Monday, April 29, 2013

Pros and cons of vitamin D screening

- Kenny Lin, MD

The U.S. Preventive Services Task Force recently announced its intent to review the evidence and issue recommendations about screening for vitamin D deficiency, after finding insufficient evidence to recommend routine supplementation for the prevention of fractures in adults. According to a 2009 review published in American Family Physician, up to half of U.S. adults 65 years and older have inadequate vitamin D levels, which places them at increased risk of falls and fractures. Two editorials in the April 15th issue of AFP debate the pros and cons of screening for vitamin D deficiency in asymptomatic persons.

Dr. Leigh Eck makes the case for targeted screening for vitamin D deficiency in at-risk populations, which include, but are not limited to, persons with malabsorption syndromes, persons with chronic kidney disease, pregnant and lactating women, and older persons with a history of falls. "Most of these factors put patients at risk of osteoporosis," Dr. Eck argues. "Given the role of vitamin D in bone mineralization, patients who are at risk of or who have osteoporosis should be considered as candidates for vitamin D screening."

On the other hand, Dr. Colin Kopes-Kerr identifies several problems with measurement of serum vitamin D levels in asymptomatic persons, regardless of risk level: lack of test standardization; disagreement about what constitutes a "normal" vitamin D level; unclear treatment implications; and uncertain cost-effectiveness. Finally, he points out, "No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone."

The Endocrine Society recommends against population-based screening for vitamin D deficiency, and the American Society for Clinical Pathology included this screening test in its list of "Five Things Physicians and Patients Should Question" for the Choosing Wisely campaign.

Monday, April 22, 2013

Shared decision making

- Jennifer Middleton, MD, MPH

Let’s say you’re seeing a healthy 21-year-old woman in your office for contraception management.  She takes no other medicines, has no personal or family history of blood clots, and has no contraindications to estrogen.  She is interested in a long-acting contraceptive that she won’t have to worry about remembering every day.  IUD, subdermal progesterone implant, q 3 months injectable progesterone – how do you choose?

Or, how about this: a 45-year-old man presents with frequent migraine headaches.  You review the best evidence for migraine prophylaxis in adults and are stuck deciding between propranolol and amitriptyline.   Which do you use?

Gray areas like these abound in Family Medicine, even with the ever-growing primary care evidence base.  In both of these scenarios, no one option is clearly superior to the other.  All of those contraceptive options would be efficacious for the 21-year-old woman, and, likewise, the efficacy of propranolol versus amitriptyline for the migraineur is probably a toss-up.

These types of situations, where multiple reasonable treatment options exist, provide an opportunity to involve the patient in the decision.  Shared decision making (SDM) brings the patient’s preferences into the conversation and gives them some ownership over the final choice. 

I wish that I could tell you that SDM has a rigorous evidence base behind it, but like many behavioral interventions, few quality studies exist to suggest patient benefit.  A study last week in the Annals of Internal Medicine, however, may help to reinforce SDM’s value.  Weiner et al engaged patients who surreptitiously recorded their office visits with Internal Medicine residents.  The residents who adapted their care plan to meet their specific patient’s preferences had, in return, improved compliance from their patients. 

This study was small and needs to be replicated in bigger settings, but its finding makes intuitive sense: patients invited to be involved in treatment decisions tend to have better adherence with those treatments.  

You can ease the loss of the extra time it takes to do SDM by billing for the time spent in counseling (10 min = 99212, 15 min = 99213, and 25 min = 99214).  Just be sure to document as such in your encounter note.

In 2010, AFP also published a nice SDM review, along with a helpful framework for the office.  You can find that Curbside Consultation here:

I welcome your thoughts on the practical use of SDM in the busy family doc’s practice.  

Tuesday, April 16, 2013

Guidance for Choosing Wisely in diagnostic imaging

- Kenny Lin, MD

Many of the primary care-relevant recommendations in the Choosing Wisely campaign advise physicians to think twice before reflexively ordering diagnostic imaging tests in certain clinical situations. Inappropriate imaging increases radiation exposure, leads to overdiagnosis and detection of incidentalomas, and increases costs for patients and health systems. In addition, as Drs. Brian Crownover and Jennifer Bepko observe in the April 1st issue of AFP, increasing radiation exposure is likely to lead to higher rates of cancer diagnoses and deaths:

In 2006, 380 million radiologic procedures (including 67 million computed tomography [CT] scans) and 18 million nuclear medicine procedures were performed in the United States. To highlight the disproportionate use, U.S. patients received approximately one-half of all nuclear medicine procedures worldwide while making up only 4.6 percent of the global population. The volume represents a sixfold increase (from 0.5 to 3.0 mSv [millisieverts]) in annual per capita radiation exposure from 1980 to 2006. ... Increasing recognition of future cancer risk from radiation exposure was illustrated in a 2009 study showing that 2 percent of all future cancer cases will likely come from previous CT exposure, resulting in approximately 15,000 deaths annually.

This article on the appropriate and safe use of diagnostic imaging goes on to review consensus indications for imaging in the central nervous system, chest, abdomen, and lumbar spine based on American College of Radiology appropriateness criteria. It includes a helpful Table on the average effective radiation doses of medical imaging procedures that clinicians may use to weigh the harm versus the potential benefit of a particular diagnostic imaging test. In general, the authors recommend discouraging patients from undergoing whole body scanning, which is associated with numerous health risks and no proven benefits.

Monday, April 8, 2013

Meet AFP Community Blog's new contributor

- Jennifer Middleton, MD, MPH

Hello!  I’m thrilled to accept AFP’s invitation to join Dr. Lin on this blog.  I thought I’d use this first entry to share a little bit about myself and what you can expect from my posts.

For about 2 and ½ years, I’ve been blogging at The Singing Pen of Doctor Jen.  Many good Family Medicine bloggers were already hard at work when I started in November of 2010, but I thought as a residency educator I might have something different to add to the mix.  I did a two-year full time faculty development fellowship in Pittsburgh before starting my career.  In my fellowship, I learned how to teach and create curricula, how to write and edit, and how to design and implement research.  During my fellowship, I also studied for a Master’s Degree in Public Health (MPH).  Between my faculty development background and my MPH training, I see the world of Family Medicine with a detached eye at times. 

You can expect musings from me about my experiences as a family doctor, a teacher, and even sometimes, a patient.  These stories will hopefully be a backdrop for us to share the challenges and joys of day-to-day Family Medicine.  You will also hear me stridently advocating for Family Medicine as the solution to many of our current healthcare woes. 

I am grateful for the opportunity to share some of these thoughts with you going forward.