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Sunday, December 9, 2012

Preventing Shingles

Shingles is a common disorder.  It’s caused by the reactivation of the chicken pox virus, varicella zoster virus, which remains dormant in one’s nerves after infection with chicken pox. Anyone who has had chicken pox is at risk.  Shingles is an unpleasant illness.  It causes prodromal nerve irritation, followed by the appearance of a blistering rash that follows the distribution of a nerve root. The rash can be painful and itchy, and can be the source of subsequent bacterial infection.  In some cases, cranial nerves, including nerves that supply the eye and ear, may be affected and this may lead to loss of vision or hearing.
The most unpleasant complication of shingles is the occurrence of “post-herpetic neuralgia,” defined as pain in the distribution of the shingles rash (or affected nerve root), which persists for more than three months after the shingles goes away--this may occur in 10 to 20% of cases.  Early treatment with antiviral therapy may reduce the risk of post-herpetic neuralgia.
One’s risk of developing shingles, and post-herpetic neuralgia as a complication, increases with age.  Immune deficiency, such as infection with HIV/AIDS or treatment with cancer chemotherapeutic drugs, also increases one’s susceptibility to shingles.  It is uncertain how the use of the chicken pox vaccine, now standard in children, will affect their adult risk of shingles compared with those who are unvaccinated.
A vaccine for shingles, Zostavax®, was FDA approved in 2006. In 2008 the CDC recommended that persons over the age of 60 receive the vaccine.  This recommendation is based on the relatively higher prevalence of shingles and its related complication in this age bracket. However, the shingles vaccine is also effective in healthy adults ages 50-59.  At this time the CDC has not recommended routine vaccination of this age group, which is likely related to lower disease incidence (about 4.6% annually in 50 year olds, compared with 7% annually in 60 years olds ,and 9 to 11% in 70 and 80 year olds).

Here are some common questions that patients ask me about the shingles vaccine:

1.       If I have already had shingles should I get a vaccine?

The shingles vaccine has not been tested in those who have already had shingles once. It is speculated that having the condition increases one’s immunity and helps prevent future recurrences. However, there is some research  indicating that those who have already been afflicted may continue to be at significant risk for recurrence. Therefore, it may be reasonable for this population to be vaccinated.

2.       What are the most common side effects related to the shingles vaccine?

According to the CDC, redness, pain, itching, and swelling at the site of the vaccine may occur in 1 out of 3 who receives the vaccine. Headache may occur in 1 out of 70.  More serious allergic reactions to the vaccine components including fever, difficulty breathing and throat swelling, are infrequent.

3.       Will it be safe for me to be around babies, pregnant women, and those with immune compromise after I have had the shingles vaccine? 

Yes, although it is a live attenuated virus vaccine, there have been no described cases of the chicken pox virus being transmitted in this manner from a person inoculated with Zostavax ®to a person who is not immune.

4.       In what population is the shingles vaccine contraindicated?

Although shingles is more common in those with immune compromise, the shingles vaccine is contraindicated in this population, which includes patients with HIV/AIDS, patients on cancer chemotherapy, patients on drugs that affect their immune system (such as oral steroids), and pregnant women. There are case reports describing disseminated shingles resulting from the vaccine in patients with established immune deficiency.

5.       I’m not sure if I had chicken pox, Should I have a shingles vaccine?

Persons who are unsure of whether or not they have had chicken pox should have blood work done to determine their immunity. If there is no evidence of previous exposure then a chicken pox vaccine (Varicella) should be administered in those who are eligible, not a Zostavax®.

6.       After 60, how often does one need a shingles vaccine?

Currently a single vaccine at or after age 60 is recommended.  The shingles vaccine is also FDA approved for patients ages 50-59 years.  However, given the lower disease prevalence and risk in this population the cost and health-benefit is not as well established and at this time the CDC does not specifically recommend it.  It remains uncertain how long the immunity conferred by a single shingles vaccine will last.

7.       What is the cost of a shingles vaccine?

A shingles vaccine costs approximately $200. Many health insurance plans, including Medicare Part D and private insurers, cover the immunization after (but not before) age 60.




Sunday, November 11, 2012


Everyone has heard of menopause, but is there a male equivalent? Two weeks ago at Personalized Primary Care Atlanta we discussed treatment of testosterone deficiency, or so called "andropause," in an evening health talk. PPC was happy to host Dr. Wayland Hsiao, Assistant Professor of Urology from Emory University as our discussant. Dr. Hsiao pointed out that declining testosterone levels are normal as men age and that while some men may be asymptomatic, others may suffer with symptoms that may negatively impact quality of life.
What are the symptoms of testosterone deficiency?  Loss of energy, decreased strength, reduced exercise capacity and erectile dysfunction are some. Testosterone deficiency may also contribute to metabolic syndrome, loss of lean muscle mass, and osteoporosis.  The ADAM questionnaire is a validated tool that can help identify symptomatic men.  Morley et al. Validation of a screening questionnaire for androgen deficiency in aging males. Metabolism. 2000;49(9):1239-1242.

Testosterone deficiency may be diagnosed on the basis of blood tests. Dr. Hsaio pointed out that saliva tests are not accurate.  Typically total testosterone and free testosterone levels are measured.  Free testosterone is the active version of the hormone.  If levels are low and men are deemed symptomatic treatment involves supplementation with testosterone, which is available in various delivery systems including transdermal gels, patches and pellets (implanted beneath the skin of the buttocks). Dr. Hsiao is of the opinion that injections of testosterone are not as well tolerated as the other delivery methods as they produce hormonal peaks and troughs that are associated with more adverse effects including flushes. 

Given the common nature of some of the described symptoms of testosterone deficiency it is not always clear who should be treated. One approach, for symptomatic men who have low or borderline testosterone levels, is a three month trial of treatment to see if symptoms improve.
What is the downside of testosterone replacement? One large clinical trial reported in the New England Journal of Medicine in 2010 demonstrated increased cardiovascular events in men who were randomized to treatment, and the trial was terminated early because of these adverse outcomes. However, Dr. Hsiao is skeptical that these risks translate to all men, and he noted that the population studied was primarily elderly, frail, and immobile.
Another concern with testosterone therapy is whether it has potential to promote prostate cancer growth in a man who may have subclinical prostate cancer or prostate cancer that has not yet been detected, and also whether it can cause enlargement of benign prostate tissue and contribute to worsening of urinary symptoms in men. Benign prostatic hypertrophy is another common condition that impacts quality of life in men as they age by causing reduced ability to urinate.  Dr. Xiao felt that evidence is lacking to suggest that either of these prostate conditions is affected much by testosterone therapy and sited data supporting this viewpoint.
It’s good to know that testosterone therapy exists as an option to help men with symptoms of andropause, which can adversely affect quality of life. However, those of us who have doctored through the era of the Women’s Health Initiative, which studied the effects of hormonal therapy for menopause, have to be somewhat cautious about prescribing treatment for a condition that affects a huge segment of the population. In the case of estrogen and progestin therapy in women, as discussed in a recent blog,  the pendulum has swung for, then against, and now recently partially back in favor of a cautionary approach to post-menopausal hormone replacement for symptom management during the time immediately following menopause in women.
To date testosterone therapy has been less well studied, and it could be years before the safety data for testosterone replacement in men is as good as the data for hormone replacement in women, which has been the subject of intense research in the previous decade.

Monday, October 8, 2012

Have Electronic Health Records Led to Fraudulent Upcoding by Physicians?

Over the past several decades medical costs in the United States have escalated rapidly, exceeding the pace of inflation and threatening bankrupt to Medicare.   As we heard in last week’s presidential debate, different solutions have been proposed on how to slow Medicare’s growth and reduce cost.  President Obama highlighted his administration’s success in tackling fraud and waste within the system. This strategy appears to be supported across party lines.  On face value it seems like a good idea, but what is not entirely clear to those of us within the medical community is how waste and fraud will be defined.  I have discussed this in a previous blog: "When is Unneeded Care Criminal?".
As reported by the New York Times last week,  recently attention has been focused on going after doctors and hospitals who some believe may be “upcoding” the complexity of their patient encounters to CMS and other insurers for the purpose of receiving better reiumbursement.  Apparently since the advent of electronic health records there has been a trend toward physicians' reporting higher complexity office visits.

The AMA (American Medical Association) Wire reports:
"The Centers for Medicare & Medicaid Services (CMS) notified the AMA that Connolly, a recovery auditor for what is commonly known as the Medicare RAC program, will begin auditing how physicians report CPT® code 99215, used to report evaluation and management (E/M) services. CMS appears to have also granted Connolly authority to extrapolate its review of sample claims to potentially recoup funds on 99215 claims it did not evaluate individually."
The AMA strongly objects to these audits and has written a letter to CMS pointing out that: 
"Audits of such complex services would result in erroneous payment recoupment and undue expense for physicians and CMS. According to the agency's own report to Congress, 46 percent of appealed Medicare RAC determinations are decided in favor of the physician or other health care professional."

What does upcoding mean? Medicare and other payers require that doctors use a convoluted coding system for billing medical visits based on their documented complexity. The system is so complex that for years it has outsmarted doctors who have been tasked with remembering the numerous elements required to justify the level of the visit (1 through 5), and then document the details required to support the billing level.

The selection of an appropriate billing code, as outlined in an 89-page guide prepared by CMS, if done correctly would without a doubt take the same amount of time (or perhaps more) as seeing the patient.  The end result:  most physicians, with limited time and partial recall of the complicated rules, pick the code that they feel best encompasses the visit level based on perceived complexity.

In the past when doctors dictated or hand wrote patient notes it was more difficult to include all of the historical factors required to support a higher level billing code. The use of electronic health records, however, has made the process easier by automating the incorporation of past medical history, medications, allergies, social history and family history into clinic notes, thereby allowing physicians to justify a higher level code. Until recently, based on personal experience, the tendency may have been to “under-code” complex visits, with fear that documentation would be inadequate to justify a more complicated billing code.  In reality, it is very time consuming to fully document the complex information that is exchanged in the context of a 15-30 minute office visit.
The purpose of medical documentation is to convey information.   Ideally doctors would be able to document the salient portions of each patient encounter that would help other providers care for the patient in the future.  In many ways electronic health records have helped facilitate medical documentation.  However, at the same time they have also led to the inclusions of extraneous information (for the purpose of supporting billing codes) that one is required to sift through while getting to the meat of the visit.
What is particularly enraging about these allegations of “upcoding” and fraud is that finally physicians have a tool to help ease the burden of Medicare’s inane billing code system—electronic health records; but now, after going through all the work and tremendous expense of transforming our practices and adopting these systems, we are threatened by the specter of accusations of fraud for “upcoding” the same visits that we’ve been “down-coding” for years.  If politicians would like to eliminate waste from Medicare why not simplify its billing system so that medical practices would not have to employ full time coding experts to ensure that their practices remain fiscally solvent? Of course, this would also eliminate a bunch of jobs.


Saturday, September 22, 2012

Managing Menopause in 2012

Recently I hosted an evening discussion for Personalized Primary Care Atlanta members on the topic of menopause. Here is a summary of our discussion:
·         Menopause is defined by no menstrual cycle for one year.
·         The average age of menopause in the US is 51.
·         90% if American women experience menopause between ages 45 and 55.
·         Prior to menopause women go through a period of transition, often referred to as perimenopause. 
·         During this time of transition women may begin by having irregular menstrual cycles with changes in cycle length and periods of heavier or lighter flow. 
·         Later in transition women may skip one or more menstrual cycles and may begin to have symptoms related to menopause.
·         Irregular menses relate to anovulatory cycles and low levels of progesterone
·         For several years prior to menopause women may have higher than normal estradiol levels and lower than normal progesterone levels.  FSH levels may also be high.
·         Following menopause FSH levels are high and estrogen and progesterone levels are low, however menopause is not defined by hormonal levels, and because of individual differences in hormone levels and also normal fluctuations in levels throughout the cycle, hormone levels can be difficult to use as parameters of change.
Common symptoms of menopause are related to a decline in estrogen levels. For most women symptoms last several years.  However, in some, symptoms may continue for up to 10 years. About 10% of women in their sixties continue to have hot flashes.
Menopause Symptoms:
·         Hot flashes (last 2-4 minutes, affect the upper body and face, occur frequently at night)
·         Insomnia (may be a manifestation of temperature regulation trouble—hot flashes)
·         Heart Palpitations
·         Forgetfulness
·         Changes in sex drive
·         Irritability
·         Vaginal dryness
·         Trouble with control of urination
·         Changes in body composition—reduced muscle mass
Menopause Risks:
Menopause increases the risk of osteoporosis. Women lose bone density quickly during the first five years following menopause.  Menopause is also associated with an increased risk of cardiovascular disease. Women develop more insulin resistance, lower HDL levels and higher LDL cholesterol.
Managing Menopause Symptoms:
Approaches to managing menopausal symptoms include hormonal therapies, off -label use of non-hormonal therapies, and natural remedies.
Hormone Replacement Therapy
·         Hormone replacement therapy is no longer recommended for menopausal women for the purpose of prevention. 
·         Hormone replacement therapy has been extensively studied in the form of conjugated equine estrogen in a dose of 0.625 mg and medroxyprogesterone at a dose of 2.5 mg in postmenopausal women with an average age of 63 in the Women’s Health Initiative trial.  This trial involved approximately 161,000 women and reported on a number of outcomes.   The Estrogen and Progesterone arm of the trial was terminated in 2002 and found that women using the two hormones had a higher risk of blood clots, heart attacks, strokes, and breast cancer.  The same women had a lower risk of colon cancer and bone fracture.
·         Women in the Estrogen alone part of the study had higher risk of strokes and blood clots, but not breast cancer and heart attacks.
·         Three years following discontinuation of the study women treated with Estrogen and Progesterone continued to have a higher risk of cancer, including lung cancer. 
·         A subgroup analysis of the study found that most of the risk conferred by hormone replacement therapy was related to the age of the treated women. Women treated from the time of menopause forward for five years did not experience significant increases in health risk. 
·         For a sense of the magnitudes of health risk I recommend looking at the handbook
Changes in Practice a Decade Later
Hormone replacement remains the most effective treatment of menopausal symptoms. However, not all women require hormone replacement to get through menopause. Currently women’s health experts prefer to use the lowest dose of hormones available to control symptoms. Today, oral estrogen is available in one half the dosage that was studied in the Women’s Health Initiative study. There are several different types of estrogen and progesterone available on the market.  All estrogens appear to carry a similar risk of blood clot.  However, it remains uncertain whether different types of estrogens and progestins confer different health risks. In the case of progestins, they do seem to vary more in their activity and side effect profiles. The adverse effects of hormone replacement are speculated to relate to dose. Current practice has shifted toward the use of transdermal estrogen and progesterone through patches—also available in low dose. Transdermal estrogen confers a lower risk of deep venous thrombosis, and it is thought by some that to be safer with respect to other health outcomes.  Vaginal estrogen is an effective means to treat the urogenital symptoms of menopause—vaginal dryness and urinary symptoms, and does not require systemic progesterone to protect the uterus as do oral and transdermal estrogen.  It is felt that if use of hormone replacement is limited to the first five years following the time of natural menopause (around age 51), the cardiovascular risks may be lower. Tapering hormonal therapy slowly after several years may produce fewer symptoms than stopping cold turkey and can help facilitate the transition to menopause for some women.  Some women may choose to live with the health risks related to hormone replacement and may continue treatment for longer than five years—reporting improved quality of life.
What are “Bioidentical Hormones?”
Bioidentical hormones typically refers to custom compounds of hormones that are also manufactured and marketed as pharmaceuticals. However, bioidentical hormones are not tested and regulated. Given the range of hormone replacement now available on the market with numerous dosing options, many women’s health experts agree that it is safer to use products that have been more thoroughly investigated and that are regulated in the U.S. through the FDA.
Non-hormonal options for treating hot flashes are available as off-label use of prescription medications and include:
·         Selective Serotonin Reuptake Inhibitors and Selective Norepinephrine Reuptake Inhibitors: paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), fluoxetine (Prozac)
·         Gabapentin (a seizure drug)
·         Clonidine (a blood pressure drug)
Natural Products
·         Plant Based Estrogens (Phytoestrogens) /Soy:  Not FDA regulated, might work in the body like a weak estrogen, might also have some health risk.
·         Black Cohosh : Also not regulated by FDA, lack of conclusive evidence that it helps, but has a fairly good safety record
For more information I also recommend the:
Or, contact me directly at

Friday, August 3, 2012

Physician Self-Disclosure: Helpful or Harmful?

How much should doctors reveal about themselves to patients? 
Whether or not “self-disclosure” is an effective communication strategy in the doctor-patient relationship has been debated.  In fact, some studies have demonstrated that doctors who talk about themselves more are rated more poorly by patients than those who are more private. This topic has been of interest to me and I have written about it in my blog:  Doctor, Patient, Friend:  Blurring the Boundaries,  and explored it further in a recent book chapter in Social Media in Medicine.   

In the case of teachers and students, communication strategies that promote “immediacy” have been found to have positive results in terms of promoting learning by creating a more open classroom environment.  Humor and self-disclosure are two strategies that promote immediacy. But, are these communication strategies effective in medicine also? I hypothesize that they are.
Recently a patient visited me to follow up after an E.R. visit. While she was in the office I recounted to her a personal tidbit that related to her day in the E.R.  While she and I were on the phone and as I was advising her the preceding Saturday afternoon, I had walked outside of a local sub-shop, Dave’s Cosmic Subs, seeking out private place to talk. On doing so, I had stepped beneath a tree into a pile of fire ants and was bitten all over my feet, which caused a degree of distraction.   For this reason I ended the phone call somewhat abruptly and later called her back. Was this self-disclosure helpful? She found it amusing, but we didn’t lose much time over the conversation.   A few days later she made mention of it again as we chuckled together about life's annoyances.
In another recent conversation with a patient who was considering various hormonal options for peri-menopausal symptoms I revealed my personal experience with using a Mirena IUD.  Several weeks later she decided this might be a good option for her as well.
Were these personal self-disclosures to my patients helpful or harmful? In the role of patient, I’ve been to see physicians who recount personal stories during an office visit that seem to take time away from my talk-time.   In a dentist's office this can provide pleasant distraction as one is held captive with her mouth open, but in a doctor's office it can be annoying to a patient when one knows that time is limited.   Nonetheless, physicians, with their expert knowledge of medicine, process medical information in the context of their own lives in ways that are sometimes helpful to patients to learn about by way of example. 
I have, on more than one occasion, shared the story: when I turned forty I was diagnosed with hypertension.  Three months after stopping oral contraceptive pills my blood pressure normalized.  I suspect that I will eventually need blood pressure medication, in light of my strong family history and current readings (130s/80s), and also despite my normal BMI and daily exercise. However, I will try to stave it off for a few more years. Are these tidbits of personal experience helpful for me to share with my patients?
As physicians increasingly engage in social media the question of appropriate self-disclosures becomes more relevant.  Should a doctor “friend” a patient on Facebook? How should a physician conduct his or herself on Twitter?  Self-disclosure is the norm for much participation in social media. The AMA has published guidelines for social media use by medical professionals.  My own theory is that physician self-disclosure can help promote intimacy and trust between doctor and patient—qualities that are increasingly lacking in the patient-physician relationship.  I might point out that in the case of social media, self- disclosures do not occur in the context of office visits, and as such are extra communications that don’t take time away from a patient’s precious appointment time.
Recently I was interested to read about a series of studies published in the Proceedings of the National Academy of Science. The studies, led by Harvard psychology researchers Diana I. Tamir and Jason P. Mitchell, made the relatively intuitive discovery: humans get a biochemical buzz from self-disclosure.  By inference, perhaps doctors who share more with their patients are happier with their patient interactions than those who are more reserved, and perhaps those positive feelings translate into a more effective health care experience.   No one knows, and more study is needed to uncover exactly what forms of physician self-disclosure are helpful to patients and what forms are more self-serving, or “narcissistic,” detracting from the patient-physician relationship.

Thursday, July 12, 2012

Are Annual Physical Exams Necessary

Recently a physician reporter for the New York Times, Elisabeth Rosenthal, argued in the cover article of the Sunday Review that routine physicals are in many ways pointless, and perhaps even dangerous.  In the article, entitled “Let’s Not Get Physicals,” Dr. Rosenthal goes on to point out that many routine tests performed during physicals --EKG’s, pap smears and blood work, are unnecessary. In my opinion, Dr. Rosenthal’s front page skepticism of the utility of the annual ritual misses the key point and sets a dangerous tone.  As every good primary care physician knows, the key benefit of an annual check-up (aka “physical”) is not the litany of tests ordered, but the opportunity it provides to do a complete review of a patient’s medical history and risk factors.  The “annual physical” also provides an opportunity for healthy people to get to know their physicians and vice versa, so that when illness arises, as it always will, the physician will understand a patient’s personality and healthy baseline.  
After years of criticism by proponents of prevention Medicare recently started to cover an annual exam, which is referred to as a “Wellness Exam.”  The Medicare preventive exam, which became a covered benefit in 2011, emphasizes history-taking as opposed to testing, which in my view is appropriate.   The Affordable Care Act also regulates the provision of preventive care by health plans requiring that plans provide a core set of preventive services without requiring a co-pay, co-insurance, or deductible.

While the physician author of the New York Times piece surely understands many of her own personal risk factors for disease and also the signs and symptoms of potentially serious underlying conditions, the general public does not have this expert knowledge. Why shun a once a year, hour-long (or, as is more often the case these days, 20 minute-long) visit to a medical expert to review one’s personal health profile, risk factors and family history?  I suppose that Dr. Rosenthal’s point is to de-emphasize the testing component.  In my view, if anything many individuals could benefit from more frequent (biannual or quarterly) preventive checks to keep them on track with their health goals and risk factors—perhaps this would keep more folks out of the ER and hospital.  As to the “testing” component of the annual physical, the visit provides an opportunity for patient and physician to discuss the state of the art, information that the patient might be reading online, and the evidence for and against screening for particular conditions. Which screening tests health insurance should pay for is a separate question. The issue here may be semantic—should it be called a "physical,"  a "wellness visit," or a "preventive check-up--" but, let’s not get rid of the annual visit.

Thursday, June 21, 2012

Two Conversations About Health Care

Last weekend I was struck by two conversations that I had with acquaintances about recent experiences that they had had with their primary care physicians.  The first occurred at my local pool. A fellow swimmer asked me if I took new Medicare patients.  She bemoaned that she was abandoned--her beloved physician of over 20 years had sent out a letter announcing that she would no longer accept Medicare patients. My friend had recently gone on Medicare.  She speculated about her physician’s  motives, but felt personally rejected, or “fired.”   After she explained her situation, I affirmed, “I do take new Medicare patients,” but qualified my response with a description of my concierge model primary care practice, which requires an annual retainer fee from members in exchange for improved access to me and other amenities, including my guaranteed smaller patient panel size. 

I started a retainer fee primary care practice after having been in a traditional fee for service practice for 12 years and then after taking a year’s leave of absence from clinical medicine. Many of my old patients sought me out, though currently most patients enrolling in my practice are new patients looking for a better primary care experience.  My swimming friend nodded that she understood and that her mother had a concierge physician--she was familiar with the concept and could see its value, though was going to have to decided whether she could afford it. 

My second conversation was at a friend’s 59th birthday party the following evening. The party was held at the upscale home of a middle-aged, gay male couple—friends of my friend. As I chatted with one of the hosts, a self-employed professional, he asked what kind of medicine I practiced. I explained that I was an internist, or a primary care physician for adults, and that I was in solo practice in Atlanta after practicing at the Emory Clinic for 12 years.  As I spoke he announced that he was in need of a new primary care physician. He went on to explain that his physician, who he was very fond of, had converted his practice last year to a concierge model practice—requiring patients to pay a membership fee in order to remain in his care.  He had made the decision not to enroll in the new practice model, in part because he was already paying a high deductible for care under his insurance and he was unsure how the annual fee would impact his out of pocket cost.  Before the host of the party said more (not wanting him to feel awkward with me), I explained that my practice was a similar model. He and I spoke for about twenty minutes about the problems in primary care and the reasons that primary care doctors were seeking out new practice models.  The man with whom I chatted pulled over his partner, who had been cared for by the same physician.  His partner reacted to our discussion—“but this is not a solution for our country’s health care problems.” I agreed, and we talked about cost and discussed new models of health care, including the Medical Home and Accountable Care Organizations, both of which have yet to materialize as answers for doctors like me.  He went on to assert that he felt that one solution to the problems in medicine would be to produce more doctors, while at the same time to lower the cost of educating them.  Personally, I doubt that producing more doctors in general, will improve primary care, nor will it reduce cost; though, better incentivizing primary care career choices would be helpful.

These conversations illustrate that for the American populous the main problems in health care today are access and affordability.   For primary care physicians the problem is not so simple.  The "system" has failed to support our work in a manner that is conducive to providing the care that we feel patients deserve. Patients may or may not be aware of the impact of this failure on our practice of medicine.

Most Americans equate spending money on health insurance with spending money on their physicians. Primary care physicians see relatively little of the money that consumers put toward their health insurance premiums. Our fees and reimbursement rates are relatively low in comparison to the exorbitant fees for tests, procedures, E.R. visits, and hospitals stays. As our overhead expense has increased, in part because of the administrative hassle involved in getting money from health insurance companies, we have responded by increasing the number of patients seen per day and our panel sizes to the point where many (including myself) feel that quality of care and the patient-physician relationship is compromised.

“Concierge medicine” and the abandonment of Medicaid, and now Medicare, by primary care practices are a reaction to these pressures, which have changed the nature of general practice and offer solutions to protect the personal aspects of the physician-patient relationship.  However, clearly these motives remain poorly understood by the average American consumer, who is faced with rising out of pocket medical costs to pay for health insurance, and increasingly feels burdened with excessive health care expense.

The disconnect leaves doctors like me in a conundrum. Do we continue to work within the confines of a system that has failed to protect primary care as an honored specialty? Do we compromise the care that we deliver in order to preserve access?  Or, do we jump ship and force change by creating new models of care—models of care that patients are increasingly seeking out as they recognize their value? It can be a difficult position to be in.

Thursday, June 7, 2012

"How can I raise my HDL?"

"How can I raise my HDL?" I have often been asked this question during my years of practice.  Lifestyle strategies include smoking cessation, exercise, and alcohol in moderation. However, evidence is mounting that perhaps this is not the salient question.
Three recent studies suggest that raising HDL levels may not be helpful in terms of reducing one’s risk of cardiovascular disease.
1)    The AIM-HIGH study compared niacin, which raises HDL, lowers LDL and lowers triglycerides, to placebo in patients at high risk for cardiovascular disease events (death, myocardial infarction and stroke).  The study was stopped because an interim analysis showed that patients taking niacin experienced no benefit from the drug with regard to preventing cardiovascular events.
2)    Dal-OUTCOMES was a study in which dalcetrapib, a new drug which causes circulating HDL levels to increase by a mechanism different from niacin (CETP inhibition),  was compared to placebo in patients at high risk for cardiovascular events . This study was also stopped early after an interim analysis showed that patients taking the dalcetrapib did not have fewer events than those given placebo.  Some years ago, another CETP inhibitor, torceptrapib, was found to actually increase cardiovascular events (though this was blamed on torcetrapib’s  side effects of increasing aldosterone levels and slightly raising blood pressure; dalcetrapib has no such side effects to blame).
3)    A recent study looked at people with genetic variations in cholesterol levels—one group with low LDL levels, and another with high HDL levels. People with genetically low LDL levels had fewer cardiovascular events than those with genetically higher LDL levels, reinforcing the concept that lowering LDL prevents cardiovascular disease. However, patients with genes that resulted in high HDL levels had similar rates of cardiovascular events to those who have genes resulting in lower HDL levels.

Epidemiological data has linked higher HDL levels to an increased risk of cardiovascular disease.  However the results of these recent studies call into question the utility of trying to raise HDL as a means to prevent cardiovascular disease.

In a separate study conducted by senior author Frank Sachs it was found that not all HDL is created equally. This study, published in April 2012 in the Journal of the American Heart Association, found that HDL molecules that contained apoprotein C-III actually were associated with increased risk of heart disease, compared with HDL that did not contain this “pro-inflammatory" protein.  

Practically, what does this mean? Those with low HDL should continue to pay attention to this as a marker that is known to be associated with higher cardiovascular risk.  However for now it remains uncertain whether HDL is actually causally related to higher cardiovascular risk.
In the words of Sekar Kathiresan (as reported in the New York Times) , Director of preventive cardiology at Massachusetts General Hospital, a geneticist at the Broad Institute of M.I.T, and investigator in the recent genetic study:
“The number of factors that track with low HDL is a mile long:  obesity, being sedentary, smoking, insulin resistance, having small LDL particles, having increased cholesterol in remnant particles, and having increased amounts of coagulation factors in the blood.  Our hypothesis is that much of the association may be due to these other factors.”

For now a person with low HDL has less reason to focus on using available HDL-raising treatments and drugs, and more reason to do everything else to reduce his/her risk of heart disease—including getting LDL cholesterol down to recommended levels, or even lower.

Guest Co-author: Kreton Mavromatis, MD, FACC, Assistant Professor of Medicine, Division of Cardiology, Emory University, Director of the Cardiac Catheterization Laboratory, Atlanta VA Medical Center and Juliet Mavromatis, MD, FACP, Adjunct Clinical Assistant Professor of Medicine, Emory University

Friday, May 25, 2012

Recommended Care, Says Who?

Guidelines for care increasingly help guide medical decision-making. If you’ve followed top health news over the past several years you’ve read conflicting statements about the utility of various medical procedures and tests. As a general internist I’ve devoured these reports with particular interest trying to wade through bias to formulate views that I believe will be of most benefit to my patients.

Recently I put together a talk about recommendations for prevention in women. As I prepared the talk I sorted through the data and opinions of various medical special interest groups.  Guidelines for care are usually developed by professional organizations or “expert panels,”  such as the Center for Disease Control (CDC), or the American Cancer Society (ACS).  One might like to think of these panels as unbiased in their advice, but clearly each expert panel is tainted, at least to a degree, by its own special interests.  Conflicting guidelines make it hard for health care consumers to figure out who to believe.

For example, several days ago the United States Preventive Services Task Force (USPSTF) came out with its final guideline on using PSA for the purpose of screening for prostate cancer. The task force recommended against using the test for screening healthy men, giving the screening test a D level rating (not recommended).

What is the USPSTF?
The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.

As a general internist I was indoctrinated to trust the USPSTF with a degree of allegiance that rivals my commitment to the University of Michigan Wolverines (my alma mater).  Nonetheless, there are other expert opinions that I also pay attention to.  In the case of PSA screening the American Urological Association (AUA) continues to make a strong argument supporting its use in screening. I discuss the debate more in my previous post:  Should Doctors Stop Using PSA to Screen for Prostate Cancer? 
Another example of conflicting opinions in medical guidelines:  Who should be screened for diabetes?  The American Diabetes Association (ADA) recommends that all adults with a body mass index >25 kg/m2 (overweight or obese adults) and one additional risk factor for diabetes be screened at least every three years, and that all adults with a BMI>25kg/m2 who are over 45 years of age be screened. In contrast, the USPSTF recommends for screening only adults with blood pressure greater than 135/80, a grade B (recommended) rating. For other healthy adults, overweight or not, it advises that the evidence is insufficient to recommend for or against screening.

These are but two examples of the numerous medical guidelines and recommendations that conflict:  who should be screened for HIV, whether women ages 40 to 50 should be screened routinely for breast cancer with mammograms, how often women over 50 should be screened with mammograms, how often women under 30 should have a pap smear, whether women need an annual pelvic exam, whether women need an annual breast exam, and at what age screening for colon cancer with colonoscopy should be discontinued.  The ADA,  the USPSTF, the CDC, the American College of Obstetrics and Gynecology (ACOG), the ACS, the AUA, the American Heart Association and American College of Cardiology—along with numerous other professional societies and expert groups have not reached consensus on various matters. 
Primary care doctors, as a group, have largely been supportive of proposed measures to reduce medical “waste”—including “unnecessary” tests and procedures that promise to bankrupt Medicare if they continue to go unchecked. In turn we stand to benefit from proposals to re-organize health care delivery and to strengthen primary care--the Medical Home Model, which may channel additional funds toward primary care. In comparison to specialists, primary care physicians have suffered in recent decades, with reimbursement policies that favor physicians who do procedures, as opposed to those who primarily talk to patients for a living.  We have been historically under-represented in the American Medical Association, the largest physician’s professional group in our country. I am part of the American College of Physicians (ACP), a national organization of internists — physicians who specialize in the prevention, detection and treatment of illnesses in adults--but recognize that we also have bias—currently, in my view, a growing skepticism of tests and procedures,  which in many ways is overdue. Yet I would wager that it’s a sentiment that primary care physicians find easier to rally behind than do many specialists, whose interests are more likely to be threatened by changes to reimbursement policy.

Who does one believe? Professional guidelines are likely to shape what is covered by Medicare and private health insurance. If you’re a gynecologist you might trust ACOG, if you’re a primary care doctor, the USPSTF or the ACP, a urologist, the American Urological Association--the politics of medicine are as real as the patients that we treat. Moreover, advocacy groups, such as the Susan G. Komen Foundation and Planned Parenthood, play a role in shaping public opinion, which no doubt can also influence the opinion of even “expert panels,”  afraid to anger these factions.
If you are a medical professional it’s important to be aware of where guidelines conflict and to avoid reflexively supporting one own expert panels.  Even better (though more difficult), read through the original data. If you’re a patient, sometimes it’s good to get the opinion of both a specialist and a generalist in these matters—each can be equally valid and it can help one see both the trees and the forest.