Patients, Populations and Policy: Season 1, Episode 2

This is the second of two podcast episodes that I created specifically for my first-year medical student class. It discusses the evolution of physician payment, the major components of the Affordable Care Act, and proposals for future health care reforms. If you haven't yet listened to episode 1, which provides some basic background information on the U.S. health system, you can find it here. And I don't intend to stop at two episodes, so if you like what you hear, please subscribe to the podcast feed to receive notifications when I release more later this year. My P3 podcast will also soon be available on ITunes, Google Play, Spotify, and Stitcher. Thanks for listening!

Patients, Populations and Policy: podcast episode 1 of 2

Nonselective full-tuition scholarships don't produce more primary care physicians

Last August, I wrote about NYU School of Medicine's decision to award full tuition scholarships to all current and future medical students, and my skepticism that this generous policy would achieve my alma mater's stated goals of recruiting a more socioeconomically diverse student body and sending more graduates into primary care fields. I was not the only person to gently criticize NYU's approach to these important issues; a few days later, Kaiser Health News editor and former emergency medicine physician Elisabeth Rosenthal wrote in a New York Times opinion piece that "instead of making medical school free for everyone, NYU - and all medical schools - should waive tuition only for those students who commit to work where they are needed most." As an example, she pointed to selective scholarships awarded by NYU's law school each year to 20 students who commit to careers in low-wage public service. Dr. Rosenthal also argued that since academic medical centers receive billions of dollars in public funds to train new doctors and don't pay taxes due to their nonprofit status, "Every academic medical center should see training the medical work force America needs not as charity but as an obligation, a 'community benefit' of the highest order."

As for increasing diversity, another laudable goal, Dr. Billy Thomas wrote in a JAMA Viewpoint:

If medical school admissions processes continue to be weighted toward metrics [e.g., GPAs, MCAT scores] and the number of minority, disadvantaged, and marginalized applicants remains stagnant, attempts to diversify the health care workforce will fall far short, despite reduced or free tuition. ... The NYU program may increase diversity at NYU, but taken in context with the stagnant national applicant pool, the increased enrollment at NYU may result in a “zero sum effect” on the national health care workforce as it relates to diversity and, by extrapolation, have no significant effect on our efforts to reduce health disparities and improve population health.

When I interviewed prospective Georgetown medical students this year, NYU usually came up in conversation, from the medical diploma hanging on my wall, if nothing else. Of course they had all applied to NYU, and if accepted, they'd most likely attend, no matter how much they loved Georgetown or Hopkins or Harvard or anywhere else without free tuition. Indeed, total applications increased by almost 50 percent, and applications from underrepresented groups more than doubled.

Another problem: according to an analysis of public data on medical school endowments, enrollment, and tuition expenses by two students at Mount Sinai (which had a brief but unsuccessful merger with NYU in the late 1990s), only 20 of 141 U.S. medical schools are financially positioned to afford going tuition-free for all students. Notably, even NYU shrunk its class size by at least a third from its size at the time of my graduation, presumably to lower the cost of providing every student with a scholarship. Like NYU, Harvard, which unsurprisingly tops the list of wealthy schools, doesn't even have a family medicine department, where establishing one would be an investment more likely to pay off for primary care than simply making school free with no service requirement.

Meanwhile, Dr. Bich-May Nguyen, a family physician with whom I've previously collaborated, just published a report in Family Medicine of a survey of 74 physicians who graduated from two BS/MD programs in Texas from 2003 through 2013 that provided full scholarships for college and medical school. 18 of these physicians went into primary care, which is about average for medical students nationally. Dr. Nguyen and her coauthor noted that the motivations for these physicians' specialty choice were similar to those from surveys of physicians who only received partial or no tuition assistance:

People interested in primary care were also interested in serving underserved or minority populations, health promotion, patient continuity, and patient advocacy. ... The second theme was found in statements supporting high income potential, prestige among colleagues, inpatient hospital care, and quick results from interventions. ... Additionally, the respondents most interested in high incomes did not enter primary care.

Ultimately, there are far less expensive solutions to the problems that NYU was supposedly trying to address by waiving medical school tuition. Want a more diverse student body? Admit more minority and low-income students. Want more students to go into family medicine and primary care? Establish and support departments in those fields, and admit more of the types of students who tend to pursue primary care. They won't necessarily have the highest GPAs or MCAT scores or the social advantages bestowed by wealthy parents (and potential future donors), but as the recent college admissions scandal showed, those things are overrated anyway.

Do subspecialist-led guidelines serve patients better - or worse?

In December 2017, the Health News Review blog posted a story questioning why there had been such extensive news coverage of the American College of Cardiology / American Heart Association hypertension guideline but so little of the American Academy of Family Physicians' announcement that it was not endorsing the guideline (the only other news outlets to have reported this decision are the AAFP's own news publication and Medscape). In this case, the AAFP decided to continue to adhere to blood pressure targets established by the JNC-8 hypertension guideline and its joint guideline with the American College of Physicians for adults aged 60 years or older.

Earlier that year, an editorial in the cardiology journal Hypertension criticized the ACP-AAFP guideline for the lack of "experts" on its panel. The 30 named authors of this 3-page piece, most of whom I suspect did not meet the International Committee of Medical Journal Editors' authorship criteria, collectively have a list of disclosures of commercial conflicts of interest that takes up nearly a column of text. Those concerns aside, Dr. Franz Messerli and colleagues stated correctly that "guidelines are traditionally scripted by a panel of experts who are intimately familiar with the topic in question." They went on to compare the glittering resumes of the JNC-8 panel ("most of them were indeed true experts") with the more pedestrian ones of the ACP/AAFP panel and asserted that the latter's dearth of expertise did not qualify them for guideline development:

As per PubMed, 3 of the 7 guideline authors have never authored an article on hypertension and 1 has coauthored a single study only. Moreover, not one of the authors of the ACP/AAFP guideline is known to be a hypertension specialist certified by the American Society of Hypertension or of the American Heart Association Council for High Blood Pressure. ... No ACP/AAFP guideline author is currently serving on the editorial board of a journal dealing with hypertension. ... The mere fact that you know how and when to prescribe hydrochlorothiazide does not make you an expert in hypertensive cardiovascular disease.

This argument echoed past complaints by subspecialty groups that the U.S. Preventive Services Task Force (USPSTF), made up entirely of primary care clinicians, could not possibly know what it was doing when it recommended fewer screening mammograms (without any radiologists!) or less prostate-specific antigen testing for prostate cancer (without any urologists!)

The question is not whether subspecialists should be involved in developing guidelines for diagnosis and management of common conditions such as hypertension: of course they should be. The question is, on what level? At the guideline review and revision phase (ACP/AAFP) or in developing the key recommendations? The ACC/AHA selected as one of its guideline co-chairs Dr. Paul Whelton, a renowned expert in hypertension who was the principal investigator for the SPRINT study, the only major trial to show that a blood pressure target of 120/80 yielded more benefits than harms compared to a blood pressure target of 140/90 in a selected group of very high-risk patients. In recognition of this intellectual bias, Dr. Whelton was relieved from chairing duties when SPRINT came up, but apparently was able to fully participate in the discussion and vote.

I had the pleasure of meeting Dr. Whelton at a conference a few years ago and came away enormously impressed by his intelligence and equanimity. But it's very hard for anyone to see something - in this case, harms of lower blood pressure thresholds - if your scientific reputation depends on your overlooking it. Also, in my experience as a staffer for the USPSTF, panel members who did not treat the condition being screened for were able to follow the evidence without being biased by clinical experience. Pediatricians who weren't conditioned to order yearly mammograms or obstetrician-gynecologists who never ordered PSA tests were more often assets than liabilities on these topics.

Primary care clinicians, particularly family physicians, have unrivaled expertise in treating the whole person, not only one body part or organ system. As I noted in a Medscape commentary on the ACC/AHA hypertension guidelines, "Cardiologists have the luxury of only needing to be concerned with cardiovascular disease, but the vast majority of my patients with hypertension have comorbid chronic conditions and take several medications. Adding one more anti-hypertensive drug means more potential side effects, medication interactions, and costs to the patient and the health system." Kudos to the AAFP for having the courage to stick with the evidence and buck the one-low-blood-pressure-target-fits-all trend.

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This  post first appeared on Common Sense Family Doctor on December 21, 2017.

Improving outcomes that matter for patients with type 2 diabetes

When comparing therapies for type 2 diabetes, physicians, patients, and quality measures often get caught up in the disease-oriented outcome of glycemic control. However, a 2014 editorial in American Family Physician pointed out that of the medications then available to lower blood sugar levels, only metformin reduced mortality and clinically relevant complications. Since that time, studies of some newer diabetes medications have demonstrated mortality benefits in patients with cardiovascular disease. However, the best second-line medication after metformin remains unclear. Although the World Health Organization guideline recommended inexpensive sulfonylureas as second-line therapy in low-resource settings, the American College of Physicians and the American Academy of Family Physicians suggested "the choice of drug [after metformin] should be based on a conversation with the patient about benefits, possible harms, and cost."

In the February 15 issue of AFP, Drs. Joshua Steinberg and Lyndsay Carlson applied the STEPS criteria (safety, tolerability, effectiveness, prince, and simplicity) to each of the 10 categories of diabetes medications (including insulin). Their analysis confirmed that metformin should be first-line pharmacotherapy for most persons with type 2 diabetes. Other key points from this article include:

Safety - Sulfonylureas, insulins, meglitinides, and pramlintide increase risk of hypoglycemia. Metformin and acarbose require monitoring, dose adjustments, or discontinuation in patients with chronic kidney disease.

Tolerability - Side effects across different drug classes range from gastrointestinal effects (metformin, acarbose, meglintinides, pramlintide, GLP-1 receptor agonists, SGLT-2 inhibitors) to weight gain (sulfonylureas), edema (TZDs), severe arthralgias (DPP-4 inhibitors), and genital and urinary tract infections (SGLT-2 inhibitors).

Effectiveness - Recent trials showed improved patient-oriented outcomes from some GLP-1 receptor agonists and SGLT-2 inhibitors in patients at high cardiovascular risk or with known cardiovascular disease. Acarbose also reduces cardiovascular events.

Price - Metformin, acarbose, sulfonylureas, and generic pioglitazone are the most affordable options.

Simplicity - Acarbose and meglitinides are taken three times daily before meals, while insulins, GLP-1 receptor agonists, and pramlintide require subcutaneous injections.

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This post first appeared on the AFP Community Blog.

Living, teaching, and valuing the pursuit of health equity

My younger son, who turned seven last week, had a minor health scare in December. After a few days of a cough and runny nose, one morning he complained that he didn't want to walk because his legs hurt. We gave him some liquid ibuprofen, wondering if these were just growing pains, but the pain kept coming back. Adding to our concern, this is a child with a high threshold for pain; for example, he barely blinked when having a cavity filled at age three. Over the next week or so, he developed red and purple blotches on his lower legs and feet that looked like this and this.

After consultations with our family doctor and other physician friends and family, he was diagnosed with Henoch-Schonlein purpura, a relatively rare condition that, fortunately, resolves spontaneously in most but can cause kidney disease in up to half of affected patients. Through the first week of January, his legs continued to hurt off and on as the rash slowly faded, but his kidney function remained normal, and the only medical bills we received were from a single clinic visit and some outpatient blood tests covered by our health insurance. We were lucky, not only because my son avoided complications, but because we had the advantage of being well positioned to obtain further care for him had they occurred.

Adjusted U.S. ESRD incidence rates, 2000-2015

Last week, I led a team-based learning exercise for the first-year class at Georgetown University School of Medicine on disparities in kidney (renal) disease. Not only are some racial and ethnic groups more likely to suffer from end-stage renal disease (when kidney function has deteriorated to the point that dialysis or a kidney transplant is often needed), but this unequal burden is unevenly distributed geographically, reflecting disparities in socioeconomic status. The graphic below, showing much higher rates of end-stage renal disease in the majority-African American northeast and southeast quadrants of Washington, DC, coincides with my years of practicing in these areas and noticing clusters of fast-food chains and dialysis centers around primary care clinics.

End-stage Renal Disease in Washington, DC

Similar large disparities in mortality and life expectancy are present nationally. In a 2006 paper, Dr. Christopher Murray (profiled in Jeremy Smith's "Epic Measures") described "Eight Americas," collections of U.S. counties defined by a mixture of race, geography, socioeconomics, and population density that demonstrated striking differences in mortality patterns. In a more recent analysis, Dr. Murray and colleagues concluded that geographic disparities in life expectancy have worsened over the past three decades: "Compared with the national average, counties in Colorado, Alaska, and along both coasts experienced larger increases in life expectancy between 1980 and 2014, while some southern counties in states stretching from Oklahoma to West Virginia saw little, if any, improvement over this same period."

Observing that overall U.S. life expectancy has been falling since 2015 after decades of steady improvement, a recent editorial in the Annals of Internal Medicine called on health research funders to "honestly recognize the interactive roles of biology and the socioeconomic and political environment ... [and] align health research resources toward an integrative model of science that seriously investigates the socioeconomic and political determinants of health alongside the biological ones." Reducing disparities in HIV/AIDS, for example, will require not only more clinical resources and affordable drugs, but more studies of policy interventions to improve social and living conditions that increase the risk of acquiring HIV infections in the first place. This means going beyond meeting individual-level social needs to changing the conditions that make people sick in communities and populations (including the Eight Americas).

As "value-based" health care payment models rapidly expand, based on the argument that we ought to be paying for good health outcomes rather than the volume of health services, we are recognizing that social determinants put some populations at a health disadvantage that effective interventions, such as increasing primary care physician supply, cannot fully overcome. As a result, physicians and health systems who serve underserved populations may be judged as providing "poor quality" care (and paid less) simply because their patients' outcomes were so much worse to begin with.

What can be done about this? Dr. Krisda Chaiyachati and colleagues have argued for a "disparities-sensitive frame shift" in value-based payment:

The health care industry cannot ignore true instances of poor quality, but it also should not worsen health care for at-risk populations. To address this tension, value-based payment models should ... integrate measures of equity into hospitals' financial calculus, incentivizing hospitals to tackle the disparities challenge without losing sight of quality. ... Concurrently, we should start paying hospitals to reduce disparities directly.

Similarly, Dr. Christopher Frank observed that "value-based payments will only work when we decide that health equity is an important value to reward."

Make no mistake: I'm happy that my son got well and has stayed well. I'm not happy that it is inherently more difficult for other children to have the positive outcome that he experienced. Reducing these disadvantages and pursuing health equity informs my clinical practice, teaching in population health, and writing projects.