Advanced access and other ways to see a doctor - stat

A few weeks ago, while at an out-of-state wedding reception, I began having chest pain that didn't immediately go away with rest and antacids. Although it was unlikely to be an early symptom of a heart attack (I'm relatively young, have good cholesterol levels, and have no relatives with early heart disease), I felt uncomfortable enough to want another physician to confirm that it was only a bad episode of heartburn. But with my family doctor's office hundreds of miles away, the only medical option seemed to be the nearest hospital emergency room. And like most people, I avoid emergency rooms unless I have a broken bone or life-threatening medical emergency.

Fortunately, the pain disappeared and I didn't need to see a doctor that night. But you don't have to be hundreds of miles from home to know that it's tough to get a doctor's appointment when you need one. According to a 2009 survey, the average wait time for an appointment with a family physician was nearly three weeks, and up to two months in some cities. Because last year's health reform law is expected to result in more people having health insurance, these wait times may become even longer, as more patients compete for increasingly scarce spots in doctors' schedules.

Primary care offices have historically handled patients with urgent problems by assigning one doctor "acute care" responsibilities for the day or squeezing extra patients into already crammed schedules. The downside: Patients can end up seeing doctors who are unfamiliar with their medical histories, harried due to time pressures, or both, which raises the risk of misdiagnosis or improper treatment.

That's why some practices (including the federally funded Veterans Heath Administration clinics) have switched to "advanced" or "open-access" scheduling. Rather than scheduling a visit weeks or months in advance, patients can call for an urgent or routine appointment the day before or the same day they want to be seen. This arrangement works because physicians' schedules are kept empty until 24 hours ahead of the appointment time. A recent review of 28 studies published in the Archives of Internal Medicine found that advanced-access scheduling increases the chance that a patient will be able to see his or her doctor and reduces no-show rates. Although there were too few data to draw firm conclusions, many experts believe that advanced access decreases emergency room visits and improves patient satisfaction and medical decision-making, too.

Another innovation to improve access is the "concierge" or direct-pay medical practice, where patients pay a monthly or annual membership fee directly to the doctor—rather than to the insurance company. Freed from the administrative expenses associated with filing insurance claims, these practices offer shorter waits, longer visit times, and unlimited telephone and E-mail consultations. Although the first direct-pay practices charged thousands of dollars per year and were therefore available only to the rich, direct-pay practices with affordable fees are increasingly cropping up. For example, California's MedLion and Seattle's Qliance Medical Group charge patients $49 to $89 per month. The Direct Primary Care Association has a state-by-state list of direct-pay practices on its website.

For patients who don't live near advanced-access or direct-pay practices, telehealth technology has made speaking with a primary care doctor by phone or online video conference easier than ever. Teladoc offers 24-hour access to board-certified primary care physicians in every state. Since virtual consultations are less expensive than in-person visits (and far cheaper than an emergency room visit), many insurers will pay for them. If you would prefer to consult your own physician, groups like Hello Health are connecting doctors with patients via online "portals" that also allow you to access portions of your electronic medical records, such as specialists' notes and laboratory test results.

So the next time you need to consult a doctor but can't wait weeks for an appointment, consider choosing a practice with advanced-access scheduling, direct-pay models, or telehealth services. These innovations will never replace the old-fashioned house call, but they are probably the next best thing.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Aspirin for primary CVD prevention: the continuing debate

In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that primary care clinicians discuss preventive aspirin use with adults at increased risk of cardiovascular events. Four years later, the National Commission on Prevention Priorities (NCPP) ranked counseling for aspirin use the number one priority on its list of the most effective clinical preventive services. According to the NCPP, if the percentage of eligible patients using aspirin (then estimated to be about 50 percent) increased to 90 percent, 45,000 additional lives could be extended each year.

At that time, the benefits of aspirin use in men and women were assumed to be the same. However, an updated USPSTF recommendation statement published in the June 15th issue of American Family Physician indicates that aspirin use actually prevents heart attacks in men, but ischemic strokes in women. In addition, physicians and patients must weigh the benefits of reduced cardiovascular risk with the risk of gastrointestinal bleeding events, and use shared decision making when these risks are closely balanced.

To further complicate matters, a 2009 meta-analysis published in the journal The Lancet questioned the value of aspirin for primary prevention, concluding that for patients who without a history of cardiovascular disease, "aspirin is of uncertain net value." In response, family physicians and USPSTF members Ned Calonge and Michael LeFevre wrote an editorial that concluded, "There is not a simple message for aspirin prophylaxis as a primary preventive strategy, and we need to consider gender, age, and the associated balance of potential risks and benefits to provide the best advice and preventive care for our patients."

The debate continues with two thought-provoking editorials in the June 15th issue of AFP. Alison L. Bailey and colleagues caution that routine aspirin use is not justified for primary prevention in adults at low risk of CVD. On the other hand, W. Fred Miser asserts that the main issue regarding aspirin for primary prevention continues to be underuse in appropriate-risk patients.

So which is the bigger problem, overuse or underuse?

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The above is a slightly edited version of a post that was originally published on the AFP Community Blog.

"It is time to stop this [PSA] screening nonsense"

In an editorial in this month's issue of the Journal of Family Practice, Northeast Ohio Medical University dean and family physician Jeff Susman, MD joins the rising chorus of voices urging clinicians to stop offering the PSA test to screen for prostate cancer. Dr. Susman writes:

I am going to go out on a limb here and suggest that, until we have fundamentally changed strategies for targeted case finding or early intervention (think genomic and proteomic markers), it is time to stop this screening nonsense. The facts speak for themselves: A trial of 182,000 patients finds in a post hoc analysis of a very narrow population that death can be averted in one of 723 individuals who are screened. What about the complications associated with diagnosis, work-up, and treatment? It is time for urologists and primary care physicians to tell patients that PSA screening is unlikely to benefit them. Some of you will suggest that we counsel patients about PSA testing to facilitate informed decision-making. But do we advise patients to play the lottery or try futile therapies?

Notably, mortality results from one of the two "definitive" randomized studies of treatment versus watchful waiting for PSA-detected prostate cancer, the Prostate Cancer Intervention Versus Observation Trial (PIVOT), were presented in abstract form at the annual meeting of the American Urological Association last month. In brief, PIVOT found no overall survival benefit in men who underwent surgery (radical prostatectomy) compared to men who did not. The only men whom the study suggested might benefit from surgery were those with a PSA of greater than 10 - in other words, those men who would be least likely to be identified via screening alone.

As we continue to wait for the long-delayed verdict of the U.S. Preventive Services Task Force on PSA screening, public opinion may finally be turning against the test, at least in older men with no realistic possibility of benefit. When primary care blogger Kevin Pho, MD recently proposed on the New York Times's Room for Debate that Medicare stop paying for prostate screenings for men over 75, the majority of responses were favorable - a big difference from the way the USPSTF's recommendation against screening in this age group was originally received back in 2008.

Thank you, Dr. Susman, for taking a public stand on PSA screening that is consistent with the scientific evidence and most likely to benefit patients. Hopefully, it will soon become obvious to all that discouraging the misuse of this test is not "going out on a limb," but rather, should be the standard of care.

How to find good health information online

A recent survey found that 60 percent of adults have gone online at least once to look up health information. Unfortunately, finding high-quality health websites is a challenge. Several years ago, a review of 79 studies published in the Journal of the American Medical Association concluded that online health information for consumers is frequently flawed, inaccurate, or biased. Based on my experience, the situation isn't any better today.

Why do some health websites contain misleading information? One reason is that the group or organization running the site may have a hidden agenda. Drug companies often create consumer demand for expensive new drugs by financing groups that promote awareness of a previously unrecognized health condition, a sales tactic known as "disease mongering." (For example, Dartmouth Medical School researchers have argued that restless leg syndrome became a disease only when a drug was developed to treat it.) Unfortunately, a study published earlier this year in the American Journal of Public Health found that most health advocacy groups that receive drug-company funding don't disclose that on their websites.

Another reason that websites may contain misinformation is that some groups willfully disregard scientific evidence to promote certain health beliefs. For example, even though the U.S. Institute of Medicine found in 2004, after an exhaustive review of the medical literature, that there is no relationship between childhood vaccines and autism, it's easy to find websites that claim otherwise. Similarly, although most researchers have concluded that Morgellons disease—a bizarre skin condition that sufferers believe to be caused by an undiagnosed parasitic infestation—is likely to be a psychiatric delusional disorder, you wouldn't know it by simply Googling "Morgellons."

Because advising my patients to make an appointment every time they have a health-related question isn't a practical solution, I refer them to websites that I trust or that have been certified by an independent, quality rating organization such as the Health on the Net Foundation. This organization's search engine only retrieves results from websites that have agreed to provide objective, scientifically sound information. One such website—Healthfinder.gov, which is a clearinghouse on a variety of general health topics— links to the latest health headlines, and provides interactive health tools that give personalized advice about screening tests and other preventive health issues. Content on Healthfinder.gov is periodically reviewed by U.S. government health experts to assure its accuracy and consistency with results from the latest scientific studies.

When I want to give patients a handout about the basics of a preventive test or newly diagnosed health condition, I turn to FamilyDoctor.org, a nonprofit website supported by the American Academy of Family Physicians. (Full disclosure: I edit a medical journal that is the source of many of these handouts.) One such handout advises that patients ask themselves 3 questions about every health-related website they visit:

• Where did this information come from?
• How current is this information?
• Who is responsible for the content on this website?

As powerful a tool as the Internet can be in giving people access to health information, it is only a starting point. With few exceptions (for example, management of the common cold), patients should never use online information to self-diagnose or treat a medical problem. However, I believe that patients who visit high-quality health websites are usually better-informed and more capable of making complex choices, such as whether or not to get a screening test for cancer. And in my opinion, that's a good thing.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Guest Blog: EMRs and primary care

Josh Freeman, MD is Chair of the Department of Family Medicine at the University of Kansas School of Medicine. The following is an excerpt from a post first published on his blog, Medicine and Social Justice.

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One of the centerpieces of health reform as promulgated by almost everyone, and very much the Affordable Care Act (ACA) is the use of electronic medical records (EMR, also called, in a more inclusive formulation, electronic health records, or EHR). The Health Information Technology for Economic and Clinical Health Act (HITECH) specifically addresses specifications for EMRs. Demonstration of effective use of EMRs, including “e-prescribing” (in which prescriptions are routed electronically directly from the physician’s office to the patient’s pharmacy of choice), maintenance of patient registries (who in your practice has diabetes?) and compliance with a set of quality measures (What percent of the people in your practice with diabetes have had their sugar measured? What percent are in control?) account for a great deal of the added payment for chronic disease management, as well as payment for patient-centered medical homes.

EMRs are a good thing for many reasons. At the simplest level, the fact that the records are online, rather than in paper charts, means that they don’t get “lost” and any doctor can see the notes of any other doctor. A number of years ago, prior to going to a real EMR, a large public hospital with many clinics where temporarily lost charts often meant that patient notes generated in one clinic visit were unavailable to another clinic, scanned literally millions of pages into a very basic EMR. While having none of the advantages described below, even this primitive method was a real step forward for them in being able to access the records. At their best, EMRs allow effective communication between doctors in a practice. For large multispecialty practices, this can also be between different specialists, and can even be integrated with the hospital’s medical record so that information from hospitalizations is immediately available in the same “chart”. The more that information is put in “digitally retrievable” format rather than free text, the more easily and thoroughly that a patient’s health trajectory can be understood. This is not only for numeric values, such as lab results and blood pressures that can be displayed on a flowsheet or graph, but even for history and physical items: Was that heart murmur present at the last visit? What is the history of the different medications that the patient has been on? Patient registries become an effective way of evaluating and improving the care given in the entire practice, not just for one patient, and are almost impossible without an EMR.

EMRs are not problem-free, however. The most common issue for physicians is that charting takes longer; filling in all this data takes time. This is worst when a new EMR is implemented, as old data has to be input, but continues to be, on average, more time consuming than paper charting. In part, this may be because the notes are “more thorough,” or, looking at it the other way, that paper chart notes were inadequate. But it is also because the very structured nature of the EMR requires that a significant number of things be entered/clicked (even to indicate “not applicable” or its digital equivalent) that would have appropriately not been mentioned in a paper note. Much of this added documentation goes beyond the information necessary to provide medical care for the patient, but is required to comply with government regulations and ensure that the document is “legally” sound. In addition, some of those regulations require the physician, as opposed to another health professional such as a nurse, to personally document certain items in the record, often to a degree that seems unreasonable to physicians.

There is an ironic turn to this. Most discussion in public policy circles is directed to increased inter-professional function and teamwork, as characterized by the patient-centered medical home. In part, this is because the current and projected shortage of primary care physicians means that there is no way that they, working alone, will be able to meet the health needs of the American people; if they are already working on a “hamster wheel” (see Family Medicine in the Era of Health Reform - 3, May 23, 2011), the changes described by Phillips (see Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 30, 2011 ) and discussed in detail by Margolius and Bodenheimer[1], will increase the burden beyond any hope of sustainability. In addition, an effectively functioning team of health professionals (including nurses, pharmacists, social workers, and others[2]) makes for higher quality care. This is very clearly articulated in Dr. Atul Gawande’s recent address to the Harvard Medical School commencement, “Cowboys and Pit Crews” published on his New Yorker blog.

The irony is that the increased requirements mentioned above, sometimes explicitly stated in law, but often in federal regulations and most commonly by Medicare “carriers” and interpreted by institutional compliance officers, have increased what the physician needs to document in the medical record (and, by implication, have actually done him or herself). These requirements both decrease effective team function, and increase the burden of electronic charting.

As in any new technology that increases the ease of accomplishing something, or the availability of a person or data, there is the corresponding tendency to expect it; this often has the ironic effect of increasing, rather than decreasing, workload. The internet and email allow us to work from home; cell phones, pagers, and email all increase our availability even when not at work or at home. This allows us more flexibility, but it has also led to the expectation of immediate access and, for many professionals including physicians, the virtual elimination of the concept of “work” versus “off” hours. The electronic medical record allows me to chart from home – or anywhere I can get an internet connection – and so I do.

An interesting, and perhaps important, sidelight of the introduction of the EMR in our family medicine clinic was that the implementation team, composed of experts from the computer company and “superusers” of nurses from our group practice, saw how much more complicated the practice – and thus the documentation – is in primary care than in other specialties. In most sub-specialty practices, a few diagnoses -- and thus a few types of workflow and documentation strategies -- account for almost all visits, while in primary care the breadth of encounters in a single session, combined with the complexity of dealing with multiple chronic conditions based in a variety of organ systems rather than one, is breathtaking (see, for example, Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010, "Uncomplicated" Primary Care?, Oct 8, 2009). Contrary to what they had been led to believe, they discovered that primary care was harder and more complex and more difficult to document – and of course required seeing more patients in shorter amounts of time for less reimbursement (which also leads to an ability to afford fewer support staff). This team, at least, gained a new respect for what primary care practice involves.

No easy victories in cancer screening and prevention

Nearly forty years ago, President Richard Nixon famously declared a "War on Cancer" by signing the National Cancer Act of 1971. Like the Manhattan Project, the Apollo program that was then landing men on the Moon, and the ongoing (and eventually successful) World Health Organization-led initiative to eradicate smallpox from the face of the Earth, the "War on Cancer" was envisioned as a massive, all-out research and treatment effort. We would bomb cancer in submission with powerful regimens of chemotherapy, experts promised, or, failing that, we would invest in early detection of cancers so that they could be more easily cured at earlier stages.

It was in the spirit of the latter that the National Cancer Institute launched the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening trial in 1992. This massive study, which eventually enrolled more than 150,000 men and women between age 55 and 74, was designed to test the widespread belief that screening and early detection of the most common cancers could improve morbidity and mortality in the long term. Not a few influential voices suggested that the many millions of dollars invested in running the trial might be better spent on programs to increase the use of these obviously-effective tests in clinical practice.

They were wrong. As of this week, the PLCO study is 0-for-2.

Miss #1 occurred in March of 2009 when the PLCO study first reported no mortality benefit from annual PSA testing, a test that a majority of men over 50 undergo routinely. Miss #2 occurred over the weekend, when the Journal of the American Medical Association published a landmark paper that ended with the following paragraph:

We conclude that annual screening for ovarian cancer as performed in the PLCO trial with simultaneous CA-125 and transvaginal ultrasound does not reduce disease-specific mortality in women at average risk for ovarian cancer but does increase invasive medical procedures and associated harms.

The lung and colorectal screening components of PLCO have not yet reported mortality data, and there is reason to believe that at least the latter will likely yield some positive results. Although it has largely been supplanted by colonoscopy and CT colonography (aka "virtual colonoscopy") in the U.S., flexible sigmoidoscopy was already shown to reduce deaths from colorectal cancer in a randomized trial published in the Lancet last year. And PLCO's screening chest x-rays are probably a loser, but a preliminary report from NCI's National Lung Screening Trial suggest that screening CT scans can reduce lung cancer mortality in heavy smokers. (Even after this report is confirmed in a peer-reviewed scientific journal, there will still be plenty of reasons not to rush into lung cancer screening, as I outlined in a previous blog post.)

Still, these are hardly the magic bullets or the resounding victories that many expected from the "War on Cancer." The same can be said for chemoprevention, or the strategy of prescribing medications for healthy adults to prevent cancers from developing at all. The vast majority of "high risk" women have avoided breast cancer chemoprevention with tamoxifen and raloxifene due to their unpleasant side effects (which include hot flashes and life-threatening blood clots), despite a 2002 recommendation from the U.S. Preventive Services Task Force for clinicians to discuss these drugs with their patients. (This recommendation has not been updated since, largely due to politics, not science.) A new study published in the New England Journal of Medicine has reported that the drug exemestane reduces the risk of invasive breast cancer without the other drugs' side effects. But here's the rub: we can't be sure how many of those breast cancers are the ones that inevitably lead to symptoms and death, rather than the 1 in 3 that are thought to be overdiagnosed.

The bottom line from recent research is that there are no easy victories in cancer screening and prevention - just slow, incremental progress. Companies that have a profitable product to push would like you to believe otherwise, but when it comes to cancer prevention, there is no substitute for a healthy lifestyle: Don't Smoke. Drink in Moderation. Exercise. And Eat a Well-Balanced Plate.