De-implementation as quality improvement in primary care

One of my roles as a residency faculty member is to make sure that every resident completes a quality improvement (performance improvement) project by the time they graduate. Nearly all of these projects focus on getting clinicians to do more of something that improves health outcomes: lowering blood pressure, prescribing controller medications for asthma, controlling blood glucose and cholesterol levels in diabetes, providing guideline-consistent postpartum care. But quality improvement also includes doing less of things that don't improve (and may worsen) patients' health: vitamin D screening and supplementation, antireflux medications for healthy infants, cancer screening in older adults with limited life expectancies.

The American Board of Internal Medicine Foundation's Choosing Wisely campaign, which concluded in 2023 but remains active in many countries outside of the U.S., identified hundreds of "low value care" interventions, such as preventive care that is provided too soon or too often (e.g., screening colonoscopy). A 2020 paper reviewed more than 400 opportunities for stopping or scaling back unnecessary services in primary care and narrowed the field to 37 valid, high-priority recommendations. But identifying health care services to do less often or stop doing is the easy part; as "too much medicine" is often deeply embedded in systems, de-implementation is the real challenge.

A systematic review and meta-analysis of randomized trials of primary care de-implementation strategies identified 140 studies that aimed to reduce antibiotic use (54%), other drug treatments (30%), imaging (12%), and/or laboratory testing (11%). The authors found moderate certainty evidence that provider education combined with audit and feedback reduced targeted low value care, while provider education, audit and feedback, and/or patient education alone had limited or no benefits. Interventions that incorporated multiple strategies were the most effective, reducing relative risks of low value care provision by 30% to 35% over a median of 287 days of follow-up.

Compared to the much larger research base on intensifying care - I suspect there are hundreds, if not thousands, of studies on lowering blood pressure alone - the foundation for de-implementing low value care clearly needs to be expanded and strengthened. But there's more than enough here for a motivated learner - say, a family medicine resident - to build on.

Primary care for all Americans: a status update

As 2025 draws to a close, how much closer/farther is the U.S. health system to/from the goal of providing primary care for all Americans? Much of the news isn't good. A recent analysis in the Annals of Family Medicine documented an 11% decrease in the number of family physicians practicing in rural areas from 2017 to 2023, with the Northeast suffering the largest proportional losses. As a faculty member at a Northeast residency program where many graduates have historically provided primary care to rural communities, this statistic hits home. Some of the "lost" physicians no doubt migrated to suburban or urban areas and continued to practice, but others developed burnout and left medicine altogether.

More and more clinicians, family physicians included, are participating in concierge or direct primary care practices, which collect an affordable up-front monthly fee per patient rather than rely on delayed insurance payments and provide relief from the burdensome paperwork that comes with third-party payers of health care. A study in Health Affairs used a national directory of direct primary care practices to create a longitudinal data set of clinicians from 2018 to 2023. During this five-year time frame, the number of practices and participating clinicians grew by 83 and 78 percent, respectively. Corporate-affiliated practices have made significant inroads into what was previously a clinician-owned model, with the percentage of independent practices shrinking from 84 to 60 percent. Although proponents tout its many advantages to clinicians and patients, the math is inescapable: every direct primary care physician who is caring for a panel of 500 patients rather than 1500 makes it more difficult for the other thousand to access traditional primary care.

With that context, what has PC4AA, the nonprofit group that I first highlighted in a blog post last year, been doing to improve primary care access? Rather than take a top-down approach like the National Academy of Medicine, they've chosen to tackle the problem from the ground up, community by community. One of those communities is New Bedford, Massachusetts, a multicultural, multilingual city of 101,000 people with just 36 practicing primary care clinicians, including 15 physicians. Of the 15 physicians, 10 are pediatricians and only 5 care for adults. An estimated 20 to 25 percent of the population does not have a relationship with a primary care clinician. Wait times for a new patient appointment range from two to nine months.

I've never been to New Bedford or spoken with anyone who provides health care there. So how do I know so much about this community and its ongoing primary care crisis? From the report released in October by PC4AA's New Bedford chapter, which contains an in-depth analysis of the state of primary care in New Bedford as well as a multi-pronged strategy to recruit more primary care clinicians to meet the needs of the population. The original working group is now convening task forces that will focus on enhancing the primary care training pipeline, making training more affordable through scholarships and loan repayment, encouraging the development of new residency programs, and supporting existing primary care practices financially to allow them to expand services to more patients in the future.

It's much too early to tell whether PC4AA will succeed in reinvigorating U.S. primary care where others have so conspicuously failed. But if, like me, you are looking for a reason to be optimistic about health care in 2026 - a year that is forecast to see the first increase in the percentage of the population that is uninsured since the Affordable Care Act's passage in 2010 - this is it. Community by community, rebuilding and remaking the system from the ground up.

Smartphones, social media, and adolescent health outcomes

The negative health consequences of social media use in adolescents and young adults are increasingly being recognized. In a previous American Family Physician Blog post on screen time use in children, Dr. Lilian White mentioned a correlation between greater social media use and reduced life satisfaction in adolescents. A 2017 Curbside Consultation discussed the relationship between social media use and mood disorders, fueled by the fear of missing out (FOMO), and reviewed resources and tools for unplugging or limiting time spent on social media.

Recently, a prospective cohort study in JAMA Network Open used objective data from a “digital phenotyping” app to evaluate the effects of a 1-week social media detox intervention on mental health. 373 U.S. young adults aged 18 to 24 years with smartphones completed a 2-week baseline assessment of their use of Facebook, Instagram, Snapchat, Tik Tok, and X. The optional intervention decreased 295 participants’ daily social media screen time from 1.9 to 0.5 hours. These changes were associated with statistically significant reduced symptoms of anxiety by 16.1%, depression by 24.8%, and insomnia by 14.5%.

Adolescents access social media platforms through smartphone apps. Another recent study examined associations of various health outcomes with smartphone ownership in a sample of more than 10,000 participants in the Adolescent Brain Cognitive Development Study. At age 12 years, 64 percent of children owned a smartphone. Compared to those without a smartphone, smartphone owners had higher risks for depression (odds ratio=1.31), obesity (OR=1.40), and insufficient sleep (OR=1.62). Risks of obesity and insufficient sleep increased with earlier age at smartphone acquisition, and the 1546 children who acquired a smartphone between the ages of 12 and 13 had worse mental health and sleep outcomes than the 1940 children who remained without smartphones at age 13.

Restricting use during school hours does not appear to affect overall smartphone or social media use or mental health. A cross-sectional study in the United Kingdom compared students at 20 secondary schools with restrictive phone policies (recreational use not permitted) with those at 10 schools with policies permitting recreational phone use. 1227 students age 12 to 15 years participated in the study, which assessed mental wellbeing using the Warwick-Edinburgh Mental Well-Being Scale. Students who attended schools with restrictive policies compensated for lower phone use during school hours by using their phones and accessing social media more after school and on weekends. Not surprisingly, there were no differences in mental well-being between the groups.

On December 10, Australia implemented the world’s first ban on social media accounts for children younger than age 16. Instagram, Facebook, Threads, Snapchat, YouTube, TikTok, Kick, Reddit, Twitch and X were all required to deactivate existing accounts for younger children and use age verification software for new accounts to avoid millions of dollars in fines. The potential health benefits of this policy remain to be seen.

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This post first appeared on the AFP Community Blog.

Shared decision making for colorectal cancer screening tests

Most of the major cancer types have a single recommended screening test. For breast cancer, mammography. For cervical cancer, cytology and/or human papillomavirus testing. For lung cancer, low-dose computed tomography (CT). Colorectal cancer is unique in that physicians and patients have a menu of acceptable screening options, ranging from various stool-based tests to CT colonography, colonoscopy, and most recently, a blood test for circulating tumor DNA.

Guidelines recommend shared decision making with average-risk adults aged 45 to 75 years to select a colorectal cancer screening strategy that aligns with patients’ preferences and values. A recent scoping review of 28 studies in the United States and Canada explored factors that play important roles in these conversations. Researchers identified 4 domains that influence patients’ decision making: test attributes (accuracy, cost, convenience, and complications); recommendations from their personal physician; fear, discomfort and embarrassment for some regarding colonoscopy and stool tests; and external factors (culture, family input, socioeconomic status, and transportation access).

The U.S. Preventive Services Task Force assigned a “C” grade (offer selectively, individualized decision) to colorectal cancer screening in adults aged 76 to 85 years due to a small net benefit of screening in this age group. A cluster randomized trial in older adults evaluated the effect of physician training in shared decision-making on receipt of patient-preferred colorectal cancer screening (which could include no testing) and on overall screening rates. At 12 months, about half of patients in each group had received their preferred approach, with no significant difference between the groups in test uptake.

A pitfall for clinicians is limiting patients’ test options to colonoscopy due to a belief that it is the “gold standard” test, even though no data have demonstrated clear superiority over fecal immunochemical tests. An editorial in the September 2025 issue of American Family Physician discussed optimizing the role of noninvasive colorectal cancer screening tests, and an editorial in the October 2025 issue reflected on downsides of colonoscopy as a primary screening strategy. For patients who choose to undergo colonoscopy, adherence to evidence-based surveillance guidelines is critical to preventing harms associated with repeating colonoscopy at inappropriately short intervals.

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This post first appeared on the AFP Community Blog.

My favorite public health and health care books of 2025

This year's best of list includes only three titles that were actually published in 2025. Six books were written by doctors, and two provide complementary perspectives on the infamous Andrew Wakefield and the epidemics of vaccine-preventable diseases resulting from falsified research and shameless self-promotion of a thoroughly debunked theory. As always, books are listed alphabetically by title. For more favorite reads, feel free to browse my lists from 2024, 2023, 2022, 2021, and previous years.

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1. Booster Shots: The Urgent Lessons of Measles and the Uncertain Future of Children’s Health, by Adam Ratner

2. The Doctor Who Fooled the World: Andrew Wakefield’s War on Vaccines, by Brian Deer

3. Dopamine Nation: Finding Balance in an Age of Indulgence, by Anna Lembke

4. Dr. Mutter’s Marvels: A True Tale of Intrigue and Innovation at the Dawn of Modern Medicine, by Cristin O’Keefe Aptowicz

5. Facing the Unseen: The Struggle to Center Mental Health in Medicine, by Damon Tweedy

6. Gettysburg Surgeons: Facing A Common Enemy in the Civil War’s Deadliest Battle, by Barbara Franco

7. My Father’s Brain: Life in the Shadow of  Alzheimers, by Sandeep Jauhar

8. One by One by One: Making A Small Difference Amid A Billion Problems, by Aaron Berkowitz

9. A Return to Healing: Flexner, Osler, and How American Medicine Went Astray, by Andy Lazris and Alan Roth

10. Slow Cooked: An Unexpected Life in Food Politics, by Marion Nestle

Upcoming article on mental health disorders during the Civil War

 

Update: The full article is now available in the Winter 2025 issue of the Journal of Lancaster General Hospital.