A few years ago, we received a letter from a physician reader who complained that the approximate prices of drugs provided in AFP were often quite different from the prices he found online or in his local drugstore. This letter ultimately led to a re-evaluation of the rationale and process for estimating drug costs in the journal, as AFP editor Jay Siwek, MD explained in this January 2010 editorial:
Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.
Although having information about the costs of drugs can be helpful, physicians are often unaware of the costs of common tests, procedures, and referrals. A recent commentary in JAMA argues that electronic medical records should incorporate such cost information to make clinicians aware of the overall costs generated by office visits and other health care encounters:
What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.
The American Academy of Family Physicians has partnered with the American Board of Internal Medicine and several other physician and consumer groups in the Choosing Wisely campaign, an initiative to promote more efficient use of limited health care resources. Although this campaign focuses on reducing use of tests or procedures that have no clinical benefits (e.g., imaging for uncomplicated low back pain, antibiotics for upper respiratory infections), it raises the question of whether physicians should take responsibility for controlling costs of health care beyond simply eliminating "waste." For example, should family physicians' virtual "shopping carts" drive more selective use of health services that have high costs and marginal benefits (e.g., coronary CT scans, cancer screening in patients over age 75 years)? Or is this type of thinking unjustified and unethical rationing? What's your view?
Monday, February 27, 2012
Monday, February 13, 2012
The state of family medicine is ... ?
A special report on "The State of Family Medicine" in the current issue of AFP's sister publication, Family Practice Management, reviews data from 2011 Residency Match and American Academy of Family Physicians' member surveys to arrive at a mixed conclusion about the current status of the specialty:
On the one hand, family medicine has its challenges, including administrative hassles, a lack of support in the health care system, and threats to its comprehensiveness and scope of practice. On the other hand, family medicine has a lot going for it, including recent efforts to create primary care incentives, incomes well above the national average, and solid evidence of its value to the health care system.
Although the glass may appear to be either half-full or half-empty for today's family physicians, depending on one's perspective, there is a widespread consensus that there aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform. An article published in last week's Washington Post quoted AAFP President Glen Stream, MD and Robert Graham Center for Policy Studies in Family Medicine and Primary Care director Robert Phillips, MD, MSPH on the urgent need to address the economic realities that drive many students away from careers in family medicine and primary care.
Since 2000, AFP has published a series of One-Pagers produced by the Graham Center that examine broad historical trends in the scope and practice of family medicine, the impact of policy changes on the primary care workforce, and the often underestimated benefits that primary care physicians bring to the U.S. health system. Collectively, they are an invaluable resource for illustrating the current "state of family medicine." The full text of each of these One-Pagers is available online without access restrictions from the date of publication.
On the one hand, family medicine has its challenges, including administrative hassles, a lack of support in the health care system, and threats to its comprehensiveness and scope of practice. On the other hand, family medicine has a lot going for it, including recent efforts to create primary care incentives, incomes well above the national average, and solid evidence of its value to the health care system.
Although the glass may appear to be either half-full or half-empty for today's family physicians, depending on one's perspective, there is a widespread consensus that there aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform. An article published in last week's Washington Post quoted AAFP President Glen Stream, MD and Robert Graham Center for Policy Studies in Family Medicine and Primary Care director Robert Phillips, MD, MSPH on the urgent need to address the economic realities that drive many students away from careers in family medicine and primary care.
Since 2000, AFP has published a series of One-Pagers produced by the Graham Center that examine broad historical trends in the scope and practice of family medicine, the impact of policy changes on the primary care workforce, and the often underestimated benefits that primary care physicians bring to the U.S. health system. Collectively, they are an invaluable resource for illustrating the current "state of family medicine." The full text of each of these One-Pagers is available online without access restrictions from the date of publication.
Wednesday, February 1, 2012
How many referrals is too many?
Most AFP review articles about conditions that may require co-management of specialists contain a short section or Table titled "Indications for Referral." For example, the January 1st article on prevention and care of outpatient burns includes a list of criteria from the American Burn Association for considering the transfer of a patient to a burn center. This and other lists generally represent expert consensus on appropriate reasons to refer a patient in a typical primary care setting; obviously, availability and accessibility of specialists has a large influence on a family physician's practice with regard to management of "referable" conditions. Clinicians' training and expertise also affect their comfort levels in caring for patients with complex problems and, as previous studies have shown, these factors lead to variations in referral rates.
Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago. What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?
Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago. What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?
Wednesday, January 25, 2012
How often should you screen for osteoporosis?
Last year, AFP published the U.S. Preventive Services Task Force's updated recommendations on screening for osteoporosis, which advised dual-energy x-ray absorptiometry (DEXA) in "women 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors." However, the USPSTF statement left one important question unanswered: when should a woman be re-screened if her first test shows normal or slightly decreased bone mineral density (BMD)? Put another way, what are the chances that a woman without osteoporosis today will develop it in the future?
A research team led by former AFP medical editor Margaret Gourlay, MD, MPH recently shed light on this question by following nearly 5000 U.S. women age 67 years or older with normal BMD or osteopenia for up to 15 years. They defined the BMD re-testing interval as the estimated time it took for 10% of women to develop osteoporosis before having a hip or clinical vertebral fracture. According to their report in the January 19th issue of the New England Journal of Medicine, more than 90% of women with initially normal BMD or mild osteopenia did not develop osteoporosis after 15 years. As might be expected, women with moderate and advanced osteopenia progressed faster, with 10% of each group developing osteoporosis after 5 years and 1 year, respectively.
This study's results have substantial implications for family physicians and their patients. In the absence of new risk factors for osteoporosis (e.g., significant weight loss, corticosteroid use), a woman with normal BMD at age 65 may not need to be re-tested until age 80, an interval that is substantially longer than current clinical practice. That's good news, since as Dr. Gourlay pointed out in a previous AFP editorial, many U.S. women who are at risk for osteoporosis have yet to receive any screening at all. Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.
A research team led by former AFP medical editor Margaret Gourlay, MD, MPH recently shed light on this question by following nearly 5000 U.S. women age 67 years or older with normal BMD or osteopenia for up to 15 years. They defined the BMD re-testing interval as the estimated time it took for 10% of women to develop osteoporosis before having a hip or clinical vertebral fracture. According to their report in the January 19th issue of the New England Journal of Medicine, more than 90% of women with initially normal BMD or mild osteopenia did not develop osteoporosis after 15 years. As might be expected, women with moderate and advanced osteopenia progressed faster, with 10% of each group developing osteoporosis after 5 years and 1 year, respectively.
This study's results have substantial implications for family physicians and their patients. In the absence of new risk factors for osteoporosis (e.g., significant weight loss, corticosteroid use), a woman with normal BMD at age 65 may not need to be re-tested until age 80, an interval that is substantially longer than current clinical practice. That's good news, since as Dr. Gourlay pointed out in a previous AFP editorial, many U.S. women who are at risk for osteoporosis have yet to receive any screening at all. Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.
Wednesday, January 18, 2012
AFP Journal Club casts doubt on NEJM study
Do children younger than 2 years of age with acute otitis media (AOM) require antibiotics, or is a watchful waiting approach just as effective? A study designed to answer this question was published last year in the New England Journal of Medicine and concluded that a 10-day course of amoxicillin-clavulanate "tended to reduce the time to resolution of symptoms and reduced the overall symptom burden and the rate of persistent signs of acute infection on otoscopic examination." However, an analysis of this study by Drs. Andrea Darby-Stewart, Mark Graber, and Robert Dachs in the November 15, 2011 AFP Journal Club concluded that the results actually supported a watchful waiting strategy because the primary outcome (likelihood of treatment failure) was disease-oriented rather than patient-oriented:
The only clinically significant outcome was likelihood of treatment failure; yet, this was defined as the presence of any symptom of AOM and persistent otoscopic signs of AOM on day 10 to 12. Treatment did not fail in any children based on symptoms alone—all treatment failures were defined by persistent inflammation on examination. The treatment failed even if the patient was symptomatically better. Most of these asymptomatic children likely would never have presented for follow-up in routine practice. And, only four to six children had to be treated to cause diarrhea, rash, or diaper dermatitis.
The January 15th AFP Journal Club continues this story by reporting an apparent discrepancy between the predesignated primary outcomes in study's original protocol (published on ClinicalTrials.gov and posted to the NEJM's website) and those that were ultimately reported in the study abstract's conclusions:
There were only three primary outcomes planned and the fourth outcome, otoscopic resolution, was one of many planned secondary outcomes. ... What is even more concerning is that the otoscopic findings are only one of 22 secondary outcomes evaluated in this study. It amazes me that a significant number of these findings, the ones that just happen to support placebo, were never reported. The secondary outcomes that demonstrated no difference between placebo and amoxicillin/clavulanate were analgesia requirements in these children; number of needed follow-up visits to a primary care physician; number of visits to the emergency department; missed hours of work by the parents; and parental satisfaction.
The bottom line: family physicians should not conclude that this NEJM study showed that antibiotics are superior to watchful waiting for acute otitis media in young children. In fact, by showing that only 6 children needed to be treated with antibiotics to cause one additional episode of diarrhea, it suggests that the opposite conclusion may be true.
The only clinically significant outcome was likelihood of treatment failure; yet, this was defined as the presence of any symptom of AOM and persistent otoscopic signs of AOM on day 10 to 12. Treatment did not fail in any children based on symptoms alone—all treatment failures were defined by persistent inflammation on examination. The treatment failed even if the patient was symptomatically better. Most of these asymptomatic children likely would never have presented for follow-up in routine practice. And, only four to six children had to be treated to cause diarrhea, rash, or diaper dermatitis.
The January 15th AFP Journal Club continues this story by reporting an apparent discrepancy between the predesignated primary outcomes in study's original protocol (published on ClinicalTrials.gov and posted to the NEJM's website) and those that were ultimately reported in the study abstract's conclusions:
There were only three primary outcomes planned and the fourth outcome, otoscopic resolution, was one of many planned secondary outcomes. ... What is even more concerning is that the otoscopic findings are only one of 22 secondary outcomes evaluated in this study. It amazes me that a significant number of these findings, the ones that just happen to support placebo, were never reported. The secondary outcomes that demonstrated no difference between placebo and amoxicillin/clavulanate were analgesia requirements in these children; number of needed follow-up visits to a primary care physician; number of visits to the emergency department; missed hours of work by the parents; and parental satisfaction.
The bottom line: family physicians should not conclude that this NEJM study showed that antibiotics are superior to watchful waiting for acute otitis media in young children. In fact, by showing that only 6 children needed to be treated with antibiotics to cause one additional episode of diarrhea, it suggests that the opposite conclusion may be true.
Wednesday, January 11, 2012
Curbing overuse of CT scans
The urban public hospital where I completed most of my training as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present the patient's case to the on-call Radiology fellow and explain how the result of the scan would potentially change management. Since my attending surgeons were usually too busy to trudge down to the Radiology suite, they deputized their residents to do so, and most of the time my residents passed this thankless task down to the students. Thus, my classmates and I learned early on the difference between appropriate and inappropriate reasons for ordering CT scans.
Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, an editorial published last year in AFP reviewed the accumulating evidence that CT scans are highly overused in current medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.
Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published recently in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.
In their AFP editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommend that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:
1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.
Since 2007, AFP has published a series of articles in collaboration with the American College of Radiology on appropriate criteria for diagnostic imaging (including CT) in specific clinical situations. The ACR Appropriateness Criteria are periodically updated, and current versions are available on the ACR website.
Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, an editorial published last year in AFP reviewed the accumulating evidence that CT scans are highly overused in current medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.
Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published recently in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.
In their AFP editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommend that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:
1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.
Since 2007, AFP has published a series of articles in collaboration with the American College of Radiology on appropriate criteria for diagnostic imaging (including CT) in specific clinical situations. The ACR Appropriateness Criteria are periodically updated, and current versions are available on the ACR website.
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