Actual causes of death in the U.S.: not what you think

Any standard public health or medical school prevention text includes (or ought to include) some version of the figure below, which illustrates that the leading causes of death in the U.S. at the turn of the century (heart disease, cancer, stroke) were actually surrogates for what have come to be known as the actual causes of death: unhealthy behaviors such as tobacco use, poor diet, and physical inactivity.

The most effective preventive services that primary care clinicians provide, then, are not screening tests but counseling interventions that aim to change one or more of these behaviors for the better. Community-level initiatives such as tobacco-free restaurants and campuses, pedestrian-friendly cities, and increasing access to nutritious food sources play a critical role in changing health-related behaviors, too.

Unfortunately, the impact of behavioral or "lifestyle" approaches to prevention is likely to be limited by two factors: 1) even intensive interventions produce very modest benefits; and 2) behaviors don't exist in a vacuum, but are largely shaped by economic and social circumstances. Family medicine professor and former U.S. Preventive Services Task Force member Steven Woolf has published a number of studies showing that the risk of death is strongly associated with levels of college education and income; his research team at Virginia Commonwealth University worked with the Robert Wood Johnson Foundation to develop an interactive County Health Calculator that illustrates how many premature deaths could be avoided by eliminating educational and income disparities.

Researchers from Columbia University went a step further by publishing "Estimated Deaths Attributable to Social Factors in the United States" in this month's issue of the American Journal of Public Health. Using estimates derived from the literature on social determinants of health and year 2000 mortality data, they found that the "actual" causes of death looked like this:

1) Low education: 245,000

2) Racial segregation: 176,000

3) Low social support: 162,000

4) Individual-level poverty: 133,000

5) Income inequality: 119,000

6) Area-level poverty: 39,000

Clearly, we know a great deal more about successful strategies for fighting clinical and behavioral causes of death than we do about social causes, some of which often appear intractable. But I could not agree more with the authors' conclusion that "these findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations." The point being: poverty, discrimination, and low education aren't just social or political issues best left to non-clinicians - they're health issues, too.

Mammograms and death panels: why the Preventive Services Task Force keeps pulling its punches

Health reform was supposed to have been good news for the U.S. Preventive Services Task Force. Until 2009, this independent panel of federally-appointed experts in primary care and preventive health was not particularly well known, and its evaluations of the effectiveness of clinical preventive services had no binding authority on public or private insurance plans. Within the small circle of physicians and policymakers who were aware of the their work, however, the USPSTF won accolades and respect for "calling it as they saw it," sticking strictly to the evidence and writing screening recommendations that frequently conflicted with more expansive guidelines promulgated by other professional organizations.

For example, the USPSTF differed from the Centers for Disease Control and Prevention in finding insufficient evidence to screen for hepatitis C, and only recommending HIV screening in high-risk patients (rather than universal screening between the ages of 13 and 64). Unlike the American Diabetes Association, which endorses testing for diabetes in all patients age 45 or older, the USPSTF found that the evidence supported screening only patients with high blood pressure. The Task Force clashed with the American Academy of Opthalmology in finding insufficient evidence to support routinely screening adults for glaucoma. And it checked the pharmaceutical company-supported enthusiasm for COPD screening by concluding that there was no benefit to routine spirometry in adults without respiratory symptoms.

A more politically-minded group (as federally-supported guideline committees tend to be) would probably have been unable to make such a series of controversial statements without stirring up a public backlash. But here, the USPSTF's low profile served to protect it from the advocacy groups that dominate conversations about federal coverage for health care services. But in 2009, that all changed, as the Task Force was prominently featured in health reform legislation proposed in the U.S. House and the Senate. Ultimately, the Affordable Care Act mandated that USPSTF-endorsed ("A" and "B") preventive services receive first-dollar coverage from Medicare and private health insurance plans.

Scrutiny of the USPSTF quickly intensified, especially after it issued a politically-radioactive new statement that stepped back from recommending routine mammography for women in their 40s. It was tagged as a "death panel" that, in the words of one spectacularly misinformed newspaper columnist, had "gone rogue" and ought to be immediately dissolved. (Not coincidentally, there is a Roger Maris-sized asterisk in the ACA's list of USPSTF "A" and "B" services that basically directs insurers to disregard the USPSTF's 2009 breast cancer recommendations and instead rely on the 2002 version.) With the Task Force literally fighting for its very survival, it was perhaps inevitable that politics would begin trumping science - which goes a long way toward explaining why members were willing to meekly go along with the absurd cover story that their November 2010 meeting was cancelled due to "scheduling conflicts."

In the 17 months since the passage of health reform, the USPSTF has been only a shadow of its independent self. After publishing an average of one new statement per month for most of my tenure on their staff (2006-2010), a public comment process imposed by the Agency for Healthcare Research and Quality turned into a bottleneck for releasing timely, evidence-based recommendations. None of the 4 new statements that have successfully traversed the public comment process has been particularly noteworthy. Osteoporosis: a modest expansion of screening to more high-risk women under the age of 65. Testicular cancer: a reaffirmation of the near-universal consensus that screening is not necessary. Prevention of newborn gonorrhea eye infections: affirming the standard of care. And earlier this week, the USPSTF retreated from its previous recommendation against screening for bladder cancer was not warranted, instead finding insufficient evidence to make a statement one way or the other.

Of course, a Task Force that makes few waves is exactly what the current Administration wants. Never mind that clinicians and patients must continue to wait for long-overdue updates on screening for prostate cancer, screening for oral cancer, breast cancer chemoprevention, and vitamin D and calcium supplements. (All of these topics had already been voted by the Task Force and were within months of publication in March 2010 but have been subsequently delayed, postponed, or suppressed from entering the public comment queue.) How long can this state of affairs reasonably continue? As the 2012 elections draw nearer, how likely is it that the USPSTF will be permitted to advance any science with even remotely political implications? And - though it pains me to ask - is a Task Force that is forced to pull its punches due to politics really that much better than no Task Force at all?

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from June and July:

1) No easy victories in cancer screening and prevention (6/7/11)

2) The difference between health care costs and investments (7/27/11)

3) How politically unpopular research helps us make better medical decisions (7/13/11)

4) Advanced access and other ways to see a doctor - stat (6/29/11)

5) Malpractice reform: unfinished business (7/6/11)

If you have a personal favorite that isn't on this list, please let me know. As always, thank you for reading!

Care transitions: 4 key questions to ask your doctor

A guest post earlier this week by David Loxterkamp, MD, "Why the Hospital Matters," reflected on some negative aspects of the continuing trend of family physicians ceding hospital care to hospitalists. The following post, first published on my Healthcare Headaches blog at USNews.com, examines care transitions from the patient's perspective.

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Doctors do the best they can to keep patients healthy and out of the hospital. Sometimes, though, hospitalization is necessary despite the best possible care. At the first private practice I joined after residency training, my colleagues and I admitted patients to a local hospital and took turns caring for those who needed inpatient treatment. This system ensured we'd have easy access to their previous medical records and often know them on a personal level. Arranging office appointments after discharge was almost never a problem, and we were guaranteed knowledge of what had happened to our patients in the hospital.

That's all changed. The way patients receive hospital care has transformed radically in the past 15 years. Many primary care physicians, pressured to take on more patients and exhausted from being on call too many nights, have stopped seeing their patients through a hospital stay. Instead, they now rely on "hospitalists," a relatively new breed of specialists whose exclusive responsibility is to care for hospitalized patients.

There are potential advantages to being treated by a hospitalist rather than a family doctor. Because hospitalists spend all their time on the wards rather than trying to juggle obligations to hospital and office patients, they're usually easier to reach with questions or concerns. Also, hospitalists may be more up-to-date on the latest medical research on inpatient treatments. These advantages should theoretically translate into better care and shorter stays for hospital patients. And they do, according to a 2007 study published in the New England Journal of Medicine; researchers found that patients cared for by hospitalists indeed had shorter hospital stays and lower medical costs than those cared for by primary care physicians.

But as hospitalists are replacing family doctors on hospital wards, concern is mounting that poor communication between hospital and office physicians could lead to worse health outcomes after discharge. I personally know the frustration of seeing a patient in the office after a recent hospitalization having not received critical information about what medicationchanges were made, what procedures he underwent, or what tests are needed to monitor his condition. Patients whose doctors don't have access to complete information during follow-up visits may be more likely to end up in the emergency room or be hospitalized yet again. (Same goes for patients who don't schedule follow-up visits at all.)

A study published Monday in the Annals of Internal Medicine seems to confirm these fears. In a nationally representative sample of Medicare patients admitted to hospitals between 2001 and 2006, those who were cared for by hospitalists had slightly shorter average hospital stays and slightly lower hospital bills than those cared for by primary care physicians. However, in the 30 days after discharge, hospitalist patients were more likely to be readmitted or land in the emergency room. One possible explanation: poor communication, since hospitalist patients were significantly less likely to follow up with their primary care physicians after discharge.

To improve the quality of "care transitions" between hospitalists and family doctors, some health systems have devised programs to ensure patients get the recommended follow-up care. Two studies published in last week's Archives of Internal Medicine evaluated two such programs. In one study, seniors who'd been hospitalized for heart failure at Baylor Medical Center in Garland, Texas received several home visits by specially trained nurses between three days and three months after discharge. Those enrolled in the nurse-visit program were only half as likely as past heart failure patients to be readmitted within 30 days. In another study, patients at six Rhode Island hospitals were assigned health coaches (nurses or social workers) who visited them once in the hospital, once at home, and telephoned them twice to encourage follow-up with primary care physicians and ask about any worrisome signs or symptoms. Patients in that program were nearly 40 percent less likely to be readmitted within 30 days than patients who received no health coaching.

Because it's impossible to predict whether you or a loved one will need to be hospitalized, it's important to understand your doctor's policies for patients who require hospital care. You can start by asking these 4 questions:

1. Do the practice's physicians care personally for patients in the hospital, or do they rely on hospitalists?

2. If you live in a metropolitan area with multiple hospitals to choose from, which hospital does your doctor prefer?

3. If you are seen by a hospitalist, what protocols are in place to ensure timely communication between the hospital and your doctor's office about follow-up plans?

4. Are you eligible for any programs that assist patients with care transitions?

Given all of the changes that have taken place in medicine, it's unlikely that we will return to the "old days" when the same doctors were responsible for caring for their patients both in and out of the hospital. Consequently, patients need to be proactive to be sure that they receive the best post-hospital care. Being hospitalized is always stressful, but knowing that your follow-up care won't fall through the cracks may give you peace of mind.

Guest Blog: Why the hospital matters

David Loxterkamp, MD is a family physician who lives and works in Belfast, Maine. He has authored A Measure of My Days: The Journal of a Country Doctor (U Press of New England, 1997) and numerous articles for professional and lay publication. He is the Medical Director of Seaport Family Practice, which was one of 36 family practices to participate in the AAFP National Demonstration Project (2006-8) and one of 25 practices chosen for the Maine Patient-Centered Medical Home Pilot (2010-12). His new book on the transformation of primary care (Conversation, Friendship, & Hope: The Journey of a Country Doctor) will be published in 2012 by the University of Michigan Press.

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Four years ago, Seaport Family Practice providers stopped caring for their hospitalized patients and gave up OB. Both services were an integral part of our practice for over 25 years.

There were compelling reasons for stepping back. We had tired of guideline-directed inpatient medicine and its narrow markers of achievement. Frankly, we were not as good at it as others who spent most of their day in that environment. We grew tired of the hierarchy, which is not surprising for occupants of its lowest rung. We just plain tired, too, of the night call that was required of those who maintained active membership on the hospital staff. We knew that most of our work took place in the office, even when we were performing the occasional delivery, attending the episodic medical crisis, or responding to an emergency visit in the middle of the night. With all of the new talk about patient-centered medical homes, we wanted to put our time and energy into advancing that cause, on whose success was pinned the hopes and survival of family medicine. That we were, first and foremost, a discipline of ambulatory clinicians was an easy argument to make. After all, that’s where our priorities should lie.

We knew that we could visit our patients any time we wanted to, although we never did, having allowed the hamster wheel to drive us with its own sense of urgency, its own unyielding momentum. Lastly, it was not hard to see that time in the hospital was financially irresponsible– slow and obtuse and unpredictable. It was much more efficient (a.k.a. lucrative) to pound out 25 office visits a day, see nursing home patients at our own convenience, and make home visits on our way to and from the clinic. Hospital CEOs and corporate executives also understand the calculus. With the majority of young graduates now preferring employment to ownership, most contracts do not include (or specifically exclude) the option of caring for inpatients.

But I missed doing it, and my patients missed me. There was a longing there that I attributed to an altered sense of identity. I had gone from being the doc who did it all to a more selective provider who did some. I had chipped off a piece of my generalist framework for taking in the world.

And 9 months ago I returned to the hospital as an experiment, n =1, to see if it really mattered to me or my patients, after all. The data set is not complete, but I can report on some preliminary findings:

1. Patients greatly appreciate it. Hospitalization often marks a dramatic reversal in a patient’s personal health. They are understandably afraid. The presence of a familiar face, an old friend, someone who takes time to talk and cares if they understand, let alone gives the patient his say, matters a lot.

2. The nursing staff appreciates it. They know that I am not there on business; I am there because I care about my patients. We have things to talk about. I listen to them, too.

3. The transitions of care go a little more smoothly. I can make sure that the medication lists between home and hospital reconcile; I can make sure that follow-up appointments are arranged for the next or most appropriate day. But I really don’t care if it prevents a re-hospitalization. Don’t get me wrong: I’m glad if it does, but sometimes patients need the hospital, or their own stubbornness puts them in harms way, which to the inevitable, or we all miscalculated the degree of need. It is not my fault that the hospital is so expensive, so I don’t make fixing it my top priority.

4. Lastly– and here’s the surprise– I have something to learn there, and I have something to teach. Hospitalist and ambulatory physician alike operate within a limited field of vision. We both make assumptions and decisions based on our varied training, experience, and perspective. We seldom (read that “never”) take the time to let the other know when a different decision would have led to a better for the patient, preferring instead to remain smug, distanced, and annoyed.

I know it's not easy to overcome the mutual defensiveness, embarrassment of being wrong, and fear of legal reprisal that is so endemic in modern medicine. But without the effort, our patients suffer, and we never learn. It is now commonplace for hospitals and practices to implement elaborate protocols at the time of discharge, often overseen by well-meaning nurses who have been renamed as “care managers.” But they are following protocol. They are not bridging the intellectual gap, the collegial gap, between hospital doctor and his outpatient counterpart.

Without the two sides talking on equal footing, neither side listens, neither side learns. We are losing opportunities to do what is right for the patient. Instead, we simply respond to payment incentives that punish hospitals for readmissions. We are following the dollar. We are not following the age-old family medicine directive to “do the right thing.”

Not every family doctor needs to be in the hospital, or deliver babies, or make home visits, or perform colonoscopies, or provide addiction treatment. But someone in his or her practice does. Or should, for the good of their patients, and for the completeness of care that their practice should provide. We are, after all, generalists. We must work hard to guard that mantle, and to emphasize the importance of human relationships across the professions, and follow our unflinching desire to do what is best for the patient, no matter what it costs in our, or someone else’s, time and money. This is why I think hospital care should matter to family medicine, from someone who has seen it professionally from both sides now.