Low back pain is a distressing, and distressingly common, problem encountered in family medicine. Although this symptom is usually self-limited in otherwise healthy patients, there are few truly effective treatments other than time. Seeking faster relief, many patients visit chiropractors or osteopathic physicians who provide spinal manipulative therapy. Three pro/con editorials in the April 15th issue of AFP debate the effectiveness of spinal maniplation relative to other commonly used treatments for low back pain.
In the first editorial, Drs. James Arnold and Shannon Ehleringer point out that "in two large systematic reviews, manipulation decreased pain and improved range of motion in patients with chronic neck pain and in patients with acute and chronic back pain. Manipulation improved symptoms more effectively than placebo and was as effective as nonsteroidal anti-inflammatory drugs, home exercises, physical therapy, and back school." Dr. Melicien Tettambel concurs in the second editorial, arguing that since "it is unrealistic to expect any single treatment modality to be universally effective across all patients," manipulation has a useful role as an adjunct therapy.
On the other hand, Drs. Peter Cronholm and David Nicklin contend in a third editorial that much of the evidence supporting spinal manipulation for low back pain consists of low-quality studies that demonstrate statistical but not clinical benefit. Since the benefits of manipulation are comparable to watchful waiting, they argue that the latter option should generally be preferred:
Patients in pain are unhappy, and they want relief. The evidence shows that taking acetaminophen or a nonsteroidal anti-inflammatory drug and resting as needed is as effective as spinal manipulation. However, patients attribute pain resolution to active treatment. Although a course of spinal manipulation, or physical therapy, may keep the patient happy (and occupied) while his or her pain spontaneously resolves, the improvement in pain and function is not based on large, quality studies. Whether improved patient satisfaction with spinal manipulation versus watchful waiting is worth the cost of the therapy depends on who pays and how the paying party values satisfaction. As controlling costs becomes more important, incentives make watchful waiting with nonsteroidal anti-inflammatory drugs or acetaminophen the preferred approach.
What do you say when patients ask if seeing a specialist in spinal manipulation will relieve their low back pain?
Jumat, 20 April 2012
Senin, 09 April 2012
Counterintuitive findings on quality incentives and patient satisfaction
They've been repeated so often that many health care quality gurus take them for granted: 1) paying physicians for performance will improve quality of care; 2) increasing patient satisfaction will reduce care costs and improve outcomes.
Not necessarily, two recent studies suggest.
A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of AFP concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes Dr. Elizabeth Salisbury-Afshar, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from AFP readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.
In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:
Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.
Not necessarily, two recent studies suggest.
A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of AFP concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes Dr. Elizabeth Salisbury-Afshar, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from AFP readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.
In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:
Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.
Selasa, 27 Maret 2012
Patents versus patients? Revisiting the Journal Club on donepezil 23 mg
In the March 15, 2011 issue of AFP, Drs. Mark Graber, Robert Dachs, and Andrea Darby-Stewart analyzed an industry-funded trial that compared the effects of two daily doses of the Alzheimer's disease drug donepezil (Aricept): a new 23 mg version and the existing 10 mg version that would soon lose its patent protection. Despite the trial authors' finding that the higher dose of donepezil slightly improved cognitive outcomes, AFP Journal Club commentators determined that this difference was clinically unimportant, and was greatly outweighed by the higher frequency of adverse effects in patients using the higher dose:
First, the authors did four comparisons. Three were negative and only one was positive. And the one that was positive was only two points different on a 100-point scale. So, although this is statistically significant, it is clinically meaningless. There is no discernible benefit for the patient or caregivers. ... Also, the drop-out rate in this study was an astounding 30 percent in the higher-dose group and 18 percent in the lower-dose group.
Adverse effects of donepezil include bradycardia, falls, nausea, diarrhea, and anorexia. In fact, a recent study demonstrated that community-dwelling older persons with dementia who are taking currently available cholinesterase inhibitors have higher rates of hospitalization for syncope, bradycardia, pacemaker insertion, and hip fractures compared with similar patients with Alzheimer disease who are not taking these medications. So, the idea of increasing the dose to 23 mg, potentially resulting in more serious adverse events while achieving no clinical gain, is ill-conceived at best.
First, the authors did four comparisons. Three were negative and only one was positive. And the one that was positive was only two points different on a 100-point scale. So, although this is statistically significant, it is clinically meaningless. There is no discernible benefit for the patient or caregivers. ... Also, the drop-out rate in this study was an astounding 30 percent in the higher-dose group and 18 percent in the lower-dose group.
Adverse effects of donepezil include bradycardia, falls, nausea, diarrhea, and anorexia. In fact, a recent study demonstrated that community-dwelling older persons with dementia who are taking currently available cholinesterase inhibitors have higher rates of hospitalization for syncope, bradycardia, pacemaker insertion, and hip fractures compared with similar patients with Alzheimer disease who are not taking these medications. So, the idea of increasing the dose to 23 mg, potentially resulting in more serious adverse events while achieving no clinical gain, is ill-conceived at best.
Nonetheless, based on this study, the U.S. Food and Drug Administration eventually approved the 23 mg dose of donepezil against the advice of its own medical reviewers. One year later, though, the Journal Club on donepezil has proved to be prescient. Last week, in a scathing editorial published in BMJ, noted physician-researchers Lisa Schwartz and Steven Woloshin echoed AFP's earlier critique. They also rebuked the FDA for allowing Eisai, the manufacturer of donepezil, to include a false statement on the drug label and physician advertisements that touted "important clinical benefits" on measures of cognition (which, as noted, were clinically meaningless) and global function (which were not even statistically significant). Schwartz and Woloshin concluded by calling on the FDA to exercise greater oversight of such ethically questionable practices:
Alzheimer's is an awful disease. Sadly, the available drugs don't work well. But that is no excuse for emotionally manipulating vulnerable patients, desperate family members, and their doctors to use a product that is more likely to add harm than benefit. Nowhere - not in the direct to consumer or the physician advertisements, nor even in the FDA approved label - are the great uncertainties about this drug explained. ... That it is so easy to send doctors and patients incomplete and distorted messages about drugs is depressing. To make good decisions about drugs, doctors and patients need the evidence. The FDA should not forget to give it to them.
Kamis, 15 Maret 2012
Smoking cessation: what works, and what doesn't
In the cover article of the March 15th issue of AFP, Drs. Michele Larzelere and Dave Williams review evidence-based strategies to promote smoking cessation, including the five A's framework (Ask, Advise, Assess, Assist, and Arrange), stages of behavior change, and motivational interventions. In addition, they provide practical information about first-line medical therapies that improve smoking cessation rates in adults: nicotine replacement, sustained-release bupropion, and varenicline.
Despite the existence of well-established guidelines for clinicians on applying these effective interventions in practice, however, one in five adults in the U.S. continues to smoke. This fact has led researchers to explore other ways to motivate smokers to quit, such as using imaging technology to show them the personal consequences of tobacco use. In a randomized trial recently published in the Archives of Internal Medicine, researchers tested the "pictures are worth a thousand words" theory by comparing cessation rates between smokers who received standard therapy plus carotid plaque ultrasonographic screening to smokers receiving standard therapy alone. Even though 58 percent of smokers in the intervention group were found to have carotid plaques, there was no statistical difference in cessation rates between the groups after one year, and patients with plaques were not more likely to quit smoking than those with normal ultrasound results.
In an accompanying editorial, Dr. Patrick O'Malley called for a renewed emphasis on developing communication skills throughout medical training:
We rely too much on technology and testing that are misapplied to problems that really should be addressed with cognitive, emotion handling, and relationship-centered skills. We need a paradigm shift in priorities and incentives to shift from excessive reliance on technologies, a terribly wasteful practice, to training and cultivation of communication- and relationship-based skills that are likely much more effective in the psychosocial domains of care.
The bottom line for family physicians: when it comes to promoting smoking cessation, talking to patients trumps technology.
Despite the existence of well-established guidelines for clinicians on applying these effective interventions in practice, however, one in five adults in the U.S. continues to smoke. This fact has led researchers to explore other ways to motivate smokers to quit, such as using imaging technology to show them the personal consequences of tobacco use. In a randomized trial recently published in the Archives of Internal Medicine, researchers tested the "pictures are worth a thousand words" theory by comparing cessation rates between smokers who received standard therapy plus carotid plaque ultrasonographic screening to smokers receiving standard therapy alone. Even though 58 percent of smokers in the intervention group were found to have carotid plaques, there was no statistical difference in cessation rates between the groups after one year, and patients with plaques were not more likely to quit smoking than those with normal ultrasound results.
In an accompanying editorial, Dr. Patrick O'Malley called for a renewed emphasis on developing communication skills throughout medical training:
We rely too much on technology and testing that are misapplied to problems that really should be addressed with cognitive, emotion handling, and relationship-centered skills. We need a paradigm shift in priorities and incentives to shift from excessive reliance on technologies, a terribly wasteful practice, to training and cultivation of communication- and relationship-based skills that are likely much more effective in the psychosocial domains of care.
The bottom line for family physicians: when it comes to promoting smoking cessation, talking to patients trumps technology.
Jumat, 09 Maret 2012
Addressing gaps in end-of-life planning
A recent article by family physician Ken Murray in the Wall Street Journal, titled "Why Doctors Die Differently," observed that doctors are more likely than other people to decline end-of-life interventions that have little likelihood of benefit:
It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.
Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).
In a published survey of older physicians cited in the article, 64 percent of physicians had created an advanced directive, which Dr. Murray argues is essential to planning for end-of-life care: "Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements."
In the March 1st issue of AFP, Drs. G. David Spoelhof and Barbara Elliott review strategies for implementing advance directives in office practice. The authors recommend that family physicians have interactive discussions with patients regarding their end-of-life care preferences over multiple office visits, and they provide guidance for overcoming common patient- and physician-related barriers to completion of advance directives. A suggested approach for physicians is to bring up the topic of advance directives at routine visits for patients age 50 years or older and intensify discussions upon the diagnosis of a chronic and progressive illness such as cancer, heart failure, or dementia:
Following a realistic discussion of the patient's prognosis, the physician initiates a more in-depth discussion, including the proxy and family members as desired, that centers on the patient's care goals. Adding a values history to the advance directive may be helpful. After the discussion, the advance directive is updated and made as specific as possible. These issues should be readdressed periodically and as circumstances change. The last phase occurs with the onset of frailty or the need for long-term care. The discussion, centered on the patient's care goals, may result in consistent and specific physician orders regarding life-sustaining interventions.
To ensure that patients' end-of-life wishes are respected, advance directives should avoid vague language (e.g., "no heroics"), be shared with proxy decision-makers, and be made accessible in the medical record so that they are easily transferable to multiple levels of care.
It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.
Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).
In a published survey of older physicians cited in the article, 64 percent of physicians had created an advanced directive, which Dr. Murray argues is essential to planning for end-of-life care: "Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements."
In the March 1st issue of AFP, Drs. G. David Spoelhof and Barbara Elliott review strategies for implementing advance directives in office practice. The authors recommend that family physicians have interactive discussions with patients regarding their end-of-life care preferences over multiple office visits, and they provide guidance for overcoming common patient- and physician-related barriers to completion of advance directives. A suggested approach for physicians is to bring up the topic of advance directives at routine visits for patients age 50 years or older and intensify discussions upon the diagnosis of a chronic and progressive illness such as cancer, heart failure, or dementia:
Following a realistic discussion of the patient's prognosis, the physician initiates a more in-depth discussion, including the proxy and family members as desired, that centers on the patient's care goals. Adding a values history to the advance directive may be helpful. After the discussion, the advance directive is updated and made as specific as possible. These issues should be readdressed periodically and as circumstances change. The last phase occurs with the onset of frailty or the need for long-term care. The discussion, centered on the patient's care goals, may result in consistent and specific physician orders regarding life-sustaining interventions.
To ensure that patients' end-of-life wishes are respected, advance directives should avoid vague language (e.g., "no heroics"), be shared with proxy decision-makers, and be made accessible in the medical record so that they are easily transferable to multiple levels of care.
Senin, 05 Maret 2012
Doctors should trust their clinical judgments
A physician reader of AFP submitted the following post.
**
A case in point: a friend recently asked my opinion after her primary care physician noted a moderately elevated eosinophil level on a complete blood count. I remembered the common causes of this abnormality (allergies and parasitic infections) and asked some questions about recent changes in diet, use of herbal products, and travel. I also recalled seeing eosinophilia in patients with Hodgkin's disease and systemic vasculitides, but she was completely asymptomatic and had been told that her physical exam was normal. In reviewing the topic online, I read about other rare causes of eosinophilia, but told her that in my judgment the chance that she had ovarian cancer or any of these other conditions was extremely low. This was, after all, a healthy 35 year-old woman who regularly ran marathons.
Our job as physicians should be to educate patients so that they can make informed decisions. Based on the information I gave, my friend seemed comfortable with a "wait and see" approach. She was not particularly concerned, as she recalled an aunt having been told for years that she had an elevated eosinophil count. However, her doctor pushed her to see a hematologist. After she endured CT scans of her chest, abdomen and pelvis, followed by a bone marrow biopsy, she wrote again to ask my opinion. It seems that the hematologist had found nothing and now wanted her to see an infectious disease specialist.
What drives doctors to order tests that, in their hearts, they must know have a remote chance of being helpful? For some, it may be medical-legal considerations. For others, there is a financial incentive. But at a deeper level, I think it is that too many doctors are unable to live with medical uncertainty. They want a definitive answer, even when it is unlikely that it would alter the patient's long-term well-being. We must learn to trust our clinical judgments, and to educate our patients and involve them in decision-making, if we ever hope to rein in health care costs.
Robert G. Brown, MD
Lovettsville, VA
E-mail: olddocbob@hotmail.com
Senin, 27 Februari 2012
What's in your health care shopping cart?
A few years ago, we received a letter from a physician reader who complained that the approximate prices of drugs provided in AFP were often quite different from the prices he found online or in his local drugstore. This letter ultimately led to a re-evaluation of the rationale and process for estimating drug costs in the journal, as AFP editor Jay Siwek, MD explained in this January 2010 editorial:
Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.
Although having information about the costs of drugs can be helpful, physicians are often unaware of the costs of common tests, procedures, and referrals. A recent commentary in JAMA argues that electronic medical records should incorporate such cost information to make clinicians aware of the overall costs generated by office visits and other health care encounters:
What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.
The American Academy of Family Physicians has partnered with the American Board of Internal Medicine and several other physician and consumer groups in the Choosing Wisely campaign, an initiative to promote more efficient use of limited health care resources. Although this campaign focuses on reducing use of tests or procedures that have no clinical benefits (e.g., imaging for uncomplicated low back pain, antibiotics for upper respiratory infections), it raises the question of whether physicians should take responsibility for controlling costs of health care beyond simply eliminating "waste." For example, should family physicians' virtual "shopping carts" drive more selective use of health services that have high costs and marginal benefits (e.g., coronary CT scans, cancer screening in patients over age 75 years)? Or is this type of thinking unjustified and unethical rationing? What's your view?
Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.
Although having information about the costs of drugs can be helpful, physicians are often unaware of the costs of common tests, procedures, and referrals. A recent commentary in JAMA argues that electronic medical records should incorporate such cost information to make clinicians aware of the overall costs generated by office visits and other health care encounters:
What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.
The American Academy of Family Physicians has partnered with the American Board of Internal Medicine and several other physician and consumer groups in the Choosing Wisely campaign, an initiative to promote more efficient use of limited health care resources. Although this campaign focuses on reducing use of tests or procedures that have no clinical benefits (e.g., imaging for uncomplicated low back pain, antibiotics for upper respiratory infections), it raises the question of whether physicians should take responsibility for controlling costs of health care beyond simply eliminating "waste." For example, should family physicians' virtual "shopping carts" drive more selective use of health services that have high costs and marginal benefits (e.g., coronary CT scans, cancer screening in patients over age 75 years)? Or is this type of thinking unjustified and unethical rationing? What's your view?
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