Thursday, December 8, 2016

Signed Out Of Prison But Not Signed Up For Insurance, Inmates Fall Prey To Ills

Jay Hancock, Kaiser Health News and Beth Schwartzapfel, The Marshall Project

INDIANAPOLIS — Before he went to prison, Ernest killed his 2-year-old daughter in the grip of a psychotic delusion. When the Indiana Department of Correction released him in 2015, he was terrified something awful might happen again.

He had to see a doctor. He had only a month’s worth of pills to control his delusions and mania. He was desperate for insurance coverage.

But the state failed to enroll him in Medicaid, although under the Affordable Care Act Indiana had expanded the health insurance program, making most ex-inmates eligible. Left to navigate an unwieldy bureaucracy on his own, he came within days of running out of the pills that ground him in reality.

“I have a serious mental disorder, which is what caused me to commit my crime in the first place,” said Ernest, who asked reporters to use only his middle name to protect his privacy. “Somebody should have been pretty concerned.”

The health law was expected to connect Ernest and almost all other ex-prisoners for the first time to Medicaid coverage for the poor, cutting expensive visits to the emergency room, improving their prospects of rejoining society and reducing the risk of spreading communicable diseases that flourish in prisons.

But Ernest’s experience is repeated millions of times across the country, an examination by The Marshall Project and Kaiser Health News shows.

Most of the state prison systems in the 31 states that expanded Medicaid have either not created large-scale enrollment programs or operate spotty programs that leave large numbers of exiting inmates — many of whom are chronically ill — without insurance.

Local jails processing millions of prisoners a year, many severely mentally ill, are doing an even poorer job of getting health coverage for ex-inmates, by many accounts. Jail enrollment is especially challenging because the average stay is less than a month and prisoners are often released unexpectedly.

Ex-inmates with the worst chances of getting insurance and care are in 19 states that did not expand Medicaid. Only a small number qualify for coverage. Enrollment efforts by prisons and jails are almost nonexistent.

Nationwide, 16 state prison systems have no formal procedure to enroll prisoners in Medicaid as they reenter the community, according to a survey by The Marshall Project. Nine states have only small programs in select facilities or for limited groups of prisoners, like those with disabilities. These 25 states collectively release some 375,000 inmates each year.

Failure to link emerging inmates to health insurance is a missed opportunity to improve health and save money by cutting recidivism as well as visits to the hospital emergency room, advocates say. Studies have showed Medicaid access in Florida and Washington cut return trips to jail among the mentally ill by 16 percent.

“I hate to say it — it’s a captive audience. You have somebody there! You know they’re going to be released in a few weeks,” said Monica McCurdy, who as head of a clinic for Project HOME in Philadelphia constantly sees homeless, recently released prisoners without Medicaid coverage. “Why not do the handoff that’s needed to prevent this person winding up in the ER? It defies common sense.”

Health Risks Soar After Prison Release

Before the Affordable Care Act, state Medicaid programs covered mainly children, pregnant women and disabled adults, which included only a small number of ex-offenders. That’s still generally the case in the 19 states that didn’t expand Medicaid.

President-elect Donald Trump has vowed to repeal the health act and replace it with something else, leaving the law’s Medicaid expansion and eligibility for ex-prisoners in doubt. Rep. Tom Price, Trump’s pick to head the Departmetn of Health and Human Services — which oversees Medicaid — has been one of Obamacare’s most vociferous critics in Congress.

But some analysts expect parts of the law to survive, perhaps including Medicaid expansion managed more directly by states than by Washington.

Even some Republicans have supported the idea, suggesting that revoking Medicaid coverage from millions of new recipients would be difficult. Republican Gov. John Kasich expanded Medicaid in Ohio in part for ex-inmates, he has said, “to get them their medication so they could lead a decent life.”

Other parts of the health law received more attention, but advocates saw giving Medicaid coverage to ex-inmates as one of its most transformative aspects. Illness for illness, inmates are the sickest people in the country.

They have far higher rates of HIV, hepatitis and tuberculosis than the general population. They’re also more likely to have high blood pressure, diabetes and asthma. More than half are mentally ill, according to the Bureau of Justice Statistics, with up to a quarter meeting criteria for psychosis. Between half and three-quarters have an addiction problem.

Prisons and jails have their own doctors, but their responsibility to provide care stops upon an inmate’s departure. Inmates generally aren’t eligible for Medicaid while imprisoned.

No time is more critical than the days immediately after release. One study showed that in the first two weeks, ex-prisoners die at a dozen times the rate of the general population. Heart disease, drug overdose, homicide and suicide are the main causes.

But even in states that expanded Medicaid, the most vulnerable and sometimes dangerous ex-inmates are often left on their own.

Ernest went to prison for shooting and killing his daughter amid a psychotic religious delusion. Re-enacting the biblical story of the sacrifice of Isaac, he thought God would intervene to save the girl. News reports from the time say police found him naked, carrying the child’s lifeless body through the streets of an Indianapolis suburb.

Indiana expanded Medicaid under the health law in February 2015 and set up a system to enroll all eligible prisoners upon release. Yet when Ernest got out in August 2015, he was not enrolled in Medicaid, let alone connected to doctors.

Prison officials say they applied for Medicaid on Ernest’s behalf, but Medicaid records show he applied when he got home. It’s not clear where the system failed.

“It is important that the offenders have some accountability in the process,” said Douglas Garrison, a spokesperson for the Indiana Department of Correction. “The IDOC has worked diligently to ensure released offenders are receiving coverage.”

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled.

“Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Failure to sign up ex-inmates for health care is a common occurrence in states that expanded Medicaid under the health law, even in places such as Indiana where agencies have provided enrollment assistance.

No Enrollment For Thousands Of Chronically Ill

Two-thirds of the 9,000 chronically ill prisoners released each year by Philadelphia’s jails aren’t getting enrolled as they leave, said Bruce Herdman, medical director for the jails. The city lacks even the $2 million necessary to supply a month’s worth of medication for released inmates with prescriptions, he said.

“They give you like two weeks’ supply of medication,” said Ricky Platt, 49, who left the Philadelphia jail in 2015, quickly ran out of Zoloft antidepressants and became homeless. “They don’t give you any resource of where to go or get a doctor and get your prescription filled or anything.”

Emergency doctors at Thomas Jefferson University Hospital in Philadelphia often see released inmates with kidney failure who are at risk of dying if they don’t receive dialysis almost immediately, said Dr. Priya Mammen, one of the hospital’s emergency physicians.

“We’re kind of the go-to spot for many people, but particularly for people who have been released from prison,” she said. “Either in the first week we see them or when their prescriptions run out.”

Kara Salim, 26, got out of the Marion County, Indiana, jail in 2015 with a history of domestic-violence charges, bipolar disorder and alcoholism — and without Medicaid coverage. As a result, she couldn’t afford the fees for court-ordered therapy.

Without therapy she wasn’t allowed to see a psychiatrist for her medications. Without medication she spiraled downward, eventually threatening suicide at a court hearing. When court officers tried to bring her to a psychiatric hospital, she erupted, kicking and scratching them and landing back in jail, with new felony charges: battery against a public safety officer.

“I wish I could tell you she’s the exception,” said Sarah Barham, an addiction counselor with Centerstone, an Indiana nonprofit.

Medicaid enrollment requires resources that many prison systems and local jails — often overcrowded and operating in crisis mode for years — lack or have been reluctant to commit.

“Most of the county sheriffs don’t have the proper staff they need to even run the jails,” said Bill Wilson of the Indiana Sheriffs’ Association. Many jails are making an effort, but in some places “pulling the resources out to enroll an inmate in Medicaid is not something the sheriff’s able to do.”

In Minnesota, only those eligible for special release planning programs are offered assistance in applying; as a result, fewer than 1,000 of the 6,800 prisoners the state released last year applied for Medicaid, according to corrections officials there. Minnesota is one of seven states — Alaska, Hawaii, Arizona, Montana, Louisiana and Illinois are the others — that expanded Medicaid but have not implemented a large-scale enrollment program.

In many states, even prerelease registration requires a follow-up visit to a local Medicaid or welfare office to “activate” the coverage on release. Obtaining a phone, paying for minutes and navigating bus lines to state offices can be daunting for newly released inmates who often struggle with basic needs such as food and shelter.

Indiana officials applied for Medicaid on behalf of more than 7,000 state prisoners from March through September — nearly 90 percent of those released. (Many of the others were released to other states or deported, officials said.) Yet only a little more than half called to activate their coverage when they got home, according to state data. The state said in recent weeks it eliminated the requirement to activate coverage with a call.

Released prisoners also often need to reestablish identification by applying for Social Security cards and birth certificates. That can take weeks or months. Sometimes there’s another step: enrolling in one of the private, managed care networks that many states hire to administer Medicaid benefits.

In the chaotic days and weeks after release, red tape can mean the difference between joining Medicaid or remaining cut off from community caregivers.

William Santee, 46, released from Pennsylvania state prison this year, has diabetes, high cholesterol and high blood pressure. He learned about Medicaid enrollment requirements and the need to visit a welfare office from workers at a homeless shelter.

The prison “didn’t tell me about where to go or anything like that,” he said. “They don’t consider that their responsibility.” Waiting in line and completing the welfare-office paperwork took five hours.

Getting The Details Right

Almost as critical as successful enrollment is choosing a Medicaid plan that covers medicines and services ex-inmates need. Jail and prison workers are rarely equipped to wade through such details.

“That’s a huge issue for us,” said Susan Jo Thomas of Covering Kids and Families, a nonprofit that helps enroll people in Medicaid in Indiana. “You finally get a person to the place where they are ready … to go into detox, but if they have aligned with an insurance company that doesn’t cover the medicine that program uses, then you have a problem.”

In some extreme cases bureaucratic rules clash, leaving ex-prisoners stranded between agencies. In Indiana and several other states, corrections departments consider prisoners in work release programs, who report to jobs during the day, to be free. That means they’re not eligible for care from the prison system.

Medicaid, on the other hand considers them still incarcerated. So they can’t enroll in community health coverage, either.

“We got all excited when Obamacare came out, because everybody’s going to be covered,” said Peggy Urtz, who runs an Iowa work release facility for women. Instead, she said, the women “are going to ERs when they’re ill and racking up medical bills. We have good providers, well experienced in working with women, and they can’t go to them because they don’t have insurance.”

A few states and localities reap praise for innovative and comprehensive attempts to enroll emerging prisoners in Medicaid.

Ohio recently finished phasing in Medicaid registration at all state prisons and is one of the few states giving inmates a managed-care insurance card as they leave, said John McCarthy, that state’s Medicaid director. Chicago’s huge Cook County jail puts prisoners on the Medicaid books as they enter, rather than before they leave, to sidestep the common problem in jails of unpredictable release dates.

More often the process looks like what was happening one recent Friday in Indiana’s Marion County jail, where Lt. Debbie Sullivan was trying to rouse sleepy women to sign up for health insurance.

The document she distributed was three pages long, authorizing a Medicaid application on inmates’ behalf. It asked for names, addresses, birth dates and Social Security numbers. The handwritten information would later be entered into computers — a recipe for transposed digits and misspelled names.

“The program remains a work in progress,” said Katie Carlson, a spokeswoman for the Marion County Sheriff’s Office, which runs the jail. “It has proven a daunting task to enroll, track and provide meaningful information on both Medicaid and health care.”

Experts say such sessions require a half hour or more to get the details right and answer questions about picking the right plan and following up with doctors and insurance officials after release.

Sullivan’s knowledge of the women’s next steps was minimal. In response to questions, she simply told them to contact their local social service office when they get out. She walked out of the block with about 30 signed applications. It was over in 15 minutes.

“Thank you ladies!” she called on her way out, as the heavy steel door slammed behind her.

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This post was originally published on Kaiser Health News (KHN), a national health policy news service and an editorially independent program of the Henry J. Kaiser Family Foundation. This article is published in partnership with The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system, NPR, and Side Effects Public Media, a news collaborative covering public health.

Thursday, December 1, 2016

The USPSTF weighs in on statins for primary CVD prevention

In other blog posts, I have discussed the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline, offered additional perspectives on its 7.5% 10-year CVD event risk threshold for starting a statin, and noted that existing cardiovascular risk calculators tend to overestimate risk by significant margins. The ACC/AHA guideline's expansion of the proportion of adults recommended for statin therapy has remained controversial. The American Academy of Family Physicians partially endorsed the guideline with qualifications (disclosure: I am a member of the AAFP Commission that made this recommendation), and a 2014 guideline from the U.S. Departments of Veterans Affairs and Defense recommended higher thresholds for considering (6%) or starting (12%) statins.

Last month, the U.S. Preventive Services Task Force weighed in with a new recommendation statement on the use of statins for primary prevention of cardiovascular events. The recommendations are similar to those from the ACC/AHA; the USPSTF recommends initiating low- to moderate-dose statins in adults aged 40 to 75 years with at least one CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater ("B" recommendation). They recommend shared decision making and selective statin prescribing for similar adults with a 7.5% to 10% CVD risk ("C" recommendation).

The USPSTF's higher risk thresholds for statin therapy may compensate for uncertainty regarding the accuracy of CVD risk calculators, and the "C" recommendation recognizes that in persons at lower risk, the benefits of statins are less likely to outweigh the harms, which include liver enzyme abnormalities and muscle toxicity and a small increased risk of new-onset type 2 diabetes.

Although a prior USPSTF statement had recommended screening for lipid disorders in adults as early as 20 years of age, a new systematic review found no direct evidence on the benefits and harms of screening for or treatment of dyslipidemia in adults aged 21 to 39 years. So when should family physicians check cholesterol levels in an asymptomatic adult, if statins don't become a treatment option until age 40? This is an area to exercise clinical judgment on an individual basis, keeping in mind that healthy lifestyle counseling is more likely to be beneficial in adults with CVD risk factors than in adults without known risks.

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This post first appeared on the AFP Community Blog.

Thursday, November 24, 2016

Give thanks for small primary care practices

When I was in high school, a national hardware retailer opened a new franchise down the street from the mom-and-pop hardware store that had served my neighborhood for many years. Since the new store had the advantage of larger volumes and lower costs, it seemed to be only a matter of time before it drove its smaller competitor out of business, the way that big bookstore chains and fast-food restaurants had already vanquished theirs.

But a funny thing happened on the way to the inevitable. By the time I left for college, the new hardware store had folded, and the mom-and-pop operation had moved into their former building. How did this small business manage to retain its customers and win new ones without prior loyalties? The answer was quality of service. I remember visiting both stores when a classmate and I were working on a physics project. At the mom-and-pop store, the owner himself happily held forth for several minutes on the advantages and disadvantages of various types of epoxy adhesive. At the national hardware chain, the staff consisted mostly of kids my age who didn't know much more about glue than I did.

Six years ago, an editorial authored by White House officials in the Annals of Internal Medicine blithely predicted that small primary care practices would eventually be absorbed by "vertically integrated organizations" as a result of health reforms. The editorial prompted the American Academy of Family Physicians to send the White House a letter defending the ability of solo and small group practices to provide high-quality primary care. Despite the migration of recent family medicine residency graduates into employed positions, researchers from the Robert Graham Center estimated that up to 45% of active primary care physicians in 2010 practiced at sites with five or fewer physicians.

The limited resources of small practices seem to put them at a disadvantage relative to integrated health systems and Accountable Care Organizations. Small practices have less capital to invest in acquiring and implementing technology such as patient portals, and fewer resources (dollars and personnel) to devote to quality improvement activities, such as reducing preventable hospital admission rates. Nonetheless, like the small hardware store of my youth, some small practices are not only surviving, but thriving in the new health care environment. Dr. Alex Krist and colleagues reported in the Annals of Family Medicine in 2014 that eight small primary care practices in northern Virginia used proactive implementation strategies to achieve patient use rates of an interactive preventive health record similar to those of large integrated systems such as Kaiser Permanente and Group Health Cooperative. An analysis of Medicare data published in Health Affairs found that among primary care practices with 19 or fewer physicians, a smaller practice size was associated with a lower rate of potentially preventable hospital admissions.

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement. For example, Dr. Jennifer Brull reported how her practice and four others in north-central Kansas succeeded in improving hypertension control rates in an article and video in Family Practice Management.

These examples illustrate that the demise of the small primary care practice has been greatly exaggerated. Whether small practices can continue to flourish in the era of health care consolidation and questionable quality metrics remains an open question, but I do know this: the small hardware store in my home town is still thriving, a quarter century later.

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This post first appeared on Common Sense Family Doctor on September 22, 2014. Happy Thanksgiving, everyone!

Friday, November 11, 2016

Repeal Obamacare; sustain the Affordable Care Act

On the Election Day that made Donald Trump the next President of the United States, I traveled to Lancaster, Pennsylvania to give a lecture. Long a conservative political stronghold, Lancaster County was dotted with "Make America Great Again" campaign signs, forecasting Trump's comfortable 47,000 vote margin there, which ended up being more than two-thirds of his 68,000 victory margin in Pennsylvania, one of the states that effectively decided the election. Ironically, Lancaster is where I trained to become a family physician from 2001 through 2004, and it is the place where I first recognized that the health care system our country had then was not up to the task of caring for all the people. Lancaster, which started me on my path toward advocating for reforms that ended up in the Affordable Care Act, voted overwhelmingly for a candidate who has promised to repeal it.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy has been a mess. The trillions of dollars in debt that the U.S. has run up over his term will hurt my generation and future generations, and if Republicans should be faulted for their fantasy that the federal budget can be balanced exclusively through spending cuts, Obama has sustained the Democratic fairy tale that raising taxes on "millionaires and billionaires" is all that is necessary to pay the skyrocketing bills. On multiple occasions during my time in government, the President had no qualms about squashing science and scientists for political convenience. And for all of his rhetorical gifts when preaching to the choir, he's been one of the least effective persuaders-in-chief to have held the office.

And so, naturally, I oppose Obamacare. I oppose a government takeover of health care that included morally repugnant death panels staffed by faceless bureaucrats who decide whose grandparents live or die and make it impossible for clinicians to provide compassionate end-of-life care. I oppose the provision in Obamacare that said that in order for some of the 50 million uninsured Americans to obtain health insurance, an equal or greater number must forfeit their existing plans or be laid off from their jobs. I oppose the discarding of personal responsibility for one's health in Obamacare. I oppose Obamacare's expansion of the nanny-state that regulates the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories, doesn't exist and never will.

Instead, the Affordable Care Act (which I support) is based on a similar politically conservative law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieved the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discouraged irresponsible health care "free riders" and provided support for people of modest means to purchase private health insurance in regulated open marketplaces. It told insurers that in exchange for millions of new customers, they could no longer discriminate against the old and sick. Finally, the ACA rewarded physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may not improve health.

The ACA has flaws. It didn't narrow the income disparity between different types of physicians or encourage more medical students to choose careers in primary care. It didn't prevent pharmaceutical companies from arbitrarily jacking up prices on old but essential drugs. Its provisions to discourage overuse of unnecessary medical services were limited and inadequate to the scope of the problem. But it's worth noting that all of these problems all predated the law. We don't have enough family physicians and other primary care clinicians, drugs in the U.S. cost more than anywhere else in the world, and overdiagnosis and overtreatment have been rampant for years. That the ACA took on these issues at all was a small victory.

It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the 2008 Republican Presidential nomination and then narrowly defeated Hillary Clinton, the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed 1994 reform plan that makes right-wing objections to the ACA look insignificant by comparison. Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? Perhaps. But it underlines the need for thoughtful Republicans to look past their leaders' overheated rhetoric about repealing Obamacare and focus on strengthening and sustaining the ACA, starting now.

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A slightly different version of this post first appeared on Common Sense Family Doctor on September 30, 2013.

Thursday, November 3, 2016

When treating addiction, the words we use matter

In a JAMA editorial last month, Director of National Drug Control Policy Michael Botticelli and former DHHS Assistant Secretary for Health Howard Koh wrote that it was time to change the language health professionals and researchers use to refer to patients who suffer from addictions. This isn't simply an exercise in political correctness. Stigmatizing terms that "describe [patients] solely through the lens of their addiction or their implied personal failings" have been shown to negatively influence mental health clinicians' attitudes: someone described as a "substance abuser" was considered less treatable and more likely to be blamed for his or her condition than a "person with a substance use disorder." Similarly, they recommended describing someone with a history of having abused substances as "in recovery" rather than "clean." Botticelli knows his subject perhaps better than any previous U.S. "drug czar" (another term he prefers to not use), being in recovery himself from alcoholism.

I've written before about the failure of our criminal approach to drug misuse and the problems that misuse of legal pain medications have created for patients who suffer from chronic pain. Abetted by pharmaceutical companies whose sales representatives convinced many doctors that opioids were safe and non-addictive, the medical profession handed out powerful drugs like OxyContin as freely as Halloween candy, with devastating consequences.

Those consequences were more devastating in some communities than others. For almost every imaginable medical condition, members of racial and ethnic minorities receive less care and have poorer health outcomes, and addiction is not an exception. An article titled "Deconstructing Addiction" in NYU Physician began by describing two men in their 20s who sought treatment for heroin addictions and severe mood swings. One was diagnosed with bipolar disorder and prescribed antipsychotic medications and supervised methadone treatment. The other received an antidepressant and buprenorphine. Why were their medical plans so different? The first man was "a Latino living in a poor section of Brooklyn," while the second was a "middle-class white man from suburban Queens." Helena Hansen, an NYU psychiatrist and medical anthropologist, has worked to unravel the complex web of social and political forces that created these care disparities:

Methadone, she learned, was initially presented to the public as a tool for lowering crime in black and Latino communities. Accordingly, methadone clinics were mostly located in those areas. ... By the start of the new millenium, media reports warned of an epidemic of OxyContin addiction sweeping suburban and rural America. Buprenorphine maintenance, Dr. Hansen found, was aimed expressly at this new, overwhelmingly white cohort of substance abusers. ... When buprenorphine came on the market, ads portrayed the typical user as a white, middle-class dad who'd become addicted to painkillers after a back injury and wanted to return to coaching the son's baseball team. Even now, many buprenorphine providers accept only private insurance or out-of-pocket payments - unlike methadone clinics, which rely mostly on Medicaid reimbursements.

Although this two-tiered approach to treatment was not intended to create inequality, Hansen emphasized, it rapidly became incorporated into the structure of medicine and perpetuated stereotypes about white versus nonwhite patients with substance use disorders:

For addicted people in private care, most of whom are white, therapy is designed to minimize stigma and get the patient back to work or college; buprenorphine is used as a means toward these ends. Addicted people in public care - which covers most poor and nonwhite patients - are administered methadone under stringent supervision, steered into perceiving themselves as permanently disabled, and prescribed psychotropic medications that may further compromise their health.

On a related note, I've given some serious thought recently to going through the certification process to prescribe buprenorphine. Few family physicians currently possess a Drug Abuse Treatment Act (DATA) waiver to do so, not because the process is particularly onerous (eight hours of mandated education, half live and half online), but because most feel poorly trained and equipped to manage the psychosocial needs of these patients. I can't get a psychiatrist to see my few patients with mental illness that I consider beyond my capabilities unless they can pay cash; my heart sinks when I ponder how to arrange necessary care and social services for patients with substance use disorders. Working for a health system connected to a tertiary medical center, living in a city where the doctor to population ratio is one of the highest in the country, I rarely view myself as the health care option of last resort for anyone. But the need for accessible addiction treatment is great, and it isn't being met.

Wednesday, October 26, 2016

Underperforming big ideas in diabetes and breast cancer

Management of type 2 diabetes and screening for breast cancer make up a large portion of most family physicians' practices, including my own. Care and prevention for these patients is based on straightforward underlying theories of disease causation and behavior. Patients with type 2 diabetes have high blood glucose levels; treatment involves normalizing blood glucose through lifestyle modification and medication. Small, nonpalpable breast cancers eventually become large, symptomatic tumors. Smaller tumors are more likely to be curable, so undergoing regular screening mammography is preferable to not doing so.

But what if these underlying theories are wrong?

In a recent editorial in JAMA, Drs. Michael Joyner, Nigel Paneth, and John Ioannidis explored how the "big idea" or narrative that investments in genetics and information technology will lead to a revolution in health care has captured a large share of biomedical research funding and journal publications. They then illustrated how this big idea has "underperformed," as central assumptions of precision/personalized medicine have not been borne out in studies and tens of billions of dollars invested into electronic health records since 2009 have not made patient care measurably better or patient data more accessible to researchers.

Is tight glycemic control for patients with type 2 diabetes mellitus an underperforming clinical big idea? In an analysis in Circulation: Cardiovascular Quality and Outcomes, Drs. Rene Rodriguez-Gutierrez and Victor Montori compared clinical policy statements and practice guidelines for patients with type 2 diabetes between 2006 and 2015 with evidence from randomized controlled trials. Despite little or no evidence that tight glycemic control (hemoglobin A1c less than 6.5 or 7.0%) improves microvascular or macrovascular outcomes compared to less strict hemoglobin A1c goals, the majority of guidelines continued to endorse tight control for one or both of those outcomes. (In contrast, American Family Physician editorials and articles have asserted that "Physicians should not let well-intentioned but misguided concern for glucose levels distract them from attending to other interventions that more profoundly affect mortality [in patients with type 2 diabetes]: smoking cessation, blood pressure control, metformin therapy, and lipid reduction.")

And do small breast tumors detected by mammograms become large, lethal ones? Sometimes, but not as often as most patients and physicians think, according to an observational study in the New England Journal of Medicine that concluded: "Women [with tumors detected on mammography] were more likely to have breast cancer that was overdiagnosed than to have earlier detection of a tumor that was destined to become large." This study also concluded that most of the reduction in breast cancer mortality over the past 40 years could be attributed to improved systemic therapy rather than earlier tumor detection. In an editorial on counseling women about breast cancer screening, Dr. Mark Ebell and I discussed the benefits and harms of mammography in younger women and noted that for every additional breast cancer death prevented by starting at age 40, two women will be overdiagnosed with (and overtreated for) breast tumors that never would have become clinically apparent.

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This post first appeared on the AFP Community Blog.