Does every discharged patient need close outpatient follow-up?

- Jennifer Middleton, MD, MPH

Reducing unnecessary readmissions has been of increasing interest to hospitals and health systems, but, until recently, no evidence base supported the current Medicare strategy of incentivizing outpatient follow-up within 30 days of discharge. Theoretically, this close follow-up allows the patient's outpatient physician to proactively address issues that, left unaddressed, could result in the patient being readmitted. Jackson et al in this month's Annals of Family Medicine showed that this strategy is beneficial, but only for patients with multiple chronic conditions.

The authors examined a year's worth of North Carolina Medicaid claims data to identify which patients had follow-up after hospital discharge and when after discharge they had it. They also stratified patients into risk categories for readmission in 30 days; to determine this risk, they looked at patients with similar diagnoses in the previous 5 years of claims data and identified readmission trends. They found that patients with 0 or 1 chronic medical conditions didn't benefit from close follow-up, as their baseline readmission rate was already quite low. For patients with multiple chronic medical conditions, though, close follow-up significantly reduced readmissions:

For those whose readmission risk exceeds 20%, our analysis suggests that 1 readmission may be prevented for every 5 patients who receive outpatient follow-up within 14 days. These patients are characterized by having 3 or more chronic conditions, often including advanced coronary artery disease, chronic obstructive pulmonary disease, chronic renal failure, congestive heart failure, diabetes, ischemic vascular disease, or a history of organ transplant, dialysis, or total parenteral nutrition. 

The challenge, conclude the authors, is that risk stratification for readmission is not common practice at the time of discharge.

The authors used claims data to identify regional "bounce back" trends, but validated tools like LACE might be easier for busier family physicians (Length of stay, Acute admission, Charlson comorbidity index tool, and number of Emergency Department visits in the last 6 months). The tricky part may be incorporating a tool like LACE into a busy outpatient-only family physicians' office. If the hospital discharging a patient doesn't calculate a LACE score, should the physicians' office prior to scheduling a follow-up appointment? It may be easier to just keep scheduling all discharged patients a follow-up appointment within 14 days, but how patient-centered is it to do so for the patients who may not benefit? How much responsibility for ensuring timely post-discharge follow-up should fall on the hospital, and how much on the outpatient family physician?

The question left unanswered by this study is what other benefits patients get from close follow-up besides lowered readmission rates. Are they more confident managing their medical conditions? Do those low-risk patients still find value in close follow-up? Hopefully researchers are focusing on other elements of post-hospital care besides readmissions to answer these patient-oriented questions.

In the meantime, the Family Practice Management website includes this article on using the Medicare transitional care management codes along with blog posts answering common questions about the codes and this list of additional resources.

The SGR is history, but will its replacement improve care?

- Kenny Lin, MD, MPH

Last night, the U.S. Senate overwhelmingly passed the Medicare Access and CHIP Reauthorization Act of 2015, which, among other things, repealed Medicare's sustainable growth rate (SGR) formula that for the past 12 years had threatened to slash physician payments in order to meet targets for overall program spending. The American Academy of Family Physicians was one of many medical groups that declared victory. Instead of cuts, physicians will now receive annual 0.5% increases to payment schedules through 2019, after which payments will be designed to reward quality over quantity of care.

As many have pointed out, though, the devil of quality measurement is in the details. In family medicine, "high quality" care has often boiled down to how often physicians provide a service to eligible patients: what percentage had smoking cessation counseling, had tests for blood glucose control, or underwent appropriate screenings. Despite the existence of the Choosing Wisely campaign, physicians are rarely, if ever, rewarded financially for forming therapeutic relationships with patients and collaboratively deciding not to provide a service. That's a big problem, since the original intent of the SGR wasn't to improve quality, but to reduce costs (or at least slow the rate of cost growth) of care. Although Medicare officials are hopeful that accountable care organizations will save money in the long run by coordinating care and reducing redundant services, it's not at all certain that this will happen.

Screening mammography is a good example of how current quality measurement approaches could end up increasing costs of care. Fee-for-service Medicare spends about $1 billion each year on mammography; across all payers, about 70% of U.S. women age 40 to 85 years are screened annually at a cost of just under $8 billion. A provision of the Affordable Care Act mandated that women over 40 receive screening mammograms at no cost, and it's easy to measure if women are screened or not. So am I a necessarily a better doctor who deserves higher pay because more of my patients get mammograms? Medicare officials would say yes, but I'd argue that they're wrong. Screening mammography's benefits and harms are closely balanced, and as Drs. Russell Harris and Linda Kinsinger observed in a previous issue of American Family Physician, some women might reasonably make an informed decision to decline this test:

Over the years we have learned more about the limited benefits of screening mammography, and also more about the potential harms, including anxiety over false-positive results and overdiagnosis and overtreatment of disease that would not have caused health problems. More and more, the goal for breast cancer screening is not to maximize the number of women who have mammography, but to help women make informed decisions about screening, even if that means that some women decide not to be screened.

A recent study estimated that patients and insurers in the U.S. spend an additional $4 billion annually on working up false-positive mammogram results or treating women with breast cancer overdiagnoses. That's an extraordinary amount to spend for no health benefit, and it could be substantially less if physicians had the time and resources to explain difficult concepts such as overdiagnosis. But that doesn't appear to be where we're headed.

Don't get me wrong: I'm happy that the SGR is history. There's a lot more work to do, though, to prevent it from being replaced down the line with crude measures of physician quality that will end up costing even more money and make few patients happier or healthier.

Acetaminophen ineffective for chronic low back pain - now what?

- Jennifer Middleton, MD, MPH

Acetaminophen has been a mainstay of treatment for chronic low back pain (LBP) for years, but a recent study turns that conventional wisdom on its head.

In a meta-analysis that was published in the BMJ last month, Machado et al searched multiple medical literature databases looking for randomized controlled trials (RCTs) evaluating acetaminophen against placebo in patients with chronic "non-specific" low back pain, hip osteoarthritis (OA), or knee OA. They ended up with 13 RCTs of fair to high quality: 10 RCTs for hip and/or knee OA, and 3 RCTs for chronic LBP. All of the studies for chronic LBP were from 2014.

For chronic LBP, the authors found a non-significant difference for both pain and measures of disability for acetaminophen compared to placebo. For hip and/or knee OA, the difference was statistically significant but likely not clinically significant (only a 4 point difference on a 100-point scale).

Intuitively, acetaminophen seems like a reasonable choice for treating chronic LBP. It's inexpensive and relatively safe when used at recommended doses. A 2009 AFP article on treating chronic LBP advises a trial of acetaminophen prior to trying other medications; that recommendation was based on the best evidence available at the time. This 2015 meta-analysis, that includes newer studies, overturns that recommendation and should prompt a change in the clinical guidelines.

This study raises significant questions about appropriate treatments for this common condition. Opiates can cause dependence and addiction, and long-term NSAID use is also of questionable safety as discussed here in 2013. A 2011 AFP article describes non-pharmaceutical treatments for chronic LBP with some evidence of efficacy; back exercises, acupuncture, massage, spinal manipulation, behavioral therapy, and intensive multidisciplinary treatments programs are all reasonable treatments to offer patients. Perhaps chronic LBP treatment should focus more on these physical modalities and less on medications, though for some patients physical therapies alone may not be enough. Hopefully, we will see future studies addressing the care of patients with this common condition, because right now our medication treatment options feel limited with acetaminophen and NSAIDs both potentially off the table.

Keeping up with changes in the primary care evidence base can feel like a daunting task, even more so, perhaps, when new studies challenge assumptions that once seemed immutable. Chances are, your favorite journals have Twitter and Facebook accounts (AFP does!), and the print version of AFP also includes a round-up of recent evidence-base game changers in its "Cochrane for Clinicans" and "AFP Journal Club" sections.

How do you care for patients with chronic LBP? Will this meta-analysis change your practice?