Another strike against annual pelvic exams?

- Jennifer Middleton, MD, MPH

Despite changes in cervical cancer screening guidelines and the lack of an evidence base to support it, many physicians are still recommending and performing annual pelvic exams. The May 15 issue of AFP reviews the new recommendation from the American College of Physicians (ACP) about annual pelvic exams; similar to many others in the last few years, the ACP finds only harms associated with screening pelvic examinations that are not associated with cervical cancer screening.

The ACP performed a systematic review that included both benefits and harms of annual pelvic exams. They found that pelvic exams did not help women to live longer or better; detection rates of both ovarian and cervical cancer were unchanged. Admittedly, the authors found no studies assessing rates of asymptomatic pelvic inflammatory disease or cancers other than ovarian or cervical, but they did find:

Many false-positive findings are associated with pelvic examination, with attendant psychological and physical harms, as well as harms associated with the examination itself. Harms of pelvic examination include unnecessary laparoscopies or laparotomies, fear, anxiety, embarrassment, pain, and discomfort. 

The AFP Community Blog has tackled this subject twice before; in 2013, Dr. Lin reviewed the lack of evidence to support the reasons clinicians give for continuing this practice, and in 2014, he discussed an earlier iteration of the ACP's recommendation and connected it to the Choosing Wisely recommendation against the annual physical exam. Despite ever-increasing objections and a lack of supporting evidence, subjecting women to annual pelvic exams - sometimes still accompanied by an annual pap test - remains a common practice. The American Congress of Obstetricians and Gynecologists (ACOG) continues to recommend annual pelvic exams for women aged 21 and up, though they acknowledge the lack of evidence to support this stance. It's not hard to find appeals from OB/GYNs to continue this practice, however; they argue that the annual gynecologic visit provides the benefit of reassurance to women when everything "looks normal" and the opportunity for physicians to uncover embarrassing complaints that might, otherwise, have gone unvoiced.

Doing less in health care is hard, and changing practice habits can be difficult, especially when specialty organizations disagree. Family physicians, historically, have depended on other specialist organizations to provide us with guidance about caring for patients with various conditions. Unfortunately, the narrowed patient populations that those specialists see in practice are often quite different than the broader, undifferentiated population seen by primary care physicians. Family physicians should not hesitate to follow population-based screening recommendations oriented to primary care that deviate from other specialty organizations who care for different subsets of patients.

The United States Preventive Service Task Force (USPSTF) is currently preparing to issue an recommendation regarding annual pelvic examination, so stay tuned; in the meantime, the AFP By Topic on Health Maintenance and Counseling contains several helpful resources.

Do medical scribes improve physician or patient experiences?

- Kenny Lin, MD, MPH

According to a national survey, a typical family physician spends nearly half of his or her working hours outside of the examination room doing follow-up care or documentation. I think most of my colleagues would agree that entering notes into the electronic health record is one of their least favorite parts of practicing medicine. After all, we went into medicine to care for patients, not to spend endless hours scrolling through screens full of check boxes to prove to payers that we are caring for patients. At the same time, patients may be unable to connect emotionally or convey subtle physical findings when their doctors spend so much of the visit looking at a computer screen.

One solution to the problems posed by electronic documentation requirements is for physicians to delegate the task to a medical scribe. As described in a recent article in Family Practice Management, this trained assistant (medical assistant, medical student, licensed practice nurse, or registered nurse) gathers initial data; documents the physician's examination, assessment, and plan; and provides patient education and implements the care plan while the physician moves on to the next patient. One of the authors reported that his increased efficiency and net revenue more than made up for cost of training and paying for an additional medical assistant functioning as a scribe. Further, the presence of the scribe seemed to have positive effects on the patients' experience:

We've also noted significant increases in our patient satisfaction scores as we've adopted this new model of care. One thing that surprised me was the relationships my patients developed with my MAs, sometimes telling my MAs things they won't tell me. Patients consider the MAs as additional advocates to whom they can go with problems or questions. I thought more patients would object to having another person in the exam room, but that has not been the case.

Beyond this suggestive anecdote, what is the evidence that medical scribes improve practice productivity, revenue, or the physician and patient experience? A systematic review on the use of medical scribes in the Journal of the American Board of Family Medicine found only five studies, none performed in primary care practices. In emergency department, cardiology, and urology settings, scribes appeared to improve clinician satisfaction, efficiency, revenue, and patient-clinician interactions, but did not improve patient satisfaction. Still, given the ever-increasing burden of documentation in primary care, the demand for medical scribes is likely to increase in the future.

Helping patients choose nutritious foods

- Jennifer Middleton, MD, MPH

Most of us spend little time in medical school and residency learning about nutrition; in 2010, only 25% of U.S. medical schools required any nutrition education. Few medical students value learning about nutrition and what interest does exist at the beginning of medical school tends to wane over time. The sum total of my education in nutrition, for example, consisted of telling patients to eat fewer calories if they wanted to lose weight. An article in the May 1 AFP, "Nutrition Myths and Health Dietary Advice in Clinical Practice," provides an evidence-based structure for providing more meaningful dietary counseling and dispels several common myths along the way.

Perhaps most significantly, they challenge the common dogma that 3500 calories equals 1 pound of body weight; they provide a link to the National Institutes of Health's (NIH) body weight simulator which provides more accurate estimates of expected weight loss based on diet and exercise changes. By entering in a patient's age, gender, current weight, weight loss goal, and willingness to exercise (with specific entries for several types of exercise), the patient's physician can provide more accurate counseling regarding how many calories to cut and how much exercise is needed to reach specific goals. This simulator might be a nice tool to use with patients in the office to concretely demonstrate how the size of their calorie reduction and/or exercise will influence their weight loss success. With all of these components, the NIH researchers wisely included a 2-minute video explaining optimal use of the simulator.

The article also discusses the evidence base against calcium and fiber supplements; multiple meta-analyses have failed to demonstrate any benefit in patient-oriented outcomes from using either. Patients should mostly consume whole foods and minimize ultraprocessed foods; the authors vindicate dietary fats while warning against excess refined sugar consumption. These recommendations, and especially the list of whole food alternatives in Table 1, provide concrete counseling points for family physicians. There's also an AFP By Topic on Nutrition which provides additional resources along with patient education materials.

All of our patients would benefit from eating more whole foods, but finding and cooking healthier foods may be challenging for patients who live in neighborhoods bereft of grocery stores and/or inundated with advertising for ultraprocessed foods. Providing guidance regarding good nutrition smartphone applications ("apps") might help patients make better choices. Apps that only provide calorie counts won't reinforce the importance of choosing fresh, whole foods, but other apps can help patients make better choices at the grocery store (Fooducate and Shopwell) and direct them to fresh, local foods (Lovacore is one example). EatingWell and How to Cook Everything can help patients prepare meals from whole foods who might not know how.

It's up to each of us to overcome the deficiency we likely had in our nutrition education to help our patients make good nutritional choices.

PSA screening by the numbers: no benefits, many harms

- Kenny Lin, MD, MPH

Previous studies found that two-thirds of men who receive prostate-specific antigen (PSA) screening for prostate cancer didn't have shared decision making with their physicians. If shared decision making occurred at all, patients were more likely to remember hearing about the advantages than the disadvantages of PSA screening, and many older men with a high probability of death within the next 9 years were screened nonetheless.

These findings, along with a Cochrane review and another systematic review (that I co-authored) which both found no pooled mortality benefits in several randomized controlled trials, led the U.S. Preventive Services Task Force to recommend against PSA-based screening for prostate cancer in 2012. Since then, the American Academy of Family Physicians and the American College of Preventive Medicine have added this service to their Choosing Wisely lists of tests and procedures that patients and physicians should question.

The Medicine By the Numbers published in the May 1st issue of American Family Physician clearly illustrates that the harms of PSA screening exceed the benefits. 1 in 5 men who received PSA screening ended up undergoing a biopsy for a false-positive test; 1 in 34 and 1 in 56 screened men, respectively, suffered erectile dysfunction or urinary incontinence as a result of prostate cancer treatment. In contrast, PSA screening prevented zero deaths from prostate cancer or all causes. In other words, no benefits.

This review begs the question of why clinicians should bother with shared decision making in most average-risk men, rather than simply telling them that this test is a bad deal.

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.