Monday, May 3, 2021

Understanding and managing long COVID

 - Kenny Lin, MD, MPH

Although 90% of non-hospitalized patents with acute COVID-19 have complete symptom resolution by 21 days, the rest suffer from a wide range of nonspecific symptoms for weeks to months, collectively known as post-acute sequelae of SARS-CoV-2 (PASC) or long COVID. An AFP editorial on long COVID published last December advised that family physicians perform limited testing in these patients guided by the clinical assessment; for those with normal results, "recommended management ... consists of emotional support, ongoing monitoring, symptomatic treatment (e.g., acetaminophen for fever), and attention to comorbidities." A virtual workshop convened that month by the National Institutes of Health (NIH) noted that long COVID symptoms "have been reported among persons of all ages," including children, and that this syndrome potentially represents an enormous chronic health burden; since at least 32 million people have had COVID-19 in the U.S. alone, 3 million or more could be affected. 

Evidence gaps highlighted by workshop speakers included the epidemiology, clinical spectrum, and natural history, and pathophysiology of long COVID. In January, Dr. Francis Collins announced that the NIH would use a Congressional appropriation of $1.15 billion over four years to fund a PASC Initiative to support "a combination of ongoing and new research studies and the creation of core resources ... to help us understand the long-term effects of SARS-CoV-2 infection, and how we may be able to prevent and treat these effects moving forward." 

Two recent electronic health record studies have advanced our understanding of long COVID in the U.S. A cohort study of more than 73,000 non-hospitalized COVID-19 survivors in the Veterans Health Administration (VHA) found that compared to non-hospitalized VHA users who did not have COVID-19, the former group had an increased risk of death beyond the first 30 days of illness (HR 1.59, 95% CI 1.46-1.73) and were more likely to seek outpatient care and have more frequent visits. In addition, the study found an excess burden of respiratory conditions, nervous system conditions, mental health disorders, metabolic disorders, cardiovascular conditions, and gastrointestinal disorders in the COVID-19 cohort at 6 months of follow-up. Similarly, a Centers for Disease Control and Prevention (CDC) study of 3,171 non-hospitalized adults at Kaiser Permanente Georgia who had a positive SARS-CoV-2 polymerase chain reaction result from April to September 2020 found that 69% attended one or more outpatient visits 28 to 180 days after their COVID-19 diagnosis. 68% of these patients had visits for a new primary diagnosis; although most visits were with primary care clinicians, 38% visited with a new specialist. The volume of visits for symptoms potentially related to COVID-19 (throat or chest pain, shortness of breath, malaise and fatigue) declined after 60 days, but some continued through 120 to 180 days.

In a perspective paper in The Milbank Quarterly, Dr. Zackary Berger and colleagues observed that primary care clinicians will play important roles in providing and coordinating care for vulnerable patients with long COVID. The racial health disparities seen in acute COVID-19 will likely translate into similar disparities in long COVID, exacerbated by structural barriers to health and care access (economic, geographical, housing and segregation, and occupational) that could impede recovery. The authors recommended boosting health system resources devoted to primary care and addressing the root causes of inequity though actions to mitigate the social determinants of health. Whether the upcoming CDC guidelines on long COVID heed these sensible recommendations remains to be seen.

Monday, April 26, 2021

What is the connection between eczema and learning disabilities?

 - Jennifer Middleton, MD, MPH

A cross-sectional study of over 2000 children with eczema in the United States found that their self-reported severity of eczema correlated with the diagnosis of a learning disability.

This study's researchers reviewed data from the Pediatric Eczema Elective Registry (PEER) of over 2000 children with eczema who had been enrolled for at least 10 years. PEER was initially designed as a post-marketing study to assess the long-term risk of malignancy in children who received pimecrolimus to treat their eczema. While these children were followed in the registry, data on multiple other factors, including school functioning and additional diagnoses, were collected. The average age of eczema diagnosis among participants was 9 months, the average age at 10-year follow-up was 16.1 years, and 53.8% of participants were girls. 44.9% of participants identified as Black, and 53.8% of participants identified as white. Severity of eczema/atopic dermatitis (AD) was determined according to the Patient-Oriented Eczema Measure (POEM). The researchers found that: 

In multivariable logistic regression models adjusted for sex, age, race/ethnicity, annual household income, age of AD onset, family history of AD, and comorbid conditions, participants with mild AD (odds ratio [OR], 1.72; 95% CI, 1.11-2.67), moderate AD (OR, 2.09; 95% CI, 1.32-3.30), and severe to very severe AD (OR, 3.10; 95% CI, 1.55-6.19) on the POEM were all significantly more likely to have reported [a diagnosed] LD than those with clear or almost clear skin.

The authors are quick to point out that "causality cannot be inferred from the findings of the present study," though it's also not implausible. The itching and scaling from chronic eczema can decrease quality of life for both adults and children. Since difficulties with focusing attention can be a component of learning disabilities, it's possible that children distracted by their eczema symptoms might more easily meet criteria for an LD diagnosis. It may also be only correlation, since both learning disabilities and eczema are diagnosed more often in children of lower socioeconomic status. And, no study to date has assessed whether successful treatment for eczema improves LD symptoms.

Despite these unanswered questions, taking the time to assess how our young patients' eczema is impacting their quality of life (QOL) seems reasonable. Educating families about eczema management may improve pediatric patients' QOL, and following QOL scores may provide another metric to track the degree of treatment success. Since early diagnosis of learning disabilities leads to improved outcomes, remaining vigilant for signs of an LD in children with eczema may be beneficial. 

If you'd like to read more, this 2020 article provides an overview on "Atopic Dermatitis: Diagnosis and Treatment," and this 2019 article reviews "Specific Learning Disabilities: The Family Physician's Role."

Tuesday, April 20, 2021

Interpretation and use of COVID-19 diagnostic tests: key resources

 - Kenny Lin, MD, MPH

Despite the recent decision by U.S. health agencies to pause administration of the Johnson & Johnson vaccine to investigate rare blood clots in several young women, the pace of vaccinations against SARS-CoV-2 is accelerating. The Centers for Disease Control and Prevention reports that more than half of U.S. adults have now received at least one dose, and 33% are fully vaccinated. (In patients age 65 years and older, the respective percentages are 80% and 65%.) However, with more than 50,000 new cases being reported every day, including a small number of breakthrough infections, the need for COVID-19 testing is not going to go away any time soon.

A few weeks ago, the U.S. Food and Drug Administration announced that it had authorized several COVID-19 tests for over-the-counter use for serial screening of asymptomatic persons. Soon to arrive in national chain pharmacies and other stores, these tests and others - mostly of the rapid antigen variety - will cost between $10 and $110. A clinical and cost-effectiveness analysis in the Annals of Internal Medicine estimated that a weekly home-based antigen testing program could avert 2.8 million infections and 15,700 deaths in the U.S. over a 60-day time frame, at a cost of less than $8000 per infection averted. Not only could frequent testing make residences and workplaces safer, it could also improve the safety of in-person K-12 schooling and summer camps, since children younger than age 16 are not yet eligible to receive any of the vaccines.

The April 15 issue of AFP includes an article by Dr. William Nettleton that discusses several common questions and answers about SARS-CoV-2 diagnostic test interpretation

How Do Test Characteristics Such as Sensitivity, Specificity, and Percent Agreement Inform SARS-CoV-2 Diagnostic Test Interpretation?

How Should Clinicians Counsel Patients about Serologic SARS-CoV-2 Test Results?

In addition to describing key features of molecular and antigen diagnostic tests, the article includes a useful leaf plot figure that allows clinicians to translate pretest to posttest probability of COVID-19 infection based on a positive or negative test result and the test's sensitivity and specificity.

Family physicians who need a quick refresher on clinical probability formulas and related conceptual issues can read a recent article in BMJ Evidence-Based Medicine. Those seeking a more in-depth discussion of COVID-19 test use and clinical scenarios may consult an evidence-based review that I co-authored in the Journal of the American Board of Family Medicine. Notably, we observed: "Often lost when testing is encouraged is that testing does not by itself confer health benefits. Rather, testing is useful to the extent it forms a critical link to subsequent medical or public health interventions." Although access to COVID-19 testing is absolutely necessary for an effective pandemic response, it is not sufficient in the absence of equitable interventions to support behaviors that prevent viral transmission (e.g., paid leave to support self-isolation and quarantine, laws requiring mask use in crowded indoor spaces). Finally, the American Academy of Family Physicians has a comprehensive guide to COVID-19 testing on its website.

Monday, April 12, 2021

Physician losses during COVID-19: necessary next steps

 - Jennifer Middleton, MD, MPH

As we pass the one-year mark of the COVID-19 pandemic, let us pause to grieve the colleagues and teammates we have lost. 

Over 3,600 healthcare workers in the United States have died from COVID-19 according to "Lost on the Frontline," a year-long investigation by The Guardian and Kaiser Health Network (KHN). Dr. Lin tweeted last week about this project, which identified 17% of these deaths as physicians. Those lost included Dr. Frank Gabrin, an Emergency Medicine physician in New York City, and Dr. Susan Moore, a pediatrician in Carmel, Indiana. Dr. Moore, who was Black, highlighted in her final days the endemic racism in healthcare that she, too, experienced; the pandemic's greater toll among Black and brown communities is reflected in the "Lost on the Frontline" statistics. Also unsurprisingly,

[t]he yearlong series of investigative reports found that many of these deaths could have been prevented. Widespread shortages of masks and other personal protective gear, a lack of covid testing, weak contact tracing, inconsistent mask guidance by politicians, missteps by employers and lax enforcement of workplace safety rules by government regulators all contributed to the increased risk faced by health care workers. Studies show that health care workers were more than three times as likely to contract covid as the general public.

These failures have further compounded the mental health burden carried by many physicians during the pandemic. These burdens have claimed some of our peers' lives. The "Lost on the Frontline" project's numbers do not include physicians who have completed suicide, such as Dr. Lorna Breen; given pre-pandemic estimates that one physician a day commits suicide in the United States, at least another 300-400 physician lives need to be added to the "Lost on the Frontline" tally.

The April 1 issue of AFP includes this article on "The Suicidal Patient: Evaluation and Management," and its tenets apply equally to caring for our physician-patients. As family physicians, our colleagues are often also our patients, and we owe them compassionate, discreet, accessible mental health care. With our generalist approach, we can be leaders in advocating for physician wellness in our health systems and training centers. We can contribute to an environment that recognizes and honors our struggles instead of silencing and stigmatizing them. 

The AAFP has a website for COVID-19: Physician Well-Being with resources relevant to all specialties. The American Psychiatric Association's Physician Wellbeing Resources site includes both personal and organizational mental health interventions. The American Medical Association also has a site with several resources to help promote physician wellness. Let's lead the way, family physicians, in building systems and relationships that care for each other the way we all deserve.

If you or someone you know is considering suicide, call Doctor Lifeline (1-888-409-0141), the National Suicide Prevention Lifeline (1-800-273-8255); en Espanol (1-888-628-9454); TTY users, use your prefered services or dial 711 then 1-800-273-8255; go to https://suicidepreventionlifeline.org; or text HOME to 741741.

Monday, April 5, 2021

Premature adoption of 3D mammography threatens study that aims to prove its value

 - Kenny Lin, MD, MPH

Although digital breast tomosynthesis (DBT; 3D mammography) was approved by the U.S. Food and Drug Administration a decade ago and has since been rapidly adopted by breast imaging centers, no studies have shown that it is more beneficial or less harmful for breast cancer screening than traditional digital mammography. In a Diagnostic Tests review in the April 1 issue of AFP, Drs. Kathleen Barry and Chelsea Evans noted that DBT offers a "modestly increased cancer detection rate" and lower recall rate, but also costs about 40% more per test and exposes patients to a higher dose of radiation. It is unclear if additional cancers detected by DBT would have eventually become symptomatic, and "no studies have evaluated mortality as an outcome in women screened with DBT compared with digital mammography."

To address these important questions, in 2017 the U.S. National Cancer Institute (NCI) and the Canadian Cancer Trials Group launched a $100 million randomized trial, TMIST (Tomosynthesis Mammographic Imaging Screening Trial). With a planned enrollment of 165,000 women at 100 North American clinical sites, TMIST was designed to compare the incidence of advanced breast cancer after 4.5 years of follow up in women receiving either digital mammography or DBT. However, by early 2020, investigators had managed to enroll fewer than 23,000 women and were forced to expand to include overseas sites in Asia and Europe. The reason, according to an article in Medscape: already convinced that DBT was a superior technology, large numbers of U.S. and Canadian radiologists were declining to participate. Then the COVID-19 pandemic hit, further hindering recruitment efforts.

Meanwhile, a national study of Breast Cancer Surveillance Consortium sites found substantial racial and ethnic disparities in DBT access, with Black, Asian, and Hispanic women significantly less likely than White women to be screened at a facility with DBT or to receive DBT if the facility offered both DBT and digital mammography. If DBT is truly superior to digital mammography, this apparent disadvantage may worsen existing disparities in breast cancer outcomes. If it isn't, then widespread DBT use is unnecessary and wasteful.

After the NCI director suggested in the fall of 2020 that the "feasibility and relevance" of TMIST was in jeopardy, a working group was formed to reevaluate the trial. In its report released last month, the group recommended that the trial continue, but with protocol revisions that included reducing the sample size to 102,000 and developing specific targets for enrolling women from racial and ethnic minority groups. Unlike European trials that are also evaluating DBT, the group noted, TMIST is the only study that is representative of the U.S. population, includes women younger than age 50, and includes multiple rounds of screening.

In a 2019 commentary, Drs. Joy Melnikow and Joshua Fenton observed of DBT:

Diffusion of medical technology ahead of definitive evidence is common in the United States. ... Societal attitudes that place high value on innovation and technology create a fertile environment for the rapid adoption of novel but unproven interventions. ... When the evidence from randomized clinical trials catches up, interventions shown to add little value to previous approaches are often already embedded in practice, widely covered by health insurance (sometimes by mandate), and difficult to withdraw.

Initial findings from TMIST will be available in 2027 at the earliest if investigators can reach its lower enrollment goal. As radiology facilities across the country continue to "upgrade" from digital mammography to DBT and more states mandate insurance coverage of the newer but unproven technology, it remains to be seen whether this study's findings will have any effects on clinical practice.

Monday, March 29, 2021

Answering questions about AstraZeneca's COVID-19 vaccine

 - Jennifer Middleton, MD, MPH

The recent stream of headlines regarding the AstraZeneca COVID-19 vaccine may prompt your patients to ask about its safety and availability.

 A week ago, AstraZeneca reported that its COVID-19 vaccine, after interim analysis of United States (US) trial data, was 79% effective at preventing symptomatic COVID-19 and 100% effective at preventing COVID-19-related hospitalizations and death. This statement was met with skepticism, however, by the US National Institute of Allergy and Infectious Diseases (NIAID), which released a statement that it had "expressed concern" with AstraZeneca regarding the veracity of their data. NIAID reportedly also sent a private letter to AstraZeneca accusing them of "cherry-picking" their data and criticizing them for risking its credibility. The next day, AstraZeneca released updated "primary analysis" data from its US trials demonstrating 76% effectiveness at preventing symptomatic COVID-19 and 100% effectiveness at preventing COVID-19-related hospitalizations and death. 

It's unclear why AstraZeneca publicly reported interim data, "when final results were so close;" it's also unclear why the NIAID made their concerns public when, typically, these "back and forth" concerns are shared "behind the curtain." The NY Times reported late last week that "the brushback from federal officials appeared to reflect high levels of distrust between American regulators and AstraZeneca." 

AstraZeneca vaccine's reputation problems precede this latest incident. Its multinational phase 2 and 3 trials last year were plagued by dosing discrepancies and communication failures with the US Food and Drug Administration (FDA). Recent reports of thrombocytopenia, disseminated intravascular coagulation (DIC), and cerebral venous sinus thrombosis (CVST) following vaccination in Europe, although rare, led some countries to temporarily halt its distribution until the World Health Organization (WHO) and the European Medicines Agency (EMA) asserted its overall safety earlier this month. 

Despite evidence that this vaccine is safe and effective, along with its successful use around the world, lay press coverage of these events may be lowering our patients' willingness to get vaccinated. Family physicians can expect their patients to ask about this controversy and, potentially, express concerns about getting vaccinated. Being prepared to listen to our patients' concerns and address them without judgment may help reduce vaccine hesitancy. For those patients in the US with continued reservations about the AstraZeneca vaccine, it may also help to inform them that they are unlikely to receive it; sufficient COVID-19 vaccine supply from Pfizer, Moderna, and Johnson & Johnson has already been procured to vaccinate the entire US population by late spring. 

If you'd like to read more, the AFP By Topic collection on Coronavirus Disease 2019 (COVID-19) continues to be regularly updated, and the Centers for Disease Control and Prevention (CDC) website includes regularly updated information regarding all of the COVID-19 vaccines currently available in the US. 

Monday, March 22, 2021

Increasing clarity about benefits and harms of screening for diabetes

 - Kenny Lin, MD, MPH

Affecting about 6 percent of pregnancies in the United States, gestational diabetes increases risks of preeclampsia, shoulder dystocia, and macrosomia, and is associated with a 10-fold greater risk of developing type 2 diabetes mellitus in later life. In a recent draft statement, the U.S. Preventive Services Task Force (USPSTF) affirmed its previous recommendation to screen pregnant persons for gestational diabetes at or after 24 weeks of gestation. Historically, there have been two screening options: a non-fasting 50 gram oral glucose challenge test followed by a fasting 100 gram glucose tolerance test if the first test result exceeds a threshold value (typically 130-140 mg/dL), or a single fasting 75 gram glucose tolerance test. Although two-step screening is more commonly used in the U.S., until recently the comparative outcomes of these approaches were uncertain. This evidence gap is important because the diagnosis is associated with increased psychological and emotional burden; labeling more persons as having gestational diabetes with the one-step screening approach would only be justified if doing so resulted in better pregnancy outcomes than the two-step approach.

A pragmatic, randomized trial recently compared the one-step and two-step approaches in more than 23,000 women who received prenatal care at Kaiser Permanente Northwest and Kaiser Permanente Hawaii. Researchers evaluated five primary outcomes: "diagnosis of gestational diabetes, large-for-gestational-age infants, a perinatal composite outcome (stillbirth, neonatal death, shoulder dystocia, bone fracture, or any arm or hand nerve palsy related to birth injury), gestational hypertension or preeclampsia, and primary cesarean section." As expected, a diagnosis of gestational diabetes was more common in participants who underwent one-step screening (16.5%) compared to the two-step approach (8.5%). However, intention-to-treat analyses found no statistically significant differences in any perinatal or maternal complications. Although the trial was not designed to measure potential long-term benefits of post-pregnancy risk-reduction strategies to prevent type 2 diabetes, the results suggest that the two-step approach produces equivalent benefits, and fewer harms, than the one-step approach.

The USPSTF is also updating its recommendation on screening for prediabetes and type 2 diabetes in nonpregnant adults. Compared to its 2015 statement, which recommends screening overweight or obese adults between the ages of 40 and 70, the updated draft statement lowers the age range to include persons aged 35 to 39 years. Although the focus of the Task Force's old and new diabetes screening guidelines is identifying persons with prediabetes in order to prevent them from developing diabetes and its complications, the utility of the term "prediabetes" is controversial, as Dr. Jennifer Middleton discussed in a previous AFP Community Blog post. In older adults, prediabetes is extremely common. In a prospective cohort study of community-dwelling adults aged 71 to 90 years, 73 percent met one or both of the diagnostic criteria for prediabetes (hemoglobin A1c level of 5.7% to 6.4%, impaired fasting glucose of 100-125 mg/dL). After 6.5 years of follow-up, persons with prediabetes at baseline were substantially more likely to revert to normoglycemia or to die than to progress to diabetes. Based on these findings, stopping diabetes screening after age 70 will avoid overdiagnosis and unnecessary treatment.

Monday, March 15, 2021

Subduing influenza in the age of COVID-19

 - Jennifer Middleton, MD, MPH

Map of the United States, all states are green indicating "minimal" influenza activity except for Michigan and Alaska, which are white & reporting no activity

The 2020-2021 influenza season has been historically mild, which public health experts have attributed to the behaviors surrounding COVID-19 prevention: mask-wearing, social distancing, and self-quarantining. While we are hopefully past the point of lockdowns, perhaps the COVID-19 pandemic does have lessons to offer regarding future influenza seasons.

The Centers for Disease Control and Prevention (CDC) notes that influenza activity remains "unusually low" across the United States (US). All 50 states are currently reporting "minimal" levels of influenza activity in contrast to this time last year, when over half of states reported "high" levels of influenza activity:

The Influenza Hospitalization Surveillance Network (FluSurv-NET) conducts population-based surveillance for laboratory-confirmed influenza-related hospitalizations in select counties in 14 states and represents approximately 9% of the U.S. population.... Between October 1, 2020, and March 6, 2021, FluSurv-NET sites...reported...an overall cumulative hospitalization rate of 0.7 per 100,000 population. This is much lower than average for this point in the season and lower than rates for any season since routine data collection began in 2005, including the low severity 2011-12 season.  

Fears of a COVID-19 and influenza "twindemic" overwhelming the US healthcare system have, thankfully, not materialized. (Sadly, though, COVID-19 proved to be more than capable of overwhelming healthcare systems on its own.) It's likely that the same behaviors instituted to decrease SARS-CoV-2 transmission were even more effective at curtailing the far less contagious influenza viruses

Continued mask-wearing could dampen the severity of future influenza seasons, but, post-COVID-19-pandemic, will people still be willing to wear masks? It's not entirely implausible:

Part of why it’s possible that masks could become a more long-term fixture in the U.S. is because elsewhere in the world, previous pandemics had the same effect. In 2003, the SARS outbreaks in parts of Asia, including China, Taiwan and South Korea, required mask-wearing....In between the pandemics, consistent mask-wearing in parts of Asia evolved into an occasional polite choice someone might make if they had a cold or cough and were out in public. 

Wearing a mask and keeping 6 feet away from others would be reasonable behaviors for all people to continue who need to leave home when ill, not only to decrease the burden from endemic COVID-19 but also influenza. Whether those behaviors persist, and precisely how they might affect the 2021-2022 influenza season, remains to be seen.

We'll continue to regularly update the AFP By Topics on both Influenza and Coronavirus Disease 2019 (COVID-19) as the 2020-2021 influenza season, and hopefully the COVID-19 pandemic, begin to wind down.

Monday, March 8, 2021

Can Choosing Wisely prevent acute low back pain from becoming chronic?

 - Kenny Lin, MD, MPH

More than a dozen Choosing Wisely campaign recommendations concern what not to do for patients with acute low back pain. Based on a clinical practice guideline from the American College of Physicians, the American Society of Anesthesiologists and several other groups recommend avoiding imaging studies within the first six weeks in patients without red flags or specific clinical indications. The American Academy of Orthopedic Surgeons and the American Academy of Physical Medicine and Rehabilitation (AAPMR) advise avoiding opioids for these patients unless other alternatives have not provided pain relief. The AAPMR and the North American Spine Society discourage bed rest as treatment for acute low back pain. These recommendations are intended to reduce downstream harms and costs: for example, a spurious finding on MRI could lead to unnecessary surgery; use of opioids could lead to physical dependence and opioid use disorder; bed rest and avoidance of physical activity could increase the risk of long-term disability.

Can guideline-discordant care for patients with acute low back pain increase the risk of progression to chronic low back pain? In an inception cohort study published in JAMA Network Open, researchers enrolled 5233 adults with acute low back pain from 77 U.S. primary care practices, assessed their baseline risk of transition to chronic pain using the Subgroups for Targeted Treatment (STarT) Back prognostic tool, and followed them for 6 months. 32% of participants met clinical criteria for chronic low back pain at the study's end. Characteristics associated with transition to chronic pain included obesity (adjusted odds ratio, 1.52), tobacco use (aOR, 1.56), severe baseline disability (aOR, 1.82), and a depression and/or anxiety diagnosis (aOR, 1.66). Researchers also examined associations between chronic low back pain and inappropriate care processes within 21 days of the initial visit: 1) any opioid prescriptions, or benzodiazepines or systemic steroids prescribed without an NSAID or skeletal muscle relaxant; 2) diagnostic imaging; 3) medical subspecialty referral for back pain. Compared to the 52% of participants who received none of these, patients with 1, 2, or 3 inappropriate care processes were 1.39, 1.88, and 2.16 times more likely to develop chronic low back pain after controlling for clinical characteristics.

Although adherence to Choosing Wisely recommendations was associated with a lower risk of patients developing chronic low back pain in this study, it is disappointing that almost half of them received at least some inappropriate care. Is care for back pain an outlier, or does it reflect national trends? A recent cross-sectional study examined the use of 32 low-value health services in Medicare fee-for-service beneficiaries. The study found modest progress from 2014 to 2018 in the percentage of persons receiving any low-value service (declined from 36.3% to 33.6%), number of low-value services per 1000 persons (declined from 678 to 633), and spending per 1000 persons on low-value care (declined from $52,766 to $46,922). Three services comprised about two-thirds of low-value care: preoperative laboratory testing, opioids for back pain, and antibiotics for upper respiratory infections. While preoperative testing decreased during the study period, opioid and antibiotic prescribing both increased.

Since the campaign's inception in 2012, Choosing Wisely recommendations have been widely disseminated in AFP, FPM (formerly Family Practice Management), and other family medicine journals. The American Academy of Family Physicians periodically updates and adds new "don't do" recommendations, most recently in 2018. Other studies have recognized that clinicians in underserved or "safety net" practices are as likely to provide low-value care as clinicians in better resourced settings. A 2018 AFP editorial by Dr. Jennifer Middleton recognized that increasing awareness of best practices is necessary but not sufficient to drive implementation: "For meaningful change to occur, the workflows and systems we operate within must change so that new habits become routine." The Medicare study suggests that workflows and systems have not changed enough in the past decade to undo entrenched low-value practices.

Monday, March 1, 2021

Nutrition disparities during the COVID-19 pandemic

 - Jennifer Middleton, MD, MPH

A large, multi-year study of nutrition habits in France is yielding interesting findings during the COVID-19 pandemic. Behaviors related to nutrition are no exception to the deep-seated health inequities COVID-19 continues to expose.

The Nutri-Net Sante study began in 2009. Study researchers monitor participants using a sophisticated online survey:

[D]ietary intakes are assessed every 6 months as part of the usual cohort follow-up using three non-consecutive 24 [hour] dietary records randomly assigned over two weeks and including two weekdays and one weekend day. These web-based 24 [hour] dietary records have been validated against dietary records filled during an interview with a dietitian and against biomarkers.

In April 2020, during France's nationwide lockdown, the researchers collected data from participants regarding changes in lifestyle habits. While some participants increased their snacking frequency (an otherwise rarity in French culture) and decreased their physical activity, others instead increased their home cooking of nutritious meals and increased their physical activity. The less healthy behaviors correlated with lower socio-economic status (SES), while the more healthy behaviors correlated with higher SES.

Although these findings have yet to be formally peer-reviewed and published, they are consistent with similar studies across the globe (ItalyPolandChinaLatin America). The Centers for Disease Control and Prevention (CDC) recommends "good nutrition" to build resilience during the pandemic; they acknowledge, however, that achieving this aim is challenging for many by also listing resources regarding food insecurity. Google searches related to food insecurity ("food bank," "free food") have increased world-wide since March 2020. "The health disparities in nutrition and obesity correlate closely with the alarming racial and ethnic disparities related to Covid-19.

During the COVID-19 pandemic, it's more critical than ever that we systematically and universally screen our patients for food insecurity along with other social determinants of health. Several simple screening tools exist, including the AAFP's EveryONE Project's Social Needs Screening Tool. The EveryONE Project website also includes guidance for connecting patients with community resources. This 2018 AFP editorial on "Food Insecurity: How You Can Help Your Patients" also includes a comprehensive list of online tools and resources. 

Post-pandemic, we must support improvements in our social environment that will mitigate long-standing racial biases and provide equitable health for all; this equity cannot be achieved without access to affordable and high-quality nutrition for all persons. The COVID-19 pandemic is a powerful reminder that efforts to improve our patients' health and well-being will always be incomplete if we confine them to the interiors of hospitals, health centers, and physicians' offices.

Tuesday, February 23, 2021

Immunization and immunotherapy updates for family physicians

 - Kenny Lin, MD, MPH

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) 2021 Adult and Child/Adolescent Immunization Schedules included a number of key updates that are discussed in the February 15 issue of AFP. The schedules included information on the two messenger RNA vaccines against SARS-CoV-2 that have received Emergency Use Authorization from the U.S. Food and Drug Administration (FDA): the Pfizer-BioNTech vaccine for persons older than 16 years and the Moderna vaccine for persons older than 18 years. As Dr. Jennifer Middleton noted in a previous blog post, additional vaccines with different mechanisms may become available in the U.S. soon; data on the Janssen adenovirus vector vaccine will be reviewed at a meeting of the FDA's Vaccines and Related Biological Products Advisory Committee later this week.

The ACIP recommends shared decision-making (SDM) for the 13-valent pneumococcal conjugate vaccine (PCV13) in adults older than 65 years, meningococcal B vaccination for adolescents and young adults aged 16–23 years, hepatitis B vaccination for adults older than 60 years with diabetes mellitus, and human papillomavirus vaccination for adults aged 27–45 years. According to its website, "Generally, ACIP makes shared clinical decision-making recommendations when individuals may benefit from vaccination, but broad vaccination of people in that group is unlikely to have population-level impacts." In a study published in the Journal of General Internal Medicine, researchers surveyed 617 primary care physicians recruited from the American College of Physicians and the American Academy of Family Physicians about their knowledge, attitudes, and experience with SDM vaccine recommendations. Most participants agreed that SDM requires more time than typical vaccine recommendations, is facilitated by specific talking points, can create confusion for patients, and may be difficult to implement. Compared to family physicians, general internists were more likely to report not knowing how to implement SDM recommendations as intended by the ACIP.

The February 1 issue of AFP included an article on targeted cancer therapies by Drs. Claire Smith and Vinayak Prasad. Targeted therapies may be monoclonal antibodies, small molecule inhibitors, antibody-drug conjugates, and/or immunotherapy. Immune checkpoint inhibitors (ICIs) - monoclonal antibodies that block inhibitory regulatory proteins and lead to T-cell activation - have a wide range of toxic effects on various organ systems, with thyroiditis being the most common. Family physicians should be aware of these potential adverse effects and their initial management in patients being treated with ICIs.

Finally, the AFP article mentioned the increasing financial toxicity of targeted cancer therapy:

In 2020, the average out-of-pocket cost to a patient for a course of oral cancer therapy was estimated at $5,663. According to one large analysis, 20% of patients with cancer take less medication than prescribed, 19% partially fill oral cancer therapy prescriptions, and 24% avoid filling a prescription at all. Many patients in this study reported spending less money on food, leisure, and clothing. Approximately 2% of patients will declare bankruptcy during their treatment; those with advanced disease are more likely to declare bankruptcy. Bankruptcy during cancer treatment increases the risk of death.

In a recent commentary in JAMA Internal Medicine, Dr. Prasad argued that the problem of unaffordability is compounded by the FDA's lenient approval process for new cancer drugs and subsequent mandatory Medicare coverage for approved drugs without price negotiation. Only a fraction of cancer drugs approved in the U.S. (often based on studies with surrogate end points rather than evidence of benefits in survival or quality of life) are approved for broad coverage in England and Canada. Not only is the clinical effectiveness of many of these drugs uncertain, but their value (cost-effectiveness) is questionable as well.

Monday, February 15, 2021

New(old) treatments for COVID: inhaled budesonide & the -umabs

 - Jennifer Middleton, MD, MPH

Although the Biden administration appears to be on track to meet its goal of 100 million COVID vaccines given in its first 100 days, the United States (US) is still unlikely to get most adults fully vaccinated before early 2022. With nearly 97,000 persons a day diagnosed with COVID-19 in the US last week, the need for effective COVID-19 treatment measures isn't going away any time soon. Researchers have identified two classes of medications that may benefit patients with symptomatic COVID-19, both well-known medications already in use for other conditions.

A small trial in the United Kingdom (UK) randomized 146 persons with mild COVID-19 to receive either inhaled budesonide (Pulmicort) or "usual care;" as with many COVID studies, this study's results have been publicized prior to full peer review and publication. The researchers used a composite end point of urgent care visit, emergency department visit, or hospitalization and found a number needed to treat of 8 to prevent 1 of those events. The small size of this trial may make it tempting to dismiss its findings, but as inhaled budesonide is generally well-tolerated and is relatively inexpensive, it still may be reasonable to use. Several other larger trials are currently underway evaluating inhaled budesonide, including the PRINICIPLE trial in the UK. 

Persons with more severe COVID-19 may benefit from tocilizumab or sarilumab, interleukin-6 receptor antagonists currently used for persons with rheumatoid arthritis. Last week, the UK's National Health Service informed its physicians that a trial randomizing 800 participants in intensive care for COVID which compared these two medications to usual care found that "[h]ospital mortality was 28.0% (98/350) for tocilizumab, 22.2% (10/45) for sarilumab and 35.8% (142/397) for [the] control [group]." Smaller trials had been less promising for this class of medications, though these studies were conducted earlier in the pandemic:

More studies will be needed to clarify when, and in which patients, tocilizumab and sarilumab work best, and to untangle why their benefits cropped up clearly in some studies, but not others.... It’s also challenging to compare studies coming out now to earlier trials that were conducted when the virus was much less understood, treatments were doled out with less know-how and mortality rates were even higher.

It remains to be seen whether the US Food and Drug Administration (FDA) and/or the Centers for Disease Control and Prevention (CDC) will follow the UK's lead and formally recommend these treatments for COVID-19, though it's heartening that research efforts continue to identify ways to lessen its burden. The AFP By Topic on Coronavirus Disease 2019 (COVID-19) has a section on "Treatment" which includes this Rapid Evidence Review of Outpatient Management of COVID-19 if you'd like to read more. 


Monday, February 8, 2021

Are primary care physicians overdiagnosing cutaneous melanoma?

 - Kenny Lin, MD, MPH

In an editorial in the February 1 issue of AFP, Dr. Jenny Doust and colleagues wrote about the problem of widening disease definitions, a common phenomenon in which the definition of a disease is "broadened over time to include milder and earlier cases," leading to harm "by exposing more patients to the adverse effects of treatments, triggering investigation and prescribing cascades, increasing anxiety, and placing a financial burden on patients and the wider society." Expanding the number of patients diagnosed with disease increases the burden on primary care physicians called on to manage these additional cases, even when it is uncertain if earlier interventions prevent morbidity or mortality. Illustrative examples of wider disease definitions include hypertension, polycystic ovary syndrome, breast cancer, and autism. What can family physicians do about it? The authors responded:

Recognizing the problem is the first step in tackling it. In particular, family physicians should not blindly accept new definitions and testing guidelines without an adequate understanding of the harms and benefits of the changes and the implications for our patients and wider practice.

Along similar lines, a recent analysis in the New England Journal of Medicine by Dr. H. Gilbert Welch and colleagues examined the drivers of the dramatically increased incidence of cutaneous melanoma in the U.S., which today is 6 times as high as in 1975 despite essentially no change in melanoma mortality. They pointed out that exposure to ultraviolent (UV) radiation (including tanning bed use) cannot account for more than a small portion of this increase. Instead, they argued that increased diagnostic scrutiny - "the combined effect of more screening skin examinations, falling clinical thresholds to biopsy pigmented lesions, and falling pathological thresholds to label the morphologic changes as cancer" - is most likely to be responsible for the epidemic of new diagnoses. Not only has the annual percentage of fee-for-service Medicare beneficiaries undergoing skin biopsies nearly doubled since 2004, but pathologists frequently upgraded skin biopsy specimens obtained in the late 1980s from benign to malignant when evaluating the same specimen two decades later. Primary care physicians contribute to widening the definition of cutaneous melanoma by performing or referring for biopsy small (<6 mm), incidentally detected skin lesions and screening patients with dermoscopy, which identifies more melanomas than visual inspection alone but is not well studied in primary care settings.

The U.S. Preventive Services Task Force (USPSTF) has concluded that current evidence is insufficient to assess the balance of benefits and harms of skin cancer screening in asymptomatic adults. Nonetheless, more than half of family physicians and general internists in a 2011 survey reported performing full-body skin examinations for skin cancer screening. In a 2020 AFP editorial, Drs. Michael Pignone and Adewole Adamson (Dr. Adamson also co-authored the NEJM analysis) observed that "compared with usual care, potential effects of screening on morbidity and mortality from keratinocyte carcinoma are at most small, and screening cannot be justified based on the impact on keratinocyte carcinoma alone." Dr. Welch and colleagues went one step further, arguing that the established harms of skin cancer screening already outweigh any potential benefits:

The increase in melanoma diagnoses by a factor of 6, with at least an order of magnitude more persons undergoing a biopsy and no apparent effect on mortality, is more than enough to recommend against population-wide screening. ... It [screening] has been effectively promoted under the guise of public health, with the combination of frightening messages about skin cancer and the premise that screening can only help. However, medical care should be driven by patient needs, not system needs. Now is not the time to add more anxiety and expense to an already anxious and expensive world.

Not surprisingly, dermatologists have a more positive view of skin cancer screening, as reported in a news story about the analysis by Dr. Welch and colleagues that quoted the president of the American Academy of Dermatology as stating that "an aggressive approach to prevention and treatment is entirely appropriate for a disease that kills 20 Americans each day." Of course, no one is urging clinicians to stop counseling patients on minimizing their exposure to UV radiation; indeed, the USPSTF recommends behavioral counseling to prevent skin cancer, particularly for children, their parents, and young adults. But screening for skin cancer, which has effectively widened the definition of cutaneous melanoma and driven widespread overdiagnosis - is a different story. To give Dr. Doust and colleagues the last word: "We [primary care physicians] are not here to passively enact specialist recommendations. Instead, we need to more assertively act as advocates for our patients and our communities."

Monday, February 1, 2021

COVID vaccine update: new data & new vaccines

 - Jennifer Middleton, MD, MPH

As challenges with distributing COVID-19 vaccines continue, additional data is emerging regarding the two mRNA vaccines already being given in the United States (US) along with Johnson & Johnson's Janssen vaccine and the Novavax vaccine. The Janssen and Novavax vaccines are likely to soon apply for Emergency Use Authorization.

Preliminary data out of Israel suggests that the Pfizer/BioNTech vaccine is even more effective than phase 3 trials in the US suggested. The Israeli Health Ministry announced last week "that of 428,000 Israelis who had received their second doses, only 63, or 0.014 percent, had contracted the virus." It's important to note that this data hasn't yet been subject to peer review or published, though the health fund gathering the data reportedly plans to do so very soon.

Johnson & Johnson also shared preliminary data from its Janssen vaccine international phase 3 trial last week. The Janssen vaccine uses an adenovirus vector to deliver the SARS-CoV-2 spike protein. They enrolled over 43,000 participants from the US, Latin America, and South Africa and found that:

Among all participants from different geographies and including those infected with an emerging viral variant, Janssen’s COVID-19 vaccine candidate was 66% effective overall in preventing moderate to severe COVID-19, 28 days after vaccination. The onset of protection was observed as early as day 14. 

Although these numbers are not as impressive as the Pfizer/BioNTech and NIH/Moderna vaccines, they still represent acceptable efficacy. Perhaps more importantly, the vaccine demonstrated "complete protection against COVID-related hospitalization and death," with none of the vaccinated participants experiencing hospitalization or death 28 days or more after vaccination. With the added bonuses of only requiring one vaccination and much simpler storage requirements (regular refrigeration), the Janssen vaccine may be an important addition to the COVID-19 pandemic arsenal. 

Lastly, the Novavax vaccine (NVX-CoV2373), which works via engineered spike proteins, is showing reasonable efficacy in trials in the United Kingdom (UK). Over 15,000 participants received the 2 doses of the Novavax vaccine in the UK:

The first interim analysis is based on 62 cases, of which 56 cases of COVID-19 were observed in the placebo group versus 6 cases observed in the NVX-CoV2373 group, resulting in a point estimate of vaccine efficacy of 89.3% (95% CI: 75.2 – 95.4). Of the 62 cases, 61 were mild or moderate, and 1 was severe (in placebo group).

"The newer, more contagious variant first identified in Britain was found to have caused about 50 percent of the cases in the trial, Novavax said.Phase 2b trials in South Africa have been less impressive, with only 60% efficacy (though with a very wide 95% confidence interval of 19.9-80.1), likely due to the South Africa SARA-CoV-2 variant. Novavax is already at work on another vaccine targeting this variant. Similar to the Janssen vaccine, the Novavax vaccine can be stored in a regular refrigerator

Assuming supply and distribution challenges are eventually overcome, vaccine hesitancy may pose another threat to decreasing SARS-CoV-2 transmission, which is critical to slowing the development of additional COVID variants. The Centers for Disease Control and Prevention (CDC) has resources and talking points to support clinicians with these conversations, and the AFP By Topic on Coronavirus Disease 2019 (COVID-19) also includes this article on "Helping Patients Make Healthy Decisions on COVID-19."

Tuesday, January 26, 2021

Aligning unhealthy drug use guidelines with evidence-based medicine

 - Kenny Lin, MD, MPH

According to a health advisory from the Centers for Disease Control and Prevention, drug overdose deaths increased substantially during the first few months of the COVID-19 pandemic, rising by a record 2,146 and 3,388 deaths from March to April and April to May 2020, respectively. Overall, "approximately 81,230 drug overdose deaths occurred in the United States in the 12 months ending in May 2020," with synthetic opioids, particularly illicit fentanyl, driving the increases. In response to this acceleration, last year the U.S. Preventive Task Force (USPSTF) for the first time recommended routine screening for unhealthy drug use in adults age 18 years and older, reasoning that identifying persons who are using illicit opioids, stimulants, cannabis, and other drugs would facilitate appropriate treatment. However, the American Academy of Family Physicians (AAFP), after reviewing the USPSTF's summary of the underlying evidence, determined that it did not support this sweeping recommendation. Instead, the AAFP issued an insufficient evidence statement on screening for all drugs except for opioid use disorder (OUD), and advised that clinicians screen adults selectively for OUD "after weighing the benefits and harms of screening and treatment."

In an editorial in the January 15th issue of AFP, Drs. Sarah Coles and Alexis Vosooney, members of the AAFP's Commission on the Health of the Public and Science (Dr. Coles is the current Chair of the Commission and an AFP contributing editor) explained their reasoning for disagreeing with the USPSTF. They noted that the originally commissioned USPSTF evidence report found that "for screen-identified populations, psychosocial interventions and pharmacotherapy do not improve drug use or the consequences." Although the USPSTF then requested a second report that found some effective interventions to reduce unhealthy drug use in treatment-seeking populations,

The AAFP believes that it was inappropriate to rely on this indirect evidence and to generalize the benefits of OUD treatment to screening and treatment of other substance use disorders [SUDs]. Readiness for treatment and availability of effective treatment modalities are key in the successful treatment of SUDs. These data prompted the AAFP to issue an insufficient evidence grade for screening for unhealthy drug use in adolescents and adults, except for OUD.

In an independent commentary that accompanied the publication of the USPSTF recommendation statement in JAMA, Dr. Richard Saltz made similar points in calling screening for unhealthy drug use "neither an unreasonable idea nor an evidence-based practice." Regarding the USPSTF's reliance on studies demonstrating benefits in treatment-seeking populations, he wrote:

Considering this latter set of studies that included patients seeking treatment for drug use is akin to considering studies of chemotherapy for patients seeking care for breast cancer or thrombolysis for symptomatic myocardial infarction as relevant to questions of cancer and cardiovascular disease screening efficacy; efficacious treatment is necessary but not sufficient for making a case for screening. ... Many patients identified with drug use by screening will not have any intention of changing their use of drugs and are not ready to begin treatment, whereas a patient seeking treatment is more ready for change and willing to begin treatment (the success of which relies on readiness and adherence).

Further, Dr. Saltz observed, "the applicability of both [USPSTF] reviews to primary care in the US ... may be limited because many studies were conducted in settings outside primary care; the good-quality studies in primary care settings were null." He also expressed concern that universal screening for unhealthy drug use in pregnant persons and documentation of such use, as the USPSTF advised, could cause considerable harm since nearly half of states consider drug use in pregnancy to be child abuse; in contrast, the only two studies of psychosocial counseling for unhealthy drug use in pregnancy found no benefits.

Lack of access to medication-assisted treatment with buprenorphine remains a significant problem for patients with OUD who desire it; a Graham Center One-Pager found that only 11% of psychiatrists and 2.4% of family physicians prescribed buprenorphine to Medicare beneficiaries between 2013 and 2016. In order to encourage more clinicians to treat OUD with evidence-based medications, the U.S. Department of Health and Human Services (HHS) recently announced that it would allow all outpatient physicians registered with the U.S. Drug Enforcement Administration, rather than only those with a Drug Addiction Treatment Act of 2000 or "X" waiver, to prescribe buprenorphine to up to 30 patients at one time. Unfortunately, the Biden administration is unlikely to implement the new guidelines due to concerns that HHS does not have the legal authority to override the act of Congress that established the "X" waiver process in the first place. For many communities devastated by the opioid overdose epidemic during the COVID-19 pandemic, the lack of accessible and affordable treatment for OUD may continue to be a barrier to care.

Monday, January 18, 2021

Do behavior therapy apps help people quit smoking?

 - Jennifer Middleton, MD, MPH

A common New Year's resolution is tobacco cessation, but for many patients, 2021 will be far from the first time they've tried to quit. Enter a new smartphone app, iCanQuit, which showed promising results in a recent study. Although there are some methodological concerns with the study's outcomes, this app may still be worth discussing with patients eager to improve their chances of finally quitting tobacco.

The researchers conducted a randomized, double-blind clinical trial comparing iCanQuit to the National Cancer Institute (NCI) QuitGuide app. The researchers recruited participants with online (primarily Facebook) advertisements; the mean age of participants was 38.2 years, and most (83%) had smoked for over 10 years. 70.4% of identified as female, and 35.9% identified as a member of a racial/ethnic minority group. Since all participants were enrolled and followed online only, the researchers took extra measures to ensure that responses were legitimate by requiring CAPTCHA authentication, monitoring IP addresses, and monitoring the time participants spent completing their online surveys. They enrolled 2415 participants who reported active tobacco smoking, provided the apps, and followed them for 12 months. 

Acceptance and commitment therapy (ACT), the theoretical underpinning for iCanQuit, emphasizes "acceptance of smoking triggers," while the NCI QuitGuide app emphasizes "avoidance of smoking triggers." 87% of participants stuck with the study for the entire 12 months; after that time, participants in the iCanQuit group were more likely to report having been smoke-free for 30 days prior (odds ratio 1.49; 95% confidence interval 1.22-1.83). There has been significant debate regarding the need for more objective measures (such as saliva or urine cotinine measurements) to validate self-reported cessation, but one of this study's shortcomings may be the impossibility of verifying these online participants' reports of smoking cessation. One argument supporting these participants' veracity, though, is their reported success rates; among all participants, 24.6% achieved 30-day cessation by the 12 month mark, while only 10.6% achieved "prolonged abstinence" (>30 day cessation). These rates are consistent with the success rates reported for several other tobacco cessation interventions

The use of apps to facilitate tobacco cessation is not new, but the evidence for their efficacy has room for improvement. A 2019 Cochrane review on mobile tobacco cessation programs found only low quality evidence for smartphone apps, though it found text-based smoking cessation programs to have modest efficacy. A 2020 systematic review that focused on smartphone apps found that:

The majority of studies that use tobacco cessation apps as an intervention delivery modality are mostly at the pilot/feasibility stage. The growing field has resulted in studies that varied in methodologies, study design, and inclusion criteria. More consistency in intervention components and larger randomized controlled trials are needed for tobacco cessation smartphone apps.

Tobacco smoking remains the "leading cause of preventable disease and death in the United States," and working with our patients to empower them to quit can have a tremendous impact on their health. Apps such as iCanQuit and the NCI QuitGuide may be another tool to share with patients. Check out the AFP By Topic on Tobacco Abuse and Dependence, which includes evidence-based overviews of several other cessation supports, if you'd like to read more. 

Sunday, January 10, 2021

Gender equity gaps persist in family medicine

 - Kenny Lin, MD, MPH

In a Graham Center Policy One-Pager in the January 1 issue of AFP, Dr. Yalda Jabbarpour and Elizabeth Wilkinson examined the growing role of women in family medicine. Compared to 2010, when 34% of practicing family physicians in the American Medical Association Physician Masterfile were identified as women, the share of women rose to 42% in 2020, mirroring increases in the share of female physicians in primary care and all medical specialties during the past decade. Another recent analysis by Dr. Jabbarpour and others found a statistically significant increase in female first and last authorship of research articles published in 3 family medicine journals (Family Medicine, Journal of the American Board of Family Medicine, and Annals of Family Medicine) between 2008 and 2017. However, they noted that women represented less than 40% of the combined editorial boards of these journals, which did not change significantly during this time.

A Graham Center study utilizing 2017 and 2018 certification survey data from the American Board of Family Medicine found that women self-reported working an average of 49 total hours and 34 direct patient care hours per week compared to 54 and 39 hours, respectively, self-reported by men. In an accompanying commentary on this "gender penalty," Dr. Kathryn Hart (an academic family physician colleague of mine) observed:

Traditional gender roles are still very much at play. The “invisible work” of raising children often falls on mothers, regardless of employment status. This begins with breastfeeding (and the natural carry-over to the intensive caregiving responsibilities of infancy) and evolves into scheduling doctor's appointments, completing school forms, coordinating activities, and arranging childcare, among thousands of other small tasks that cumulatively take up hours over the course of the week.

The work disparities that affect female-male dual professional couples have widened over the past year. The widespread transition to virtual learning from home during the COVID-19 pandemic has substantially increased the burdens of unpaid work (domestic chores and family care) that employed women perform relative to employed men worldwide.

Whether the physician gender pay gap can be attributed solely to female physicians working fewer hours than men was the subject of a recent analysis of data from more than 24 million primary care office visits in 2017. Despite spending 2.6% more observed time in visits overall than male primary care physicians, female primary care physicians conducted 10.8% fewer total visits and consequently generated 10.9% less revenue. Female physicians spent 15.7% more time (2.4 minutes) with each patient than male physicians did, but generated no more revenue per visit. In addition to the many other good reasons to retire the antiquated fee-for-service payment system in primary care, this study suggested that it remains an inherent obstacle to pay equity between male and female physicians.

Monday, January 4, 2021

Introducing Dr. Renee Crichlow, AFP's Medical Editor for Diversity, Equity, and Inclusion

 - Jennifer Middleton, MD, MPH

In AFP's first editorial of 2021, "Systemic Racism and Health Disparities: A Statement from Editors of Family Medicine Journals," the editors of several Family Medicine journals "commit to actively examine the effects of racism on society and health and to take action to eliminate structural racism in our editorial processes." AFP committed last year to "recruit editors and editorial board members from groups underrepresented in medicine," and please join us in welcoming AFP's new medical editor for Diversity, Equity, and Inclusion, Renee Crichlow, MD, FAAFP. Dr. Crichlow is the Director of Advocacy and Policy at the University of Minnesota School of Medicine where she holds the Mac Baird Endowed Chair in Family Medicine Advocacy and Policy. Here are some highlights from a recent interview!

1. Tell us a little about yourself and your background.

I grew up in the South, and I have lived on both coasts, the Mountain West, and the Midwest. I have seen communities and medical practice in many regions and I have come to realize that, first and foremost, I am a Family Medicine zealot. This country needs us. I have always practiced and taught full-spectrum care with Obstetrics having lived and worked in both rural and urban communities. I have known these communities as both a physician and a patient. When I gave birth to my son, I lived in a town of fewer than three thousand people and the hospital two blocks from our house had stopped doing deliveries a few years prior. I know personally what it means for a patient to drive sixty miles from home to have a safe delivery. I have done two fellowships, one at UCSF/UCDavis as a clinical research, faculty development fellow and the second through a Department of Health and Human Services Primary Care Health Policy Fellowship. As such, I believe that Family Medicine physicians working with their patients in the exam room is necessary for the health of our patients, and Family Medicine physicians working with health systems, stakeholders, and policymakers to develop evidence-based decisions is necessary for the health of our communities and the survival of our specialty.

2. What are your goals for this new position at AFP?

We aim to provide systemic support, including advising for authors and editors as we all engage with becoming an anti-racist, inclusive, and equitable specialty in our efforts to both care for and represent all of the communities we serve.

3. What advice might you share regarding specific actions each of us can take toward a more inclusive and equitable world?

First, do no harm, primum non nocere.

Second, ask yourself if you really care about anti-racism and inclusion and their impact on health equity. You may be comfortable with the current health inequities and prefer to attribute their causes to poor personal and individual choices. If not, you may care that the structures of current systems facilitate and perpetuate the status quo, a status quo that is inequitable to many of the patients and communities we serve. Third, consider this work more with a mindset of transformation than a change. The idea of change can seem very polarizing, e.g. light switch turns on the light, the light switch shuts off the light. That is categorical change and that type of change is not possible when dealing with anti-racism, inclusion, and equity, because the work that needs to be done has no predictable path; at its best, this process is co-creative where, working together, we all engage in transforming our systems to facilitate more inclusive and equitable outcomes.

4. Is there anything else you'd like AFP readers to know about you?

We are Family Medicine physicians. We deal with growth and change every day. I believe we are our best when we are helping each other grow through the challenges and choices of life, and these are indeed challenging times. Right now, our whole society is undergoing growth and change at an unprecedented pace. As with all growth, there will be some discomfort. We are Family Medicine physicians, trained to care for the full life cycle of our patients. We are not afraid of growth. I understand that, often, what people really fear is not change but loss. We understand that people may be concerned with changes where they will lose systems and structures that were familiar and dependable. But we know that the current systems and structures are inequitable for many and expensive and inefficient for all. I believe that addressing healthcare information and education using the lens of health equity and inclusion can contribute to systemic transformation. It provides a path for functional excellence, evidence-based structural revision, and systemic transformation.

Caring for all of our patients in an equitable and effective health system is a reasonable goal. We are Family Medicine. We can do this.