Sunday, December 27, 2015

The top ten AFP Community Blog posts of 2015

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

Some themes that emerged from this year's list of most-read posts included avoiding overtreatment, challenging medical dogma in management of low back pain and myocardial infarction, and estimating efficacy and adverse effects of depression therapies in primary care settings. Happy holidays and best wishes for the New Year!

1. Advise patients to steer clear of these six orthopedic procedures (March 16) - 1804 views

What accounts for the continued popularity of ineffective orthopedic procedures? Excessive magnetic resonance imaging (MRI) plays a role. Patients who perceive surgery to be a "quick fix" may not have the patience to stick with physical therapy and rehabilitation. And there is the inescapable reality that, necessary or not, these procedures pay well.

2. Can treating mild hypertension be too much medicine? (January 2) - 935 views

Key take-home points are that the absolute benefits of treating otherwise healthy persons with mild hypertension are relatively small; lifestyle modification should generally precede medication; and blood pressure measurement should be performed and repeated carefully to ensure accurate identification of hypertensive patients.

3. ACC/AHA and Framingham calculators overestimate cardiovascular risk (March 3) - 841 views

Men in the Multi-Ethnic Study of Atherosclerosis cohort with a calculated ACC/AHA risk score of 7.5 to 10 percent had an actual event rate of only 3 percent; and just over 5 percent of women with a similar risk score experienced cardiovascular events.

4. Acetaminophen ineffective for chronic low back pain - now what? (April 6) - 826 views

Intuitively, acetaminophen seems like a reasonable choice for treating chronic LBP. It's inexpensive and relatively safe when used at recommended doses. This 2015 meta-analysis overturns that recommendation and should prompt a change in the clinical guidelines.

5. Stop beta-blockers 30 days after acute MI? (March 23) - 794 views

The greatest challenge for family physicians managing patients following up after an AMI admission may be the decision to stop a beta-blocker. Discontinuing therapies may be difficult for physicians.

6. Guest post: quality medical care makes patients feel at home (Sept. 7) - 766 views

In my view, the definition of good care includes communication, patience, concern, and perseverance. A high quality, "patient-centered" medical home is based on these human characteristics and not on outcome criteria, EHR meaningful use, or other measures.

7. Announcing the #AFPTop20 Tweet Chat on August 26th (August 17) - 760 views

On Wednesday, August 26th at 4 PM Eastern, @AFPJournal held its first #AFPTop20 Tweet Chat to take a deeper dive into the findings of some of the top POEMs of the year and their ramifications for family physicians.

8. Which antidepressants have the highest suicide risk? (July 6) - 748 views

In a United Kingdom cohort of 240,000 adult patients with depression, the adjusted hazard ratios for venlafaxine and mirtazapine for suicidal behavior were 1.70 (1.44 to 2.02) and 1.85 (1.61 to 2.13), respectively, compared with citalopram.

9. How to make sure your patients understand health information (July 15) - 713 views

A large body of evidence demonstrates strong associations between low health literacy and poorer health outcomes; compared to patients with high health literacy, patients with low literacy have more hospitalizations, more emergency department visits, and are less likely to receive appropriate preventive and chronic care services.

10. Depression treatment: the evidence base from a primary care perspective (Feb. 23) - 695 views

This systematic review provides guidance for family physicians treating patients with mild to moderate depression as well as severe depression; it provides reassurance to patients unable to attend multiple psychotherapy sessions that even a few sessions can provide benefit.

Monday, December 21, 2015

Link to your favorite references from the AFP home page!

- Jennifer Middleton, MD, MPH

When I was a resident 10 years ago, I carried several references in the pockets of my white coat. My Palm pilot was useful for referencing medical equations but little else, so I carried everything else in paperback: a drug reference guide, an antibiotic guide, a book on common on-call patient situations. Online reference tools were in their infancy, and by the end of my intern year several pages in those books were dog-eared and memorized.

Fast forward to 2015: my smartphone contains all of those resources and more - I don't even have to carry a printed patient census in my pocket anymore when I round in the hospital. But as nice as smartphones are, nothing beats the full view of a webpage on a computer screen, and we have endless options of medical reference websites at our fingers. Answering clinical questions at the point-of-care is easier than it's ever been, but keeping track of those websites can be difficult. Sure, you can add bookmarks to your web browser, but some health systems limit the ability to access those behind their firewalls. Plus, it takes time to bring those up and log in.

What if you could pull up a trusted website and access all of your favorite references right there? AFP recently added the ability to do precisely that - on the right side of the top banner with a gold star is the new "Favorites" section. If you're logged in to the AFP website (which you can do once and leave it if you're working on a trusted computer), clicking on "Favorites" will bring you to a page where you can quickly paste in the hyperlinks of whatever references you'd like to include - be they AFP sites or others.

AFP By Topic and the Choosing Wisely tool are available from the AFP homepage, so I decided not to add those to my Favorites list. I did add AFP's Medicine by the Numbers webpage, along with our new Podcasts. I suspect that the CME Quiz and Photo Quiz department pages will be popular on many AFP subscribers' Favorites. I've also added my prescription drug database of choice and a couple of subscription online clinical information resources to round out my list.

Answering questions quickly at the point-of-care is easier than ever with the AFP Favorites feature, as is accessing your favorite medical content when you have a little more time to peruse it. If you'd like a full tour of all of the updates to the AFP website, including the Favorites feature, you can find it here.

Monday, December 14, 2015

Pharma industry free speech is anything but free

- Kenny Lin, MD, MPH

Last month, the American Medical Association (AMA) called for a ban on direct-to-consumer (DTC) advertising of prescription drugs and medical devices, arguing that this type of advertising drives the nation's escalating drug bill by creating demand for new, expensive medications that are often no more effective than older ones. Since the first televised prescription drug ad aired in the U.S. in 1983, pharmaceutical companies have spent billions of dollars on DTC advertising, including $4.8 billion in 2014. The ads are worth every penny. According to Kantar Media, 76% of Americans have seen at least one DTC ad on television in the past 12 months, and 1 of 3 who viewed these ads took some action as a result.

The AMA's call comes at a time of increasing public concern about the potentially harmful impact of loosening restrictions on marketing and promotion of off-label use of drugs. Although the U.S. Food and Drug Administration (FDA) has historically prohibited this practice, earlier this year a federal District Court judge blocked the FDA from enforcing restrictions on promoting a prescription fish oil product for an unapproved indication. The judge determined that if the FDA refused permission to distribute the promotional materials, it would violate the company's First Amendment right to freedom of speech.

Although recent Supreme Court decisions have established that for some purposes, corporations have the same rights as people, there are real dangers to allowing the pharmaceutical industry to claim anything they want about their products to physicians or consumers under the guise of free speech. A Canadian cohort study published in JAMA Internal Medicine found that off-label drug use was 44 percent more likely to be associated with adverse drug events than on-label use, a difference driven almost entirely by the prescription of drugs without strong supporting scientific evidence (about 80 percent of all off-label prescriptions). The top five drugs used off-label were quinine, gabapentin, quetipine, amitriptyline, and risperidone.

A 2014 American Family Physician editorial by Drs. April Fitzgerald and Patrick O'Malley discussed how family physicians can "stay on track when prescribing off-label." The authors noted that the toughest calls occur when evidence suggests potential benefits but the harms are not well described:

The ethics surrounding off-label use become more complicated when considering medications with less clear-cut positive or negative risk-benefit ratios. This is the gray area where physicians individually weigh the translational gaps in evidence between effectiveness, available research, and the complexities of real-world clinical practice. Particular scrutiny is suggested when using off-label medications with red flags, such as new medications, medications with known serious adverse effects, or high-cost medications, or when considering novel off-label use.

Pharmaceutical free speech is actually anything but free. By directly encouraging patients to request new medications from physicians, and by promoting drugs for unapproved uses, the industry will not only continue to increase national spending on prescription drugs, but expose even more patients to an unacceptable risk of iatrogenic harm.

Monday, December 7, 2015

What is the best diuretic for treating hypertension?

- Jennifer Middleton, MD, MPH

Even though hydrochlorothiazide (HCTZ) was the 10th most commonly prescribed drug in the US in 2010, an FPIN Help Desk Answers article in the current issue of AFP argues in favor of chlorthalidone over HCTZ, as does a 2008 AFP editorialAlthough some studies have found HCTZ and chlorthalidone's effects on cardiovascular mortality to be equivalent, some studies have found chlorthalidone to be more effective. 

The AFP FPIN Help Desk article reviews two systematic reviews and one randomized controlled trial (RCT) comparing HCTZ and chlorthalidone for reduction of coronary heart disease (CHD) events. The first systematic review and the RCT both showed greater blood pressure lowering with chlorthalidone compared with HCTZ, but neither measured cardiovascular outcomes. The second systematic review included a network analysis comparing outcomes from studies that used chlorthalidone to studies that used HCTZ. Those researchers found that the number needed to treat (NNT) with chlorthalidone instead of HCTZ to prevent 1 additional cardiovascular death over 5 years was 27.

Some cohort studies have found chlorthalidone non-inferior to – and potentially more hazardous than – HCTZ. A 2013 prospective cohort study conducted in Canada found no difference in cardiovascular outcomes but a higher risk of hospitalization for hypokalemia; interestingly, patients on chlorthalidone were more likely to be on a beta-blocker than those on HCTZ because of a combination pill on the Canadian formulary. A retrospective cohort study reviewed by AFP in 2013 found equivalent outcomes between patients treated with chlorthalidone versus those treated with HCTZ.

These cohort studies showing equivalence between chlorthalidone and HCTZ, along with concern for more hypokalemia with chlorthalidone, may explain why HCTZ is the diuretic of choice in treating hypertension in the US.  In the level of evidence hierarchy, cohort studies sit below randomized controlled trials (RCTs) and systematic reviews because they are more prone to bias. On the flip side, however, cohort studies can sometimes provide better information about "real life" conditions; in an RCT, participants follow strict protocols, but in cohort studies, we can measure the effect of interventions as they play out in practice.  

So, overall, some cohort studies have found HCTZ and chlorthalidone to be equivalent, but some RCTs and systematic reviews have found differently. Some studies have shown increased hypokalemia with chlorthalidone use, but several large hypertension treatment trials, including the 2015 SPRINT, preferentially used chlorthalidone in their treatment protocols.  If you’d like to read more, there’s an AFP By Topic on Hypertension.

When the evidence base is conflicting, it can be challenging to decide what to do in practice. How do you decide which diuretic to prescribe for patients with hypertension?