Monday, August 25, 2014

Who is defining Family Medicine?

- Jennifer Middleton, MD, MPH

Perhaps you've already heard - a cardiologist raised the profile of family physicians last week.

National Public Radio's Fresh Air program interviewed Dr. Sandeep Jauhar, a cardiologist working in New York City, August 19 and he had this to say about family physicians:

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not one is really talking and trying to coordinate this care, so it makes it very difficult for the physician who is trying to manage the whole patient...
This particular piece of the interview reminded me of a powerful editorial written a few years ago in the Annals of Family Medicine by Dr. Kurt Stange. Published in 2009, Dr. Stange tells the story of a patient with unresolved low back pain in whom he diagnosed with a large abdominal aortic aneurysm, esophageal cancer, and incidental renal cancer. 
A narrowly focused approach is fine when an obvious problem is linked to a clear solution. When multiple problems are woven into the fabric of life, however, the generalist approach is critical.
In a recent guest post for the Community Blog, Dr. Loftus takes this idea of the generalist's role a step further:
Family physicians should then focus on mastering the knowledge and expertise that we have acquired during our medical education and embrace our role as experts at managing multiple complex chronic diseases, especially with psychosocial co-morbidities. We should be supervising and leading teams of community health workers, health coaches, care coordinators, nurses, pharmacists, physician assistants, and nurse practitioners who are managing the simpler medical issues, as is often the case in many other countries around the world. 
The struggles of our health care system are bringing our specialty to a critical juncture. Who will we be as family physicians 5, 10, 15 years from now? Will we continue to passively accept employment and reimbursement models that push us to see as many patients in as little time as possible? Will we continue to spend time counseling patients on topics that a well-trained medical assistant, nurse, or pharmacist could probably do more effectively? 

Dr. Stange ends the editorial mentioned above with a call for action to rebuild our health care system with primary care at its core. He provides a long list of concrete steps we can each take; here is just an excerpt:
We can cultivate the courage to take on the narrow self-interest that fuels our system dysfunctions. We can be willing to sacrifice in the short term for a larger good in the long term. We can develop relationships with individuals and groups and societies that are different from us, and thus develop a broader sense of community.As individuals, groups, systems, and society, we can strive to be humble, connected, and open....Think and act in ways that bring meaning to apparently low-level tasks that develop relationships, and iterate between the parts and the whole to foster a larger good.

Maybe just keeping abreast of how others are championing Family Medicine is another worthy first step. Trying to keep up with everything that is happening in the larger world of healthcare policy and legislation might feel burdensome to already overworked family docs, but AAFP News Now provides concise updates in your AFP journals. Supporting and being involved with AAFP, our specialty's advocacy organization, is an easy way to support those efforts.

Sometimes changing the world can feel too big for one person. But maybe if each of us worked within our sphere of influence on just one of Dr. Stange's action steps, our health care system could get back to serving patients instead of payors and companies. Maybe then we wouldn't need cardiologists to raise our specialty's profile.

Monday, August 18, 2014

ACC/AHA cholesterol guideline: summary and perspectives

- Kenny Lin, MD, MPH

As previewed in a previous blog post, the August 15th issue of AFP features a concise summary of the American College of Cardiology / American Heart Association updated cholesterol treatment guideline. Key points include an expansion of the role of statins in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); elimination of specific low-density lipoprotein cholesterol (LDL-C) target levels; and a new tool for assessing of 10-year and lifetime risk for ASCVD. An accompanying POEM notes that full implementation of the new guideline would increase the number of U.S. adults eligible to take statins by nearly 13 million, with the percentage of adults 60 to 75 years of age for whom statins are recommended rising from 47.8% to 77.3%.

Two editorials in the same issue further explore the implications of the new guideline. Writing for the members of the guideline panel, Dr. Patrick McBride and colleagues emphasize that the recommendations are largely based on high-quality evidence from randomized controlled trials that measured patient-oriented outcomes. They argue that "these changes should simplify the approach to clinical practice by reducing titration of medication, the addition of other medications, and the frequency of follow-up laboratory testing." In a second editorial, Dr. Rodney Hayward concurs with the panel's decision to abandon LDL-C targets, but disagrees with setting a universal 10-year ASCVD risk threshold of 7.5% for treatment with a statin:

My biggest criticism of the new guideline is that it does not acknowledge a specific gray zone—a range in which the potential benefits and harms of a statin make the “right decision” predominantly a matter of individual patient circumstances and preferences. It may be reasonable to set 7.5% as a starting point for discussion (e.g., for every 33 patients treated for 10 years, roughly one heart attack will be prevented [i.e., number needed to treat = 33]). But these risks and benefits are estimates with a nontrivial margin of error. The guideline does note that shared decision making should be used, but it provides no clear direction on when statins should be recommended rather than just discussed.

A similar debate is taking place in the United Kingdom, where its National Institute for Health and Care Excellence (NICE) recently recommended offering a statin to all persons with a 10-year cardiovascular event risk of 10% or more. An editorial in BMJ observed that doctors need better shared decision making tools to help patients understand the tradeoffs involved in taking medications that have potentially large population health benefits but are unlikely to prevent a bad outcome in an individual patient:

Doctors are unlikely to start giving patients clear numerical information simply because they are told to do so. They might do so if NICE can recommend information tools with the same force as when it recommends drugs, and if it becomes as easy to give contextual numerical advice as it is to print a prescription. ... We will need better data, from bigger trials, and better risk communication than for conventional medical treatment. ... Without such innovation in the use of medical data, we can say only that statins are—broadly speaking—likely to do more good than harm. That is not good enough.

Have you already integrated the ACC/AHA cholesterol guideline into your practice? If so, how do you decide whether to "recommend" versus "discuss" statins with patients? If not, what reservations or workflow issues have prevented you from transitioning to the new guideline?

Monday, August 11, 2014

More evidence against initiation of perioperative beta blockers in non-cardiac surgeries

- Jennifer Middleton, MD, MPH

Patients undergoing intermediate- or high-risk non-cardiac surgeries often get a perioperative beta blocker, and the American College of Cardiology Fellows (ACCF) and the American Heart Association (AHA)'s 2007 guideline advises as such. The ACCF/AHA's 2009 update, though, recommends perioperative beta blockers only in patients with a history of coronary artery disease (CAD) and/or at least 2 CAD risk factors. A 2014 meta-analysis additionally found that perioperative beta blockade in patients not chronically on beta blockers increased mortality -- even if they had CAD or at least 2 CAD risk factors.

JFP reviewed this 2014 meta-analysis recently in an online article. This article discussed serious methodological problems regarding a group of Dutch studies that heavily informed the ACCF/AHA 2007 guideline and 2009 update. These studies failed to consistently obtain written informed consent for subjects, recruited inappropriate patients, and could not produce their raw data when requested by a review panel. These flawed studies are the backbone for the ACCF/AHA's current recommendation to add a perioperative beta blocker to patients with at least 2 CAD risk factors and/or a history of CAD*.

Perioperative beta blockers were certainly controversial even prior to these studies' public disgrace; a 2012 AFP article on Perioperative Cardiac Risk Reduction cited several of the studies included in the 2014 meta-analysis and advised caution in using perioperative beta blockers in patients without known cardiac disease.

The 2014 meta-analysis examined post-operative outcomes for patients who were not taking a beta blocker prior to surgery (including patients with CAD and/or risk factors) and who were undergoing non-cardiac surgeries. The researchers included 9 high quality randomized controlled trials (RCTs) and excluded the suspect data from the Dutch trials. They found that beta blockers did decrease perioperative non-fatal myocardial infarctions (RR = 0.73 [0.61-0.88]), but they also increased the risk of stroke (RR = 1.73 [1.00-2.79]), hypotension (RR = 1.51[1.37-1.67]), and 30-day all cause mortality (RR = 1.27 [1.01-1.60]). For patients not previously on a beta blocker prior to intermediate- or high-risk surgery, adding one causes more harm than good (NNH for 30-day all cause mortality = 160).

When newer studies conflict with previously published guidelines, physicians have an important decision to make. Assuming the new study is methodologically sound, should we abandon the earlier guideline because of the updated evidence? Or, should we wait until the original recommending body assesses the new evidence?

The answer probably involves multiple variables: the amount of trust in the earlier guidelines, the degree to which our colleagues are changing their practice, and, perhaps, even our level of comfort in assessing the study's quality. Maybe it feels like the stakes are too high to change our practice based on one study, especially if larger recommending bodies have yet to weigh in.

Our specialty is fortunate to have high quality journals whose editorial experts sift through new studies and assist us with interpreting and applying them. AFP recently reviewed the ACCF/AHA guidelines for management of congestive heart failure, for example, and handily summarized the high points of this 300 page document into a brief article geared toward busy family docs. Although we should use our evidence-based medicine skills to reach our own independent conclusions about newly published studies, we can also rely on AFP and others to help confirm our assessments.

How comfortable are you changing your practice when new studies conflict with prior recommendations?

* Admittedly, most patients with CAD should be on a beta blocker chronically, but I suspect I'm not the only family doc with a couple of patients who either can't tolerate them or refuse to take one. Several of the studies included in this 2014 meta-analysis included this group of patients in their RCTs.

Monday, August 4, 2014

The most popular posts of January - June 2014

- Kenny Lin, MD, MPH

Diabetes, weight loss, the future of family medicine, antibiotic safety, and athlete's foot were the topics of the AFP Community Blog's top 5 most viewed posts from the first six months of 2014. Each of these posts has been viewed between 500 and 650 times to date.

1. Does metformin prevent recurrent events in diabetic patients with CAD? (January 20)

This study helps to reinforce that metformin (rather than a sulfonylurea) is the right choice when initiating treatment for type 2 diabetes. What to add when additional glycemic control is needed, however, remains up to each physician's clinical judgment.

2. Weight loss medications: how much of a solution are they? (March 10)

Frankly, I'd prefer to see us work to lessen biologic and environmental pressures instead of adding another pill to our patients' regimens. Our commitment as 21st century family physicians must be to our communities as well as our individual patients if we are ever to turn the tide of rising obesity rates.

3. The Future of Family Medicine - Some Sacrifices Required (June 16)

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care.

4. Azithromycin and levofloxacin safety concerns continue (March 24)

Although many physicians prefer basing practice change on a prospective study, retrospective studies are better suited than prospective studies to detect rare events.

5. What is the best topical antifungal for treating tinea pedis? (May 27)

Given that 1 week of therapy is preferable to most patients instead of 4, and the price difference is negligible (around $10-16 for 30 grams of either), I will still favor terbinafine over clotrimazole for treating tinea pedis.