Frequently in preventive health we ask patients to take medications that will reduce the risk of a certain bad medical outcome years down the road: cholesterol-lowering agents that lower the risk of a heart attack, blood pressure-lowering agents that reduce the risk of kidney disease, glucose-lowering medications that reduce the risk of diabetes-related complications. Sometimes these medications make patients feel better — for example, insulin in patients with symptomatic diabetes or a beta-blocker in someone with exertional angina — but more commonly patients get no tangible benefit from these medications on a day-to-day basis.

As doctors, we prescribe medications as a matter of course. If we deliberate, it is primarily in choosing which pill to prescribe. If the patient has hypertension, should we prescribe hydrochlorothiazide (HCTZ), an ACE-inhibitor, a calcium channel blocker, or a beta blocker? If a beta blocker, do we go with metoprolol or carvedilol or perhaps the newest beta blocker nebivolol? And what about the dose? There are sometimes good medical reasons to select one drug over another. There are dozens of clinical studies that test the use of different drugs in different patient populations and then there are evidence-based guidelines to help doctor make point-of-care decisions.

It turns out though that in practice despite the million dollar drug studies, the expert guidelines, and the deliberating, the most important thing we can do in prescribing a drug is to get our patients to actually take it. Adherence is a measure of how well a patient follows a treatment plan. Though the exact numbers vary by disease and treatment, adherence is on average 50 percent. That is, patients take their medications as prescribed about half the time. As one might expect the harmful effects of low adherence are enormous. According to a recent report in JAMA, poor adherence accounts for an estimated 33 to 69 percent of medication-related hospital admissions with an estimated cost of $100 billion.1 More importantly, poor adherence is also a major contributor to preventable deaths and reduced quality of life. Adherence is also a huge public health opportunity. In one recent study, simply improving adherence to statins from 50 to 75 percent in patients at high risk for coronary heart disease averted twice as many cardiovascular deaths than would an equivalent increase in prescribing statins for those at lower risk. I would love to hear of any new drug or device that could match that kind of impact.

So why is adherence so low? And more importantly, what can we do about it?

Part of the problem is reimbursement. It’s easier for me to get a cardiac stress test covered for a patient than it is a pill box to help him or her organize and remember to take their blood pressure and cholesterol medications.

Part of the problem is human nature. We tend to place greater value on today than tomorrow. This practice of “discounting” actually makes economic sense and is the basis for a large segment of the financial industry. However, in general we tend to discount the future more than we should – a phenomenon called “hyperbolic discounting.” Because we place undue emphasis on today compared to tomorrow, we are even less likely to take a medication that does little for us today for the sake of future benefit.

Part of the problem is the health care system. Chronic diseases are not treated in doctor’s offices or even the hospital. They are treated at home; they are treated every day in the decisions people make over what to eat and what not to eat and in the little blue pill they choose to swallow every morning or not. But the health care system has little reach on the home; it is not designed around where chronic disease management and prevention actually happens.

Reimbursement is a Washington issue (though as citizens we can certainly make an impact). Human nature, while largely unchangeable, can be tricked into working for us. This largely has to do with patient education. By helping people “see” the daily benefits of the medications they are taking today, we can improve their health tomorrow. For example, for hypertension, by encouraging people to track the change in their blood pressure daily or weekly, we can help them better relate the act of taking their medication each day to its long-term beneficial effects. Finally, we have the health care system. At my institution, I’m part of a study trying to link up a key part of a person’s daily life — his or her cell phone — to the health care system. Through automated text messages, we are helping patients with diabetes better remember to take their medications during the 8758 hours of the year they are not with us in clinic.2 But there is certainly more all of us can do. For example, doctors do not regularly assess adherence. Imagine a clinic setting where adherence was the fifth vital sign right next to temperature, heart rate, blood pressure, and respiratory rate.

As doctors, we spend a lot of time hemming and hawing about which pill to give our patients. As researchers, we study new drugs in hopes that they will be a few percentage points better than the ones we have currently. One pill may be 5 percent better than next, but if the patient only takes it 50 percent of the time, does it really matter? In our excitement over choosing between the red pill and the blue pill, we ought to spend more time just making sure our patients are actually taking the pills we give them.

- Shantanu Nundy, M.D.

1 Mike Mitka. Improving Medication Adherence Promises Great Payback, but Poses Tough Challenges. JAMA, March 3, 2010 – Vol 303, No. 9.

2 (24 hours/day * 365 days/yr) – (30 minutes/visit * 4 visits/yr), assumes the average diabetes patient has four 30-minute office visits per year.

Case 1

The first case was a 50-something year-old woman who had difficulty swallowing for the past 4 to 5 days when she started retching blood. As part of my workup, I reviewed her home medications and was surprised to learn that she was on a bisphosphonate. Given her young age, I wondered why she should taking the most commonly prescribed class of medications used to treat osteoporosis. However, in the heat of the night, I put my preventive health concerns aside and focused on her bleeding. The next day our GI specialists performed endoscopy to localize the site of bleeding. What they found was severe esophagitis, or irritation of the esophagus, a condition it turns out that is one of the major side effects of bisphosphonates. Suddenly understanding the reason why she was taking this medication became paramount. 

Osteoporosis, a disease of excessive bone loss, does not typically present until women are well into their 60s. In the past it was typically diagnosed after a patient sustained a non-traumatic fracture. Fractures occur at all ages, but in osteoporosis the bone becomes so  fragile that even minor events such as a fall cause the bones to break. A history of such a fracture is sufficient to make the diagnosis. However, in recent years, osteoporosis is increasingly being diagnosed through screening. According to the United States Preventive Services Task Force (USPSTF), screening should be routinely performed in women ages 65 and older and may be considered in at-risk women ages 60 to 64.* Screening is performed by measuring bone density using specialized xrays; once a person’s bone density gets below a certain cutoff osteoporosis is diagnosed. Screening and early diagnosis is critical because osteoporotic fractures are painful, disabling, and in the case of hip fractures potentially fatal. Studies show that women diagnosed with osteoporosis can significantly reduce their risk of fracture through a variety of medications — most commonly bisphosphonates.

The problem is that increasingly younger women and now men are being screened for osteoporosis with bone density testing despite the lack of evidence supporting its use in these groups. Furthermore, screening is being used to  treat individuals with a less advanced stage of bone loss called osteopenia, again despite the lack of evidence demonstrating effectiveness. These are classic cases of goodwill going too far. Younger women may have osteoporosis so what’s the harm in screening? Bisphosphonates are proven to be safe and effective at preventing fractures in women with osteoporosis, so why not give them to women with osteopenia?

In the case of my patient it turned out that she had been given the diagnosis of osteopenia after being screened with bone densitometry. Thus, in hindsight, she was given a test she should not have had, then given a medication she shouldn’t have been taking, and finally developed an acute complication of that medication and winded up in the emergency room.

Case 2

The second case was of a 90-year old man brought to the ER after falling at home and found to be profoundly anemic with dark, tarry stools. With a history of high blood pressure and high cholesterol, he was taking a baby aspirin a day, presumably to prevent heart attacks. But again, reviewing his medication list that night, I was surprised to see it. While I am an enthusiastic supporter of heart disease prevention, the literature is becomingly increasingly hazy about the purported benefits of aspirin for primary prevention — meaning for people who have never had a heart attack but are risk for one.** But again, I put my prevention concerns aside temporarily. The next day endoscopy revealed a large ulcer in the stomach, which most commonly results from non-steroidal anti-inflammatory medications such as aspirin.

A decade ago the existing clinical trials to date showed that in at risk individuals taking aspirin daily reduced the risk of heart attacks by one-third. While aspirin was known to be a major risk factor for GI bleeding — repeated use corrodes the stomach lining causing ulcers — in many older people the benefits of aspirin were worth the risks. In the past ten years however a number of newer trials have dampened the initial enthusiasm for aspirin in primary prevention. Now looking at all the clinical trials in aggregate it seems the benefits of aspirin are lower than previously thought. The new guidelines from the USPSTF now reflect these data, encouraging doctors to discuss the risks and benefits of aspirin with their male patients ages 45 to 79 and female patients ages 55 to 79 instead of simply starting it routinely.*** As a result in the past year I’ve found myself taking more people off aspirin than I have started it. While a great deal of controversy still remains one thing is clear: aspirin is not recommended for older adults. The risk of GI bleeding increases with age and at the same time because of competing causes of death and limited life expectancy the benefits are lower. The USPSTF guidelines suggest 80 years of age should be the upper limit. But from common sense we know that numerical age matters less than physiologic age; we all know of 80 year olds who run marathons and also 80 year olds with terminal illnesses.

In this case, just eyeballing the patient across the room it was clear he was not a good aspirin candidate. He had early dementia and lived in a nursing home. In medicine, I find, we are good at putting people on medications but bad at taking them off. Perhaps a decade or two ago it made sense for this patient to be on aspirin. He had high blood pressure and high cholesterol, at least a decade of life ahead of him, and the data of the time supported its wider usage. However, as he aged, developed significant disability, and the evidence base supporting aspirin weakened; this decision should have been revisited.

Conclusion

It’s hard to find a greater proponent of preventive health than me. But in our enthusiasm for prevention we cannot forget about the priniciple of first do no harm. We definitely don’t want too little prevention, but we also don’t want too much. Nothing in medicine is without risk and that goes for preventive health too.

- Shantanu Nundy, M.D.

* USPSTF, September 2002 http://www.ahrq.gov/clinic/uspstf/uspsoste.htm

** See my earlier blog post: http://beyondapples.org/2009/05/07/aspirin-may-prevent-heart-attacks-and-strokes-but-its-giving-me-a-headache/

*** USPSTF, March 2009 http://www.ahrq.gov/clinic/USpstf/uspsasmi.htm

On January 4th, four days after smoking his last cigarette, he updated his status: “bring it on day 5!” Within hours, three people responded that they “Like” his comment; five others commented favorably with messages such as “Good for you!!!” and “Keep it going, bro.” Encouraged by the support he received, my cousin posted another update three days later. Using his iPhone he wrote that he ”is one week non-smoking!!!” Again, within hours, eight people responded that they liked his comment and another two offered congratulatory remarks.

Though he didn’t necessarily realize it at the time, my cousin was creating a community of supporters through Facebook. The scientific literature is filled with evidence on the value of peer support for behavior modification. The “T” in the START mnemonic for quitting endorsed by www.smokefree.gov is to “Tell family, friends, and coworkers that you plan to quit.” This recommendation is based on the notion that smoking is not purely a chemical addiction; it has important environmental, social, and cultural elements, too.

Our peers do not only provide support for quitting on good days; they are equally invaluable on bad days. Three days after his last post, my cousin started feeling lousy. He posted having “a crazy head cold. Never felt this crappy in several years.” While he may have had caught a cold, it is more likely that he was going through nicotine withdrawal. Was this a simple update or a call for help? Seven of his friends responded offering home remedies and supportive messages. The next day he was feeling better and posted, “Twelfth smoke free day!,” garnering nine “Like”’s and seven enthusiastic comments. He responded, “Thanks for all the support everyone. Really helps me to stay on the path.”

People who quit often benefit from the support of a physician and other health care providers. Whether it be in the form of counseling, pharmacologic support, or referrals studies show that people who quit with the support of a health care provider have a much higher chance of success. The problem is that assistance is often needed in real-time. I once shadowed a tobacco cessation counselor at my hospital who offered his cell phone number to every patient he saw, but this kind of dedication is rare. My cousin’s next post read, ”19th smoke-free day in a row. Maybe enjoy a cigar on the 30th day…let me ask my doctor…?” Here, too, surprisingly Facebook offered a solution. I immediately responded applauding him for his progress but also gently suggesting that it was probably too early for a celebratory puff.

Real-time support is critical because the decision to quit smoking isn’t made once. It’s made every day – in fact multiple times a day – whenever the nicotine craving hits. This is a major reason why social networks are so critical. Week 3 he posted that he ”… is wondering why day 21  is harder than 3,4,5 and 6 combined.” While my cousin could have called up 10 of his friends and told them that he was having a difficult time that day, it was clearly easier and perhaps more effective to post about it instead. After seeing his post, I called him to get his mind off of smoking.

Research in smoking cessation and behavior modification has demonstrated the importance of social networks. In recent years, there has been fascinating research showing, for example, that overweight people are more likely to have overweight friends and that happiness is contagious. The challenge in modern day society is how to activate these social networks to affect good. Previous generations made greater use of formal networks such as religious gatherings, town hall meetings, and social clubs. While these avenues are still important today, increasingly technology is playing a role in defining our communities. While e-networks are less personal, this is not necessarily always a bad thing, especially when it comes to changing bad habits. They also benefit from a wider reach, being more real-time, and increasingly more dynamic.

Whether by design or accident, my cousin stumbled on an innovative approach to leverage social networks to quit smoking. And quitting smoking is just one application of e-social networks. Imagine the analogy for weight loss: “I lost 2 lbs this week!” soliciting responses of “Way to go!”, and “Feeling too lazy to go to the gym” being met with “You can do it! The hardest part is getting there!!” Finally, though it is not as readily apparent, my cousin is not the only one benefiting from his Facebook posts.  The positive effects of social networks go both ways. Friends following his posts are no doubt taking note of his success and being motivated to better themselves.  His last post reads: “Still at it 41 days now. Feeling great and about to start a kick ass work out regimen.” Who knows? If he starts posting about his work outs on Facebook, I may just go to the gym more often.

- Shantanu Nundy, M.D.

Compared to many other diseases, diabetes can be diagnosed easily. In people without any symptoms of the illness, two routine blood tests can provide the diagnosis. The first is to screen for the disease; if abnormal, the test is repeated. The most commonly used screening test for diabetes is a fasting plasma glucose test, or FPG. Because diabetes is characterized by abnormally high sugar levels in the blood (also called plasma), an FPG of 126 mg/dl or higher is suggestive of the condition.

While this sounds simple enough, diagnosing diabetes can be more challenging in practice. The problem with FPG is that it requires not eating anything for at least 8 hours prior, which is typically done by having the patient return on another day after skipping breakfast. This creates at least two barriers. First, for many patients coming to the doctor is an ordeal. My patients often have to take time off of work to see me. This is particularly true for those with blue-collar jobs that require them to report to work early in the morning, the exact time that the blood sample must be drawn. The second barrier is that returning for labs makes follow up more difficult. It is easier for doctors to keep track of tests that are done in the same office visit than those done later. As I discussed in a previous entry (http://beyondapples.org/2009/07/30/forgetting-to-break-bad-news/), studies show that over seven percent of clinically significant abnormal test results are not reported back to patients.

New recommendations from the American Diabetes Association (ADA) support the use of a new screening test, hemoglobin A1c (HbA1c), that promises to make the process easier.1 HbA1c avoids the pitfalls above because it does not require an overnight fast. Blood glucose levels change moment-to-moment with food, stress, and time of day; in contrast, HbA1c is a measure of a person’s average blood sugar levels over the previous two to three months. As a “running average,” it is less subject to daily variation and is already being used to monitor people with diabetes. An HbA1c of 6.5% or higher is suggestive of diabetes.

Another advantage of HbA1c is that it allows doctors to more reliably diagnose diabetes in hospitalized patients. Any illness creates a sympathetic “fight-or-flight” response that drives up heart rate, blood pressure, and, it turns out, glucose levels. As a result, a patient who has an elevated FPG in the hospital may have diabetes or just be hyperstimulated. With HbA1c, doctors will be able to detect diabetes in those who are often at greatest risk of having it — those who slip through the cracks of good primary care and wind up in the hospital.    

So should you be screened for diabetes? The United States Preventive Services Task Force (USPSTF) recommends routine screening for diabetes in individuals with a blood pressure above 135/80 mmHg.2 The ADA casts a wider net and recommends screening in all adults ages 45 and older, and younger adults who are overweight (body mass index or BMI > 25kg/m2) and have any additional risk factors:  

• physical inactivity
• first-degree relative with diabetes (parents, siblings, children)
• members of a high-risk ethnic population (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
• women who delivered a baby weighing > 9 lbs or were diagnosed with gestational diabetes
• hypertension (> 140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level < 35 mg/dl or a triglyceride level > 250 mg/dl
• women with polycystic ovary syndrome
• other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
• history of cardiovascular disease

To calculate your BMI, go to http://www.nhlbisupport.com/bmi/. 

Like FPG, HbA1c can also help identify individuals with pre-diabetes, those with sugar levels that are abnormal but not enough to diagnose diabetes. For FGP, individuals with a blood sugar level of 100-125 mg/dl have pre-diabetes; with HbA1c the range is 5.7%-6.4%. One-third of people with pre-diabetes will develop diabetes within 3 years; recognizing the condition is critical because studies show that through aggressive lifestyle modifications people with pre-diabetes can prevent the onset of diabetes (see http://beyondapples.org/2009/11/14/world-diabetes-day-2009/). 

Why go through all this trouble to talk about a new test for diabetes? After all, isn’t your doctor the one who decides whether to order blood work and what tests to order? The trouble is that we’ve learned the hard way that it takes anywhere from 7 to 10 years for the medical community to adopt a new guideline. For those of us at risk for diabetes that’s not soon enough. The next time your doctor orders blood work ask him or her about getting screened for diabetes. If you don’t need fasting blood work for another reason and are worried about having to come back, ask about HbA1c.

- Shantanu Nundy, M.D.

1 Standards of Medical Care in Diabetes — 2010. American Diabetes Association. Diabetes Care, Volume 33, Supplement 1, January 2010. 

2 http://www.ahrq.gov/clinic/uspstf08/type2/type2summ.htm

In the weeks leading up to the experiment, a group of us decided what the patient communication tool would look like and then actually created it. We designed the tool around three critical communication gaps. First, our patients often didn’t realize what steps we were taking to prevent cardiovascular disease. Second, even though most of us counsel our patients on preventing heart disease, they often didn’t have a complete understanding of their risk factors, including where their numbers stood with respect to their goals. And thirdly, our patients were often uncertain about the steps they needed to take to reduce their risk of cardiovascular disease, or if they were taking them, such as starting a new medication, they did not fully understand why.

What we came up with was the Heart Health Checklist, a paper form that we would fill out and discuss in clinic and then give to our patients to take home. It would serve as a “report card” of sorts. Instead of History and Math, patients were being “graded” on their cholesterol and blood pressure. The checklist showed them exactly where they stood compared to where they should be and included instructions for how to improve. We decided to focus on five elements of cardiovascular health: blood pressure, smoking, cholesterol (total, HDL, and LDL cholesterol), weight (BMI), and, for those patients with diabetes, sugar control (HbA1c). As discussed in an earlier blog post, “Are You Five for Five?”, 95 percent of heart attacks occur in people with at least one of the following five risk factors: high blood pressure, cholesterol disorder, smoking, diabetes, and obesity. By focusing on these five measures, the checklist targeted the major controllable risk factors for heart disease. Graphically the Heart Health Checklist was designed as a table. Each row was dedicated to one of the five measures of cardiovascular health. In the first column we put the patient’s goal (e.g., blood pressure < 140/90); in the second column, his or her current status (e.g.,149/86) ; and in the third column our plan for improvement (e.g., reduce salt, increase dose of HCTZ).

As part of our experiment, we will be collecting and analyzing data about patient satisfaction before and after we implementing the Heart Health Checklist. While the data won’t be available for some time, in my mind the checklist has already proved its merits. Two cases illustrate the point:

Case 1: Ms. PG is a 68 year-old woman who I have been seeing in clinic for over a year. She has been struggling with weight loss and anxiety over this time, but also with a smoking habit that just won’t quit. Every time I see her in clinic it’s pretty much the same story – ”Yes Dr. Nundy, I want to quit. No Dr. Nundy, I’m just not ready yet.” Her visit last week was no different. But just as she was heading out the door, I realized I had forgotten about the Heart Health Checklist. I reached for the checklist and frantically started filling it out, already late for my next appointment. As I went through her blood pressure, cholesterol, weight and sugar control; I wrote “excellent” in the column where I was supposed to write out her plan for improvement. As I did, she remarked at how amazed she was about how good her health was. Only one measure stood out — smoking — next to which I wrote “make a plan to quit”. Her sentiment was palpable: ”You mean to say that if I quit smoking then my heart health will be overall ’excellent’?”

Case 2: Mr. YM is a young professional in his late 20s. Since graduating from college, he has put on weight and developed prehypertension.* With relatively few medical issues, we always have plenty of time to discuss his blood pressure and weight and review proper lifestyle modifications. Like Ms. PG I went through the entire clinic session forgetting to take out the Heart Health Checklist. At the last moment I remembered, and used the checklist to go over (yet again) his blood pressure and weight and our plan for controlling them. But this time the conversation took a different tenor. With the numbers staring right at him, I could almost see the light bulb go off in his head as I explained what I was concerned about and what we could do to improve. He left the office firmly grasping the checklist in his hands, telling me that this new tool was “extremely helpful” and a “great idea.”

Much has been written about the art of doctor-patient communication — how we are supposed to listen attentively, speak with minimal medical jargon, and ask patients what they understand about their conditions. But I seldom hear much about the science of doctor-patient communication. While simple, our experiment is already having a profound influence on how I think about relaying health information to my patients. While talking clearly and openly with our patients about their medical conditions is no doubt essential, so too I am finding is simply writing it down.

Preventive health is sometimes viewed as a futile discipline. Old habits die hard; patients will never change. We look for the next breakthrough pill or wonder diet, thinking that they will curb the tide of chronic disease that is washing over our nation. But the fact of the matter is that obesity, diabetes, and even heart disease are lifestyle diseases. The problem is inherently in how we live — so too then must be the solution. It’s not that people don’t want to be healthy — everybody does — but rather that they don’t understand what is their risk of serious illness, where they stand compared to where they should be, and how to make small steps in the right direction. The next time we reach for a prescription pad to control a lifestyle disease, we should consider reaching for a blank sheet of paper, or better yet, a Heart Health Checklist.

- Shantanu Nundy, M.D.

* elevated blood pressure not high enough to be classified as hypertension; by definition, systolic BP between 130-140 mmHg and/or diastolic BP between 80-90 mmHg

Imagine a world where consumers all knew about the latest developments in preventive health…

Earlier this month the Advisory Committee on Immunization Practices (ACIP) released the 2010 immunization schedules. Revised annually, the immunization schedules are what doctors in the U.S. use to decide who should be immunized against what diseases. Far from esoteric, the schedules pertain to every single person living in the United States. If the H1N1 pandemic and subsequent mayhem over vaccination have taught us anything it’s that in the 21st century vaccines still matter.

Despite this, the release of the new guidelines was accompanied with little fanfare. Popular media mostly ignored the story. Even at my own academic medical center there has been little circulation or discussion of the new guidelines.

As individuals, we are generally of the belief that such information are more for doctors than for patients. After all, vaccines are not like healthy eating choices or the latest trends in fitness; they are prevention tools that require a health care provider to receive. As long as we show up for our doctor’s appointments, we think, we are doing our part to make sure we are taking advantage of all that medicine has to offer for preventing infectious illnesses.

Unfortunately, such is not the case. The data overwhelmingly shows that we are being under-vaccinated. A little over half of people eligible for the pneumonia vaccine receive it, about a third of those recommended to get the seasonal flu shot get it, and less than 5 percent of those who should receive the shingles vaccine have gotten it. Today, despite the initial public outcry over shortages of H1N1 vaccine, many people have not been immunized now that the vaccine is widely available. Each of these can be viewed as a missed opportunity to prevent illness, many of which have the potential to be life-threatening or disabling.

Looking at the guidelines, I suspect, would be highly instructive for many people. First, there are an astonishing number of vaccines available. Here is a partial list of diseases that vaccines protect against: chickenpox, croop, diphtheria, measles, hepatitis A, hepatitis B, HPV, influenza, meningitis, mumps, pertussis, pneumonia, polio, rotavirus, rubella, shingles, tetanus, and yellow fever.

Equally surprising to many people is that vaccines are not just for kids. (In fact, the immunization schedules are divided into ages birth to 6 years, 7 to 18 years, and ages 18 and older.) Nearly every age group is at risk for infectious illnesses for which vaccines are recommended. Children, of course, have a number of vaccines that are recommended to build their immunity, but so do adolescents. Girls ages 11 to 12 should receive the human papillomavirus (HPV) vaccine to protect against early stages of cervical cancer; those who did not receive it earlier can get it up to 26 years of age. College students living in dorms are advised to get vaccinated against meningococcal meningitis, an infection of the covering of the brain. Adults who have young children at home, who are pregnant, or work in health care are recommended to receive the flu vaccine. People who travel to endemic countries (of which there are many) are advised to receive the hepatitis B vaccine, as is anyone who simply wants to be vaccinated because 40 percent of people with hepatitis B have no identifiable risk factors. Beginning at age 50 all adults require vaccination against influenza annually; at age 60 a one-time vaccination against shingles; and at age 65 a one-time vaccination against pneumonia. And the above is just a partial list of vaccines and of those eligible for vaccination.

Given the above, it’s reasonable to consider vaccines as not only being in the medical domain. It’s just not doctors, hospitals, and the public health community that need to be apprised of the latest developments in infection prevention — the general public does too. Our experience with H1N1 shows that the public is a powerful driver for improvements in care delivery. One an individual level, too, people can advocate to receive vaccines that are recommended for them, but because of health care’s bias towards chronic and acute conditions, may escape their doctor’s attention.

Clearly we as health care providers need to do a better job vaccinating people. But there is a role for patients to advocate for themselves as well. You don’t need to be a doctor to get a sense of which vaccines are recommended for you. All you need is the latest ACIP guidelines, a working knowledge of your medical history, and ideally your vaccination history.

One day I would love to see Time Magazine do a “by the numbers” about the low rates of vaccination, or for Steven Colbert to do a “report” on vaccine-preventable diseases, or for the release of the annual ACIP guidelines to be a highly anticipated and publicized event. Until then, it’s up to us to spread the word.

- Shantanu Nundy, M.D.

Here is a link to 2010 adult immunization schedule: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Here is a link to a vaccine administration record for adults: http://www.immunize.org/catg.d/p2023.pdf

Here is a link to all the 2010 immunization schedules and other information: http://www.cdc.gov/vaccines/recs/schedules/default.htm

1. Ethnicity. Like myself, my uncle-in-law is of Indian descent. Colon cancer is much less common in Asian ethnicities than Western ones. In Japan, where the best data is available, the disease is uncommon enough that doctors do not routinely perform colon cancer screening (in contrast they routinely screen for stomach cancer, which we don’t do in the U.S.). The risks and benefits of screening for a disease are related to its prevalence. Though my uncle is 53, three years beyond the age at which screening is routinely recommended in the United States, I would not have necessarily recommended it for him given its low prevalence in India.

2. Age: Even for people living in the U.S., developing advanced colon cancer at 53 is rare. Though screening is recommended for average-risk individuals starting at age 50, the average age at diagnosis is 64. The goal of screening is to detect and remove pre-cancers before they progress into cancer or if cancer has already developed to catch it early at a curable stage. Thus had we screened my uncle-in-law for colon cancer we would be expecting, if anything, to find precancerous polyps, not full-blown cancer.

3. Family history: Every American over ages 50 to 75 needs to be screened for colon cancer, regardless of lack of family history.1 In those with a family history, screening may need to begin at an earlier age. For example, experts recommend screening first-degree relatives of people who developed cancer before age 60 starting at age 40 or 10 years before the age of diagnosis, whichever comes first.2 As far as we know, there is no history of colon cancer in our extended family. Such a history may have tipped us off to begin our prevention efforts earlier.

Our understanding of cancer and other diseases is still limited, and as a result our abilities to detect diseases early and to prevent them altogether are still crude. Most diseases result from a combination of genes and environmental exposure. The better our understanding of these elements the greater our ability for targeted prevention. Family history of colon cancer is a proxy for our genetic makeup. Thus people with a history of colon cancer in first-degree relatives with whom we share 50% of our genes or in multiple second degree relatives are at higher risk than the average person. Ethnicity is another proxy for genetic risk and one that is even more crude. In the future, we will hopefully be able to move beyond these blunt measures and better assess genetic risk. Such understanding would allow us to better target screening to those at highest risk. This would prevent unnecessary testing in low-risk adults and promote screening in people at truly increased risk. Already in diabetes researchers have identified specific genetic variants that predispose people to diabetes; in oncology, BRCA1 and BRCA2 are already being used in the clinics to identify women at very high risk of breast and ovarian cancers.

Our environment also contributes to our risk of colon cancer. Population studies have demonstrated that as people immigrate from Japan to the United States their risk of colon cancer increases. Such “natural experiments” provide strong evidence that something about our Western way of life predisposes us to colon cancer, but the exact reasons are still unclear. Though some have suggested that high fat, low fiber diets may play a role, these data have not established causality. Contrast this degree of understanding with cervical or lung cancer. In cervical cancer we have established that the cause of the disease is infection with the human papillomavirus or HPV; this understanding has led to the development of the first vaccine against cancer. Likewise, while it is easy to take for granted today, the knowledge that smoking is the major risk factor for lung cancer has had enormous implications and saved countless lives. Hopefully one day we will learn more about the modifiable risk factors for colon cancer and be able to prevent it altogether.

Given these limitations, it’s remarkable to consider that our current state-of-art — routinely screening  all Americans over age 50 with fecal occult blood testing, sigmoidoscopy or colonoscopy — is proven to reduce death from colon cancer by 33%. If we simply increased the proportion of Americans being screened today to 90%, we would prevent 19,000 deaths annually.3 Still, tragedies like the one in my family are a harsh reminder that while we have made much progress we have much farther to go.

- Shantanu Nundy, M.D.

1 http://www.ahrq.gov/clinic/uspstf08/colocancer/colosum.htm

2 http://caonline.amcancersoc.org/cgi/content/full/CA.2007.0018v1

3 http://www.prevent.org/content/view/50/120/

You never know it’s coming until it’s right in front of you – a teachable moment, the chance to make a lasting impact in the life of another person.

Yesterday, I was working in urgent care. Rarely glamorous enough to be found on House or Grey’s Anatomy, urgent care is where busy primary care offices often schedule patients who need to be seen for acute complaints on a 24- to 48-hour basis. The vast majority of cases are upper respiratory illnesses (e.g., “my nose is running), acute musculoskeletal pain (“my back hurts”), or social issues ( “ran out of meds”). It can get busy, especially in the winter, and the pace is quick — get the story, figure out what they got, and send them on their way. Preventive issues are left for the full doctor visits; the focus here is on the problem at hand.

I was having a fairly typical afternoon as I headed in to see my fifth patient. The triage sheet listed “cough ” as the chief complaint, and the temp was recorded as 97.8. Glancing at the birthdate on the chart, I calculated that the patient was 53 as I marched into the examination room. From the doorway, it was clear she was having an upper respiratory illness. Her face was slightly swollen and red, and she was breathing through her mouth. She quickly offered that her symptoms actually started improving the night before, but that she didn’t want to cancel her appointment just in case. A bit more history confirmed the diagnosis — she had a routine cold. A minute later, nearing the end of my physical exam, examining her mouth, it hit me — the smell of cigarettes.

“You smoke?” I asked half-rhetorically.

“Yea doc, I smoke,” she said, shaking her head.

“That’s no good. You know smoking’s probably a major reason why you’re here, don’t ya? Smokers get the worst cases of the flu.”

I decided to leave it at that. Get the point across, plant the seed, and hope that the over time personalized messages like that push her from pre-contemplative to being serious about quitting.

When I presented the patient to the supervising attending doctor, I kept it simple: “URI, starting to get better.” Never sure how much to say, I quickly added, “though it’s a kind of a teachable moment — she’s a smoker.”

According to Wikipedia, a teachable moment is “the time at which learning a particular topic or idea becomes easiest or possible.”* In medicine, the term is used similarly to describe a situation in which a patient is most apt to adopt a healthy behavior; for example, telling someone the importance of wearing seat belts during an ER visit for a car accident. Patient education is an essential component to being a doctor — the word “doctor” in fact comes from the Latin word “docere” meaning “to teach” – but in reality, without a meaningful context, it’s easy for patients to simply ignore a doctor’s advice. Teachable moments then become critical avenues to effectively communicate health information and affect behavior change.

Though I said it only half-seriously (“teachable moment” being a jargon term), my attending immediately answered the call. After emphasizing the benefits of quitting — not the least of which is to the pocketbook (“with the money you save, treat yourself to a vacation”) — my attending learned that over the past two weeks, while the patient was sick, she had cut down smoking from a pack a day to two cigarettes a day. Not myself realizing the significance of this, my attending pointed out to the patient that she had already gotten over the biggest hurdle to quitting – overcoming the awful symptoms of nicotine withdrawal. “Take these two miserable weeks you’ve had as an opportunity to change your life for the better.”

It was clear from the patient’s body language that the message was sticking. With my attending back seeing other patients, I pushed on and asked about her previous quit attempts. She had tried quitting in the past but would relapse after a week or so. Quitting made her stressed out and tired, which I explained were typical symptoms of nicotine withdrawal. She was definitely motivated. Both her brother and her father had passed away from lung cancer; they too were heavy smokers. But because of her failed past attempts she had given up hope that she could actually quit. I again encouraged her, saying that today doctors had more ways than ever to help people quit and stay quit. She had heard of Chantix (varenicline) and asked if it could help. I described how varenicline worked — how it reduced the cravings for cigarettes and blunted the chemical satisfaction of smoking. After advising her about its side effects (vivid dreams) and setting a quit date (next Wednesday), I wrote her a prescription, scheduled her a follow up appointment, and emailed her primary care doctor about the plan.

Though not 15 minutes earlier her mind was preoccupied with her cough, something that would have improved and gone without our help, here she was leaving with a plan to quit smoking, something that if successful would pay dividends the rest of her life. It was a teachable moment, for her and for me.

After I wished her best of luck, she said aloud but really for herself, “I think I can do it… No. I have to. I have to do it.”

- Shantanu Nundy, M.D.

* http://en.wikipedia.org/wiki/Teachable_moment

While most doctors agree that everyone who has had a heart attack should be on a statin, we are less clear about when to use statins to prevent coronary heart disease (CHD) in people who have never had an acute event before. The current guidelines for cholesterol-lowering therapy come from the National Cholesterol Education Program Adult Treatment Panel III guidelines (or ATP III) that were originally published in 2002. The guidelines suggest that the decision to start a statin be based on an individual’s risk of a heart attack and their LDL (or bad) cholesterol level.1 Below is a table that summarizes the recommendations:

Thus, deciding whether to start a cholesterol-lowering medication is a three-step process. First, doctors need to perform a risk assessment, typically by using an established risk calculator such as the Framingham risk score (to calculate your risk visit http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof). Second, doctors measure LDL cholesterol. And third, using the table above, doctors decide whether to initiate treatment based on whether the patient is at or above their goal LDL.

There are two major problems with our current treatment approach. The first is that we are woefully bad are implementing it. A recent study published in JAMA found that many Americans have LDL cholesterols above their goal levels.2 Using national data, the study investigators found that among those with high LDLs, 35 percent had not been screened, 25 percent were screened but did not know their results, and 40 percent were inadequately treated. The data was even worse for high-risk individuals — those who would benefit most from statins; in this group, two-thirds of those eligible did not receive any treatment.

The second problem is that following the ATP III guidelines sometimes leads to perverse clinical scenarios. I have thirty year-olds with 0 risk factors for coronary heart disease on statins because their LDL is 190 mg/dl. At the same time, I have older men who smoke and have diabetes not taking statins because their LDL is 90 mg/dl. Clearly, of these two types of patients, the latter are at much higher risk of CHD and therefore would benefit more from statins. And yet, following the guidelines leads to the exact opposite of what good clinical judgment would suggest.

Two accompanying editorials in JAMA propose provocative new approaches for preventing coronary heart disease.3,4 While the two editorials make two very different suggestions, both sets of authors move away from using LDL cholesterol to decide whether to initiate statin therapy:

1. Age-based:The Hingorani and Psaty editorial proposes starting statins on everyone above a certain age (note: they don’t specify what age). As rationale, they cite the limitations of current risk calculators in distinguishing who is at risk for coronary heart disease and who isn’t. Because statins have become relatively cheap and are widely considered safe, simply starting everyone above a certain age on statins would reduce heart attacks and strokes in people at high risk of CHD without significantly harming those at low risk.

2. Risk-based. The Gaziano and Gaziano editorial proposes simplifying the current algorithm so that individual risk of coronary heart disease alone be used to guide statin therapy. Thus, for example, any person with above a 20 percent 10-year risk of CHD would be placed on a statin regardless of their LDL. As evidence, they cite data that the reduction in CHD risk in people treated with statins is independent of baseline LDL; instead percent reduction in LDL seems to be more relevant.

As a first pass, prescribing a statin to everyone above a certain age seems radical. No treatment is without harm and certainly not without cost. However, there is precedent within preventive health for such a blanket approach. We give the flu vaccine to everyone over age 50 and the pneumonia vaccine to everyone at age 65, simply because above this age the risk of serious infections is sufficient enough to warrant the costs. Likewise, we give antibiotic eye drops to all infants at birth to prevent gonorrhea eye infection, regardless of their mothers’ sexual history. There is also precedent for the risk-based approach proposed by Gaziano and Gaziano. In fact, in the UK, it is standard-of-care to place patients on statins based solely on their risk of CHD.

While there is a good evidence to support these two proposals, moving to a new CHD prevention strategy is ultimately a practical decision. Do I want to underprevent heart disease or overprevent it? The data shows that our current system is simply not working. While there are some clinics that no doubt have good systems in place to effectively screen, risk-stratify, and treat patients with high LDL; most clinics, including mine, do not. While we can and should argue that these clinics need urgent redesign, until such systems are in place, it makes sense to take a simpler, more common sense approach to preventing our nation’s number one killer.*

- Shantanu Nundy, M.D.

*Author’s Note: My views on statins for primary prevention have shifted since I last wrote about them (see http://beyondapples.org/2009/08/16/statins-panacea-or-to-good-to-be-true/). This change in thinking was prompted by the increasing realization that the sophistication of evidence-based medical guidelines often exceeds our ability to effectively deliver them in practice. Is a perfect treatment algorithm performed 50% of the time really better than an imperfect treatment algorithm performed 100% of the time?  In this particular case, there is decent evidence that our algorithm itself is imperfect. That is, used correctly 100% of the time we would still misclassify and over- and undertreat a significant portion of patients. Add to this our poor track record in implementing this algorithm and you create a huge opportunity to improve CHD prevention by simplifying our decision-making algorithm.

1 National Cholesterol Education Program Adult Treatment Panel III report,  http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

2 Kuklina EV, Yoon PW, Keenan NL. Trends in High Levels of Low-density Lipoprotein Cholesterol in the United States, 1999-2006. JAMA 2009;302(19):2104-10.  http://jama.ama-assn.org/cgi/content/abstract/302/19/2104

3 Gaziano JM, Gaziano TA. Simplifying the Approach to the Management of Dyslipidemia. JAMA 2009; 302(19):2148-2149. http://jama.ama-assn.org/cgi/content/short/302/19/2148

4 Hingorani AD, Psaty BM. Primary Prevention of Cardiovascular Disease: Time to Get More or Less Personal? JAMA 2009;302(19):2144-2145. http://jama.ama-assn.org/cgi/content/extract/302/19/2144