but perhaps our visits with adolescents are among the most crucial. Discussing sexual health and risk behaviors in all adolescents can help teens avoid serious health sequelae. These discussions are especially critical for lesbian, gay, bisexual, and transgendered (LGBT) youth, as Drs. Knight and Jarrett remind us in the current issue of AFP.  In their article "Preventive Health Care for Women Who Have Sex with Women" (WSW), they assert that "sexual minority adolescents face unique developmental challenges." Providing a supportive environment for sexual minority youth to discuss their sexuality allows us to provide counseling and care regarding these health concerns.

Adopting gender-neutral language with all of our adolescent patients indicates our willingness to provide a safe space for LGBT youth to tell their story. Asking "Is there someone special in your life?" instead of "Do you have a boyfriend/girlfriend?", for example, avoids assumptions regarding sexual orientation. Confidentiality during adolescent visits is especially important to LGBT teens, who may not have disclosed their sexual identity to family and friends. Protecting confidentiality is appropriate unless the adolescent's safety is immediately at risk (such as disclosure of ongoing abuse or intent to commit suicide). Inquiring about bullying is also a must for LGBT adolescents, as they are at higher risk of peer violence compared to their heterosexual peers. Connecting adolescents, and their families, with organizations such as Parents, Friends, and Families of Lesbians and Gays (PFLAG) and the Gay, Lesbian, and Straight Education Network (GLSEN) may help sexual minority teens find support that may be lacking in school or other social environments.

Establishing rapport and a safe environment allows physicians the opportunity to screen for common adolescent risk-taking behaviors. Drs. Knight and Jarrett discuss the health concerns that are disproportionately increased in adolescent WSW, including eating disorders, depression, social anxiety disorders, sexually transmitted infections (STIs), and substance abuse. Asking specifically about each of these issues can help family physicians uncover risk behaviors and provide counseling and treatment. The authors provide helpful language and prompts for obtaining a sexual and social history in WSW (table 4) along with safer sex recommendations particular to WSW (table 6). You can review counseling recommendations for men who have sex with men (MSM) in this 2015 AFP article; highlights include ensuring that hepatitis and meningitis vaccinations are up to date for MSM who meet criteria and offering pre- and post-exposure prophylaxis when warranted to reduce the risk of human immunodeficiency virus (HIV) infection.

Having awareness of these recommendations and using these techniques as physicians is only a first step; our offices must also reflect our commitment to provide care for all. In an accompanying editorial to Drs. Knight and Jarrett's AFP article, Dr. Stumbar reminds us to "create an inclusive office environment that features photos of same-sex and opposite-sex couples, the rainbow flag, and office staff who are comfortable with nontraditional family structures."  The AFP By Topic on Care of Special Populations includes a subheading on Gay, Lesbian, Bisexual, and Transgendered Persons if you'd like to read more.

Monday, March 6, 2017

Prioritizing effective clinical preventive services: an update

- Kenny Lin, MD, MPH

In a widely cited 2003 study, Dr. Kimberly Yarnall and colleagues estimated that in order for a family physician to provide all U.S. Preventive Services Task Force-recommended services to a patient panel of 2500 with an age and sex distribution similar to that of the U.S. population, he or she would need to spend 7.4 hours per working day, leaving little time to address acute or chronic medical problems. Although the subsequent rise of the patient-centered medical home model has allowed physicians to share this work load with other primary care team members, it remains difficult to meet all preventive care needs. In 2006, the National Commission on Prevention Priorities (NCPP) ranked 25 preventive health services recommended by the USPSTF and the Advisory Commission on Immunization Practices (ACIP) based on clinically preventable burden (health impact) and cost-effectiveness. The three services that received the highest score were aspirin use to prevent cardiovascular disease (CVD), the childhood immunization series, and tobacco use screening and brief interventions in adults.

In the January/February Annals of Family Medicine, the NCPP published an updated ranking of effective clinical preventive services, using similar methods as in their 2006 study. The childhood immunization series and adult tobacco use screening and counseling remained the most highly prioritized services, joined by counseling to prevent initiation of tobacco use in children and adolescents, first recommended by the USPSTF in 2013. Although low-dose aspirin for primary prevention remained important, the more targeted 2016 USPSTF recommendation to discuss use with high-risk adults lowered the estimated population health impact of this service. In a recent editorial in AFP, former USPSTF member Douglas Owens explained the rationale for focusing on persons 50 to 59 years of age with a 10% or greater 10-year CVD risk:

The decision to initiate aspirin should be based on a discussion of potential benefits and harms. ... Persons who value avoiding long-term medication use may benefit less from taking aspirin. Cardiovascular risk is also important: the higher a person's risk of CVD, the more potential benefit aspirin provides. The most favorable balance of benefits and harms occurs in persons who are at substantially elevated CVD risk but are not predisposed to bleeding complications. Finally, although older age increases the risk of cardiovascular events, it also increases the risk of bleeding complications.

Dr. Jennifer Middleton discussed the nuances of this recommendation statement, including aspirin's benefits for reducing colorectal cancer risk, in a previous post on the AFP Community Blog.

Finally, clinicians should be aware that the Affordable Care Act (ACA) mandated that in addition to the USPSTF and ACIP, preventive services recommended by the Bright Futures guidelines and the Women's Preventive Services Initiative be fully covered by private insurance plans without cost-sharing. The methods of these groups differ significantly, and unlike the NCPP, none of them review cost-effectiveness. Although political uncertainty surrounding possible repeal of the ACA makes it unlikely that this process will change in the near future, a 2016 editorial in JAMA Internal Medicine proposed improving the consistency of the groups' evidence review methodologies and forming a separate advisory committee "to integrate economic considerations into the final selection of free preventive services." Or, perhaps the NCPP itself could take on that role?

Monday, February 27, 2017

Meaningful practice change: less "top-down," more "copy-improve"

- Jennifer Middleton, MD, MPH

I recently wrote about the slow uptake in practice changes in response to the Choosing Wisely recommendations. Understanding the potential challenges to implementing change is an important prerequisite for success, and the current issue of Family Practice Management describes these challenges in the article Why Best Practices Fail to Spread. Drs. Toussaint and Elmer discuss 4 common reasons that practice changes fail; although their discussion centers on workflow changes, the obstacles they discuss can certainly pertain to clinical change as well.

  1. A top-down approach: organizational leaders mandating how change must happen even though every practice is different
  2. A lack of compelling data: physicians won’t buy into making changes unless there is some proof those changes will provide benefit
  3. Standard work for everyone but providers: requiring standardization of everyone in an office except the physicians
  4. Lack of management: office managers must routinely audit compliance with the change plan

The authors suggest one key solution:
[O]rganizations need to include a bottom-up aspect to their change effort; that is, give clinics a playbook not to simply copy but to “copy-improve.” …. Each clinic took the standard work and adapted it to its own environment and specific needs.
Implementing office workflow changes that support Choosing Wisely could follow a similar pattern. As Dr. Lin and colleagues discussed in an FPM article last year, “Many of the recommendations can become the focus of quality improvement projects, performance metrics, and pay-for-performance measures.” Each office could choose a Choosing Wisely recommendation that is especially pertinent to their patient population’s needs and initiate a quality improvement (QI) cycle. The initial point of change could come from within the office itself. Presenting staff and physicians in the office with the evidence base behind the recommendation may increase buy-in, and standardizing the new process for everyone - including physicians - may increase the likelihood of success. Office managers must then commit to auditing workflows and charts to ensure ongoing compliance with the change plan.

FPM is an excellent source of ideas about how to implement these kinds of changes. Family physicians can also find useful articles there about partnering with insurance companies on quality efforts, using pre-visit planning to your advantage, and conducting meaningful audits. AFP has several useful tools to consider as well, including the Choosing Wisely recommendation search tool and articles such as this review of the evidence consistent with several Choosing Wisely recommendations.

Tuesday, February 21, 2017

Guest Post: On the front lines of the opioid epidemic

- Catherine Shafts, DO and Mort Glasser, MD

As a Federally Qualified Health Center in northeastern Connecticut, our mission is to improve the health of the towns we serve. In 2007, we were known as a place where one could easily get prescription opioids. At the same time, opioid abuse, addiction and overdoses were being recognized as a national epidemic. We decided to make a change. All chronic pain management plans were reviewed. Medications were not benefiting patients and often being diverted. This led to a complete reversal of prescribing practices and overhaul of how we managed chronic pain.

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. It was difficult at first. Patients complained to the medical staff, administration, chief medical officer, and Department of Public Health that their needs were not being met. Everyone realized we were not abandoning our patients but rather offering better, healthier treatments. Our efforts were supported.

Since much of our population is transient, including homeless persons, migrant farm workers, former prisoners, and patients with mental health and substance abuse disorders, we wanted a system in place that did not discriminate based on appearance or history. The policy is the same for a 70-year-old woman with osteoarthritis as a 35-year-old man with chronic low back pain.

Patients were offered help at addiction treatment centers, referred to pain management, and given non-addictive options to treat pain. It led to a cultural shift. In time, we experienced less staff stress, fewer irate phone calls, and fewer calls to police. A variety of patients began to come to the community health center instead of only those desiring opiates. Newborns, seniors and families began seeking care. Our child patient population increased significantly. We became a true Family Medicine practice.

Many patients ultimately have been thankful for the changes. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus. Each patient is screened for substance abuse. ACE (Adverse Childhood Experience) scores are being used and discussed. Consistently addressing opioids with preteen and teen patients to prevent use is paramount. With this policy and these new practices, we hope to continue to impact opioid abuse and overdoses and make our small part of the world healthier.

Wednesday, February 15, 2017

Vaccines in the news: controversies & updated recommendations

- Jennifer Middleton, MD, MPH

Vaccine safety concerns continue to make headlines, with another physician garnering attention for voicing his opinions in the last few weeks. Although his healthcare system has vehemently disavowed his statements, some physicians may fear that his claims will complicate the discussions we have with patients about vaccination. It's within this context that AFP's current issue reviews the Advisory Committee on Immunization Practices' (ACIP) updated recommendations for 2017, with articles focusing on children and adults. There are several changes for physicians to be aware of - and having strategies at the ready to respond to concerns evoked by current events may prove useful when discussing them with patients.

Some highlights from the ACIP recommendations:

* Live attenuated influenza vaccine is no longer recommended following studies showing its relative ineffectiveness. This change unfortunately eliminates what was an attractive influenza vaccine option for our needle-phobic patients.

* Only 2 doses of human papillomavirus (HPV) vaccine are now needed for healthy adolescents as long as the series is started before age 15; if started at or after age 15, then 3 doses are still required.

* Pregnant adolescents and women should receive a tetanus toxoid, reduced diptheria toxoid, and acelluar pertussis (Tdap) vaccine between 27 and 36 weeks gestation, regardless of when they last received Tdap vaccination.

* Speaking of infants, ACIP changed their language regarding the first hepatitis B vaccination to emphasize that it should be given "within 24 hours of birth."

* The new vaccine for serotype B meningococcal disease is available for adolescents between ages 16-23.

* Everyone with chronic liver disease - including non-alcoholic fatty liver disease - should receive the hepatitis B vaccine series.

It's likely that, in the course of discussing these changes with patients, that some patients will share their hesitancy to receive a vaccination themselves and/or vaccinate their children. Several techniques may be useful in overcoming vaccine hesitancy. I've written on the blog before about how eliciting our patients' specific concerns and then tailoring our message accordingly can be successful. Dr. Lin has previously provided recommendations about discussing HPV vaccination with parents. A recent editorial in AFP shared "Strategies for Addressing and Overcoming Vaccine Hesitancy," and this excellent article provides useful information about vaccinations and common concerns to share with patients as well. There are AFP By Topics on Immunizations (excluding influenza) and another on Influenza with editorials, patient information, and review articles at your fingertips. If you have concerns about reimbursement related to providing vaccines in your office, check out this 2015 article from Family Practice Management.

Recent outbreaks in the United States of measles and pertussis serve as vivid reminders of how dangerous these diseases can be. Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.