Benefits of reduced preventive care

Postponing preventive services like vaccinations or care for chronic conditions is likely to cause harm. However, the decline of routine medical care is not always a bad thing, argue Dr. Alan Roth, chair of family medicine at the Jamaica Hospital Medical Center, and Dr. Andy Lazris, primary care physician in Columbia, MD, in the latest episode in the “Right Care Series” in American Family Physician. Because certain types of routine care are unnecessary, avoiding this low-value care can actually help patients avoid the stress from false positives, additional out-of-pocket costs, harm from cascade events, and other overuse-related harms.

“The pandemic has provided an opportunity to evaluate which medical services are truly necessary and what patients can do without.”

Dr. Alan Roth and Dr. Andy Lazris, in American Family Physician

Here are a few low-value services Roth and Lazris identify as commonly overused:

• Diagnostic imaging, like MRIs and CT scans, for patients without serious symptoms (almost all hospitals in the US perform these tests, according to the Lown Institute Hospitals Index)
• Cancer screening in older adults (nearly half of older adults are overscreened for cancer)
• Pain management procedures like vertebroplasty and spinal fusion

Roth and Lazris also point out that “adult wellness examinations,” annual preventive check-ins for Medicare patients, have not been shown to measurably improve health outcomes and often lead to low-value screening tests, such as thyroid function testing, urine culture testing.

Wellness visits also can lead to cardiac testing and subsequent stenting, which has shown to be no better than medical therapy for stable heart disease. (Dr. Lown himself discovered how giving patients cardiac tests almost always led to unnecessary coronary interventions.) Roth and Lazris cite a study of 12 hospitals showing that 47% fewer patients received elective cardiac catheterizations in Spring 2020 compared to 2019.

The financial burden of low-value preventive care

Another study on low-value preventive care published last month in the Journal of General Internal Medicine shows the scope and financial harm from just a few of these services. Dr. Carlos Irwin A. Oronce, fellow at the VA Greater Los Angeles Healthcare System, and colleagues looked at how often Medicare beneficiaries received seven preventive services that have been given a “D” Grade by the US Preventive Services Task Force (USPSTF). The USPSTF gives a “D” grade to services they recommend against because they are at least moderately certain that “the service has no net benefit or that the harms outweigh the benefits.”

Just seven low-value services were performed more than 30 million times each year — that’s 13 low-value services per 100 visits.

The Grade D services measured included screening for urinary infections and cardiovascular disease for asymptomatic adults, screening for certain cancers in older adults, and vitamin D supplements for older women to prevent fractures. Oronce et al. used a sample of about 95,000 patient visits from 2007-2016, in the National Ambulatory Medical Care Survey (NAMCS). From the frequencies of the Grade D services in the sample, they estimate that these seven services were performed more than 30 million times each year — that’s 13 low-value services per 100 visits.

The total estimated cost of these services for Medicare was $477,891,886 per year. They note that three services in particular —screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years— alone made up about two thirds of this cost.

Advanced cancer crisis?

Decreased cancer screenings during Covid-19 in particular have gotten a lot of attention. Oncologists have reported seeing more patients than usual in advanced stages of cancer, which is concerning. Many patients avoided seeking medical care for concerning symptoms, like serious pain and swelling, because they were either afraid of viral spread or they had suffered financial consequences from the pandemic. It’s clear that the lack of access to diagnostic services and care early in the process has led to unnecessary suffering, borne disproportionately by people of color, as the ProPublica article points out.

Yet, we have to be careful not to conflate diagnostic cancer tests (performed when someone has symptoms) and screening cancer tests (performed when someone has no symptoms). As we’ve written on this blog extensively, cancer screening often leads to false positives, overdiagnosis, and other harms. Screening tests are also given too often to patients who are too young, too old, or at too low-risk to benefit. This pause in screening tests should be seen not as a crisis but as an opportunity to see whether we can reduce low-value screening.

The path forward

Will patients benefit overall from less low-value care? It’s likely, but we won’t know for sure until we study it. Fortunately, there are some trials in progress now to evaluate how less preventive care (and potential cascade events) have impacted health. For example, the federally-funded Breast Cancer Surveillance Consortium is collecting data from 800,000 women at 100 mammography centers across the country, to evaluate the long-term health impacts of fewer routine mammograms during the pandemic. The National Cancer Institute will also be using two national cancer tracking systems to research how less cancer screening during Covid-19 has impacted the stage at which cancer is diagnosed, STAT reports.

However, doctors don’t have to wait to deliver the right care to patients now. Roth and Lazris acknowledge that “the temptation to go back to normal will be difficult to resist,” but they encourage clinicians to use Covid-19 as a turning point to “stop providing ineffective services that have not been demonstrated to improve patients’ health.”

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In a new edition of the Lown “Right Care” series in the journal American Family Physician, Stanford University Doctors Alan Glaseroff and Ann Lindsay, and patient advocates Helen Haskell and John James offer do’s and don’ts for clinician-patient conversations about Covid-19. Here are some key points from the article:

Don’t give a lecture. Simply telling patients to do something, even if there are good reasons behind it, is a poor strategy. Not only does lecturing not convince people to change their minds, it actually has been shown to strengthen their existing beliefs. In a recent opinion piece about motivational interviewing in the New York Times, psychologist Adam Grant explains, “Much as a vaccine inoculates the physical immune system against a virus, the act of resistance fortifies the  psychological immune system.” In the medical context, giving a lecture and not listening to patients can also reduce trust, making it more likely that they won’t come back to the doctor when they have future health problems.

Do try motivational interviewing. Rather than preaching, clinicians can use motivational interviewing: A method of helping change someone’s behavior by “helping them explore and resolve ambivalence.” Often people understand the downsides of continuing unhealthy behaviors like smoking or not exercising, but they are ambivalent about changing because there is something in their way. Motivational interviewing helps people identify their own motivations behind changing a behavior and giving them actionable goals for the future to set them up for success. When used in a clinical context, this method has been shown to reduce alcohol consumption, promote diet and exercise, and help promote other healthy behaviors.

Do listen to patients’ concerns and identify goals. In motivational interviewing, “the clinician’s job is to help the patient make these changes by eliciting the patient’s life and health goals and thoughts about how they might achieve them,” the authors write. Clinicians might ask, “On a scale of 1 to 10, how important is your family’s health to you?” Haskell and James note that “people faced with difficult lifestyle changes may desire change for the sake of others more than for themselves.” Clinicians can help reinforce the importance of the goal by having the patient explain its significance in their life.

Do remain sensitive of social pressures around patients when it comes to masks and social distancing in their community. Depending on where people live, wearing a mask or taking other safety measures for Covid-19 is not just a health precaution; it has become somewhat of a political statement. “It takes courage to make a public statement such as wearing a mask in certain communities because of the emotionally and politically charged symbolism of masks in present times. This can be a barrier to change,” the authors write.

Don’t take sides. The next step is reflecting the conversation back to the patient. It’s important here to objectively state the goals that patients have and the barriers they face. “When the clinician does not take sides in the patient’s ambivalence, the patient is more likely to defend the importance of making changes,” the authors write.

Do identify specific actions to take. Clinicians should help patients start on the road to success by identifying specific actions they can take towards their goal, when they will do them, and how confident they are in their ability to follow through. For example, an action to reduce Covid-19 risk could be deciding to wear a mask inside certain stores, or to visit with friends outdoors instead of indoors. It’s better to identify small changes someone is confident they can do, rather than large changes they aren’t sure if they can do. Clinicians can ask to follow up to see if their patient has achieved their goals.

For more on motivational interviewing and Covid-19, read the full article in American Family Physician!

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In the latest edition of the “Right Care Series” in the journal American Family Physician, Dr. Ann Lindsay from the Stanford University School of Medicine, and patient partners Helen Haskell and John James tackle the subject of evaluating older adults for frailty before recommending elective surgery.

Patients will often come to their primary care clinician to ask about surgeries they are considering. Thus, primary care clinicians play a key role in helping patient and families understand the risks of surgeries and figure out whether that surgery is appropriate for them. An important part of this process is evaluating patients for signs of frailty, a condition that greatly increases the risks of surgery.

Frailty is a term that describes patients, regardless of age, who have reduced physiologic reserve and are at increased risk of dying within five years. For frail patients, even procedures described as “low-stress” can lead to significant declines in function and cognitive decline. However, as Haskell and James write, patients and their families may not be aware that disability, impairment, and worsened function are among the risks of surgery.

Lindsay recommends that clinicians use the Risk Analysis Index to determine frailty, along with the Mini-Cog screening tool for dementia to supplement. Clinicians should also evaluate the patient’s living situation: Who will be taking care of the patient after the operation? Do they have adequate resources to do so? Is their home easy to navigate for someone recovering from surgery or are there fall risks? These factors greatly impact the ability for frail patients to recover.

Clinicians can use the preoperative evaluation to inform patients and families about alternatives to surgery, such as “physical therapy, working on pain management, additional durable medical equipment, and alternate modes of physical activity.” The patient’s life goals need to inform the decision about these options.

For more, check out the article at American Family Physician, and see other pieces in the Right Care series!

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In the latest edition of the “Right Care Series” in the journal American Family Physician, primary care doctors Alan Roth and Andy Lazris, and patient partners Helen Haskell and John James review the evidence and provide guidance for how to prescribe for patients with chronic pain in a patient-centered way.

For patients dealing with chronic pain (pain that does not subside for three months), the first line of treatments should be nonpharmacologic treatments such as physical therapy, or nonopioid medications such as acetaminophen and NSAIDs. Adjuvant medications such as antidepressants or anticonvulsive medications can also be helpful, but clinicians and patients should be aware of potential drug interactions and side effects.

The authors recommend that before prescribing opioids, clinicians should assess the benefits and harms of the medication with the patient, prescribe the lowest possible dose, and implement mitigation strategies to decrease the potential for misuse. These mitigation strategies include prescription monitoring programs, prescribing naloxone, and making sure not to prescribe benzodiazepines like Xanax or Klonopin along with opioids (a combination that can lead to severe adverse events).

Just as one should start with the lowest possible dose of opioids, any reductions should also be carefully tapered, at a rate of 10% each month. The authors note that with the CDC’s 2016 guidance, many primary care doctors abruptly stopped prescribing opioids or dropped patients, even some who had been taking opioids for chronic pain for a long time. This overcorrection was not based in evidence and likely harmed patients, some doctors claim.

The potential harms of opioid addiction have been well-established in the media, but patients may not be as aware of the potential harms of other drugs commonly prescribed for pain. “As part of shared decision-making, patients should be made aware of concerns about long- term use of acetaminophen causing liver damage or use of NSAIDs causing cardiovascular, bleeding, or gastrointestinal effects,” Haskell and James write. The side effects of other drugs commonly prescribed to treat pain such as muscle relaxants or antidepressants should also be discussed. Just because it is not an opioid, does not mean it is harmless.

For more, read the full article in American Family Physician!

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Atrial fibrillation (an irregular heart rhythm affecting the heart’s upper chambers, also known as “AFib”) is a common cardiac condition, affecting as many as 6 million people in the US and leading to 130,000 deaths per year, often due to strokes. Warfarin and other blood thinners are often prescribed to prevent strokes for patients with afib, but for older adults, clinicians need to be aware of the potential harms. Taking direct anticoagulants increases the risk of stomach and brain bleeds in older adults, events that can be particularly harmful after a fall.

How can clinicians help patients decide whether taking blood thinners is the right treatment for them? The authors recommend using risk stratification tools to determine an individual patient’s risk for stroke as well as their risk for bleeding and falls. Then clinicians and patients should discuss the pros and cons of treatment options to come to a shared decision.

In the case of blood thinners for afib in older adults, shared decision making is especially important because there is no clear “right answer” for all patients.

In the case of blood thinners for afib in older adults, shared decision making is especially important because there is no clear “right answer” for all patients. For example, a 2007 Cochrane review found no difference in all-cause mortality between patients with afib taking warfarin and those taking placebo (the anticoagulant group experienced 5 out of 1000 disabling or fatal strokes, but 6 out of 1000 fatal bleeds). The lack of clinical trials of anticoagulants including older patients with comorbidities makes it even tougher to evaluate harms and benefits as well.

The authors identify questions that patients will likely want to have answered in these shared decision making conversations, and thus ones that doctors should take into consideration. For example, what are the differences between warfarin and other anticoagulant drugs? How safe is surgery for a patient taking anticoagulants? Can a patient who starts on anticoagulants stop taking them at some point? Patient partners Haskell and James write, “The goal of patients is their global well-being, a goal that does not necessarily align with the optimal end point for each of their medical conditions. It is the fundamental role of the primary care physician to balance these conflicting concerns.”

For more on the benefits and harms of anticoagulants, read the full Right Care article.

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In the latest edition in the “Right Care” series, Dr. Nick Bott and Dr. Ann Lindsay from the Stanford University School of Medicine tackle the question, “Why is it difficult to provide the right care to adults with dementia?”

A large part of the problem is the way we view dementia, write Bott and Lindsay. Currently, most clinicians view dementia as just another medical condition, like high blood pressure or diabetes, rather than a condition that affects all other aspects of the patient’s life and health. This is partly a result of our fragmented health care system, in which patients are often seen as a “collection of diseases” rather than a whole person. 

“In reality, dementia is a life-limiting terminal illness for the patient, and a life-altering diagnosis for the patient’s family or caregivers,” the authors write. “A diagnosis of dementia should be considered the primary problem under which care for all other problems is considered.” There is no cure for dementia, and generally dementia gets worse over time. This means that patients and family/ caregivers may have to reconsider health goals and treatment decisions. For example, cancer screenings are unlikely to benefit older patients with dementia, and often lead to overtreatment and harm.

Clinicians should also let patients and caregivers know about the increased risk of hospitalization and hospital complications in patients with dementia, so they can take steps to avoid preventable hospitalization whenever possible. Patients and caregivers should make use of alternatives to inpatient hospitalization, such as Hospital At Home (HAH), which delivers medical care at home for common conditions.

Another reason dementia often goes ignored is because clinicians may not know that there are steps they can take to help patients with dementia and their family/caregivers. However, primary care clinicians can change the course of a patient’s health care for the better by helping patients and their families with advanced care planning, reviewing medications, and creating a care plan that focuses on preventing harm.

“A thoughtful pause opens the door for intelligent intervention that is goal congruent and invaluable for reducing complications and preventable morbidity,” write Bott and Lindsay.

Read the full piece on American Family Physician!

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In the newest edition in the series, Right Care Alliance co-chairs and primary care doctors Dr. Andy Lazris and Dr. Alan Roth discuss the pros and cons of lung cancer screening in primary care, a practice that is promoted by some specialty societies and health providers, but often results in overuse. For patients who are former smokers and know the risks of smoking, it makes sense to ask if they should get screened for lung cancer. Further, the National Lung Screening Trial results of a reported 20% reduction in lung cancer deaths from screening makes this intervention sound very beneficial for patients. 

However, Lazris and Roth point out that the evidence of benefit from lung cancer screening in the community setting is weak. Although a 20% reduction in lung cancer deaths sound impressive, this is a relative, not absolute, reduction. According to the NLST results, about 3 in 1,000 people will be saved from lung cancer over five years. At the same time, 250 of those people will have an abnormal scan result and will have to undergo further testing, which can be stressful and costly. While a CT generally costs about $300, follow-up procedures such as lung biopsies, PET scans, and lung surgeries can cost thousands of dollars. 

For more on the costs and benefits of lung cancer screening, read the AFP commentary, and check out the debate on Twitter!

Our latest @Lown Right Care article on Lung Cancer Screening: Pros and Cons is worth reading in its entirety https://t.co/IFGBgelC7A But for those who won’t, here’s the @AFPJournal #Tweetorial version 1/ — Kenny Lin, MD, MPH (@kennylinafp) June 18, 2019

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In the newest edition in the series, Dr. Ann Lindsay, Dr. Ajay Sharma, and Dr. Alan Glaseroff tackle a tough issue in primary care — how to help patients make lifestyle changes to improve their health. Most primary care clinicians have been in a situation where they attempt to provoke a patient to make lifestyle changes, such as stopping smoking, exercising more, or losing weight, but to no avail. On the other hand, many patients can recall a time when a health care professional barked orders at them without first listening to them.

For conditions like mild hypertension, that depend a lot on patient behavior outside the clinic, adherence rates are typically very low, write Lindsay et al. This can be frustrating to many doctors; why wouldn’t a patient want to do whatever is necessary to be healthy? What doctors may not consider is there are often parts of a patients’ history, goals, and beliefs that affect how they think about certain interventions. 

So what can primary care doctors do to engage patients and make it more likely they will engage in healthy behaviors? Lindsay et al. list several steps to effective communication that even the busiest clinician should be able to do, including: Emphasizing patient ownership over their health goals, partnering with patients on what they are willing and able to do, taking small steps rather than large leaps, scheduling follow-up visits to check in, and — most importantly — listening to the patient and showing caring.

For more, read the newest piece in the AFP Right Care series here!

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“At its core, the clinicians role is to be a trusted guide in the face of shared uncertainty. And to play that role, we clinicians must recognize that the most important dimension of our care of the patient is the strength of our relationship to the patient,” write authors Dr. Vikas Saini, president of the Lown Institute, and Dr. Kenny Lin, Professor of Family Medicine at the Georgetown University Medical Center.

The first case scenario in the series, written by Dr. Alan Roth, Professor of Family Medicine at the Jamaica Hospital Medical Center, Dr. Andy Lazris, family physician practicing in Columbia, MD, and Dr. Sarju Ganatra, cardiologist at Lahey Hospital & Medical Center, identifies overuse in cardiac testing.

The authors identify several types of overuse in this area, such as screening asymptomatic patients with electrocardiography, inappropriate cardiac imaging, and stress testing in patients with low probability of coronary artery disease, that often lead to overtreatment, increased cost, and patient harm. 

Read the first case in the series on the American Family Physician website!

The amount of clinical decision-making that is discretionary is extremely high and practicing clinicians need resources to help navigate this channel more easily. We are excited to present this new series as one of these resources!

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