Monday, June 26, 2017

Strategies to limit antibiotic resistance and overuse

- Kenny Lin, MD, MPH

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more. Antibiotic resistance occurs in the community, in long-term care facilities, and in hospital settings. Another CDC report on preventing healthcare-associated infections (also discussed in this AFP article) identified six high-priority antibiotic resistance threats: carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enteroccocus, multidrug-resistant Pseudomonas, and multidrug-resistant Acinetobacter.

In a 2014 editorial, "Antibiotic resistance threats in the United States: stepping back from the brink," Dr. Steven Solomon and Kristen Oliver from the CDC identified three strategies that family physicians can use to limit antibiotic resistance: 1) Preventing infections through immunizations, standard infection control practices, and patient counseling; 2) Reporting unexpected antibiotic treatment failures and suspected resistance to local or state health departments; and 3) Prescribing antibiotics more carefully. Unfortunately, inappropriate antibiotic prescribing (also known as antibiotic overuse) is common in primary care, particularly for patients with acute viral respiratory tract infections.

Antibiotic overuse is a multifaceted problem with many potential solutions. On Sunday, July 9th at 7 PM Eastern, Dr. Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will be taking a deep dive into the evidence on the most effective strategies to curb prescribing of unnecessary antibiotics. AAFP members and paid AFP subscribers can earn 4 free continuing medical education credits by registering for the #afpcme Twitter Chat, reading three short AFP articles, and completing a post-activity assessment. We and @AFPJournal hope you can join us!

Monday, June 19, 2017

Twitter chats: 21st century CME

- Jennifer Middleton, MD, MPH

Being active on Twitter can have many advantages for family physicians. Following journals like AFP (@AFPJournal) can make it easy to keep up with the latest medical studies and news. With individual tweets limited to 140 characters, Twitter chats provide a way to explore a particular issue more in-depth and build connections among people with common interests. Increasingly, they can also be a way to increase physician knowledge and even obtain continuing medical education (CME) credit.

Typically, Twitter chats occur at a scheduled time, last for about an hour, and are moderated by one or a few members of the hosting organization. The topic for discussion is determined in advance, and the moderators usually prepare questions to ask participants throughout the hour. Participants can tweet responses to the questions - and to each other's responses - during the hour, and the conversation can be reviewed later by searching for the chat's hashtag. You can see an example of a Twitter chat here.

Several medical journals and organizations are using Twitter chats (or virtual journal clubs, as some journals prefer to call them) to engage with their members. The Annals of Family Medicine and the Society of Teachers of Family Medicine host regular Twitter chats covering a variety of clinical and educational topics pertinent to Family Medicine. In other specialties, Journal of the American Geriatrics Society, American College of Chest Physicians, Annals of Emergency Medicine, and the Society of Hospital Medicine all host or have hosted Twitter chats.

Using Twitter for medical education can have tangible benefits. Medical students who participated in Twitter activities relating to biomedical science studies had higher grades than those who did not. Medical students who participated in Twitter activities related to gross anatomy classes reported better communication with faculty, higher morale, and less anxiety. A general surgery program used a competitive Twitter microblogging project to improve their residents' in-training exam scores. An Australian research group found that online CME using Twitter and other social media platforms was perceived as more cost effective for physicians compared to attending live CME conferences.

Last year, AFP hosted its first Twitter chat, and this year, on July 9, we'll host our first Twitter chat for CME credit on the topic of antibiotic overuse. You can claim 4 hours of CME credit for participating; the chat will be 1 hour, and the additional 3 hours are allotted for the preparation time to read the articles. You can download the articles we'll be covering, learn more about the basics of a Twitter chat, and register here. If you have questions about how to get involved, you can tweet @AFPJournal or email

What benefits or barriers do you see to using Twitter for CME?

Tuesday, June 13, 2017

Start collecting community vital signs in your practice

- Kenny Lin, MD, MPH

Primary care physicians and educators are increasingly recognizing the usefulness of assessing social determinants of health (defined by the Centers for Disease Control and Prevention as conditions in the places where people live, learn, work, and play) during health care encounters. A recent National Academy of Medicine discussion paper described the Accountable Health Communities Screening Tool, developed by the Center for Medicare and Medicaid Innovation to identify and address five domains of health-related social needs: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. Since 2011, students at Morehouse School of Medicine and Georgia State University College of Law have participated in an interprofessional medical-legal curriculum; surveys suggested that medical students who completed the curriculum were more likely to screen for social determinants of health and refer patients to legal resources. In March, the American Academy of Family Physicians (AAFP) launched its Center for Diversity and Health Equity, whose planned activities will include

- evaluating current research on the social determinants of health and health equity;
- promoting evidence-based community and policy changes that address the social determinants of health and health equity; and
- developing practical tools and resources to equip family physicians and their teams to help patients, families, and communities.

In an editorial in the June 1 issue of American Family Physician, Drs. Lauren Hughes and Sonja Likumahuwa-Ackman add another potential dimension for action on social determinants of health by introducing the concept of "community vital signs." In contrast to data collected directly from patients, the authors write,

Community-level data are acquired from public data sources such as census reports, disease surveillance, and vital statistics records. When geocoded and linked to individual data, community-level data are called community vital signs. Community vital signs convey patients' neighborhood health risks, such as crime rates, lack of walkability, and presence of environmental toxins. ... This enhanced knowledge about where patients live, learn, work, and play can help physicians tailor recommendations and target clinical services to maximize their impact. Rather than simply recommending that a patient eat better and exercise more, care teams can connect patients to a local community garden, low-cost exercise resources (e.g., YMCA), or neighborhood walking groups.

To get started using community-level data to improve patient care and population health, family physicians can consult The Practical Playbook and the AAFP's Community Health Resource Navigator. The editorial also provides a suggested five-step process for incorporating community vital signs into clinical practice.

Monday, June 5, 2017

Making informed decisions about cancer screening

- Jennifer Middleton, MD, MPH

Debate within the medical community regarding when and how to screen for breast cancer, prostate cancer, and colorectal cancer continues. Helping patients make informed decisions about how they wish to participate in these screenings can be a challenge for busy family physicians. Two recent articles address this challenge by providing several solutions to help us help our patients make informed decisions.

The first article is a report of a large cohort study based in Virginia that examined patients' use of an online decision module regarding breast, prostate, and/or colon cancer screening. Patients were invited to view the module if they were overdue for consideration of these screenings (women aged 40-49 without a mammogram in the last 2 years, men aged 55-69 who had not had prostate cancer screening in the last 2 years, and men and women identified as overdue for colorectal cancer screening). Uptake was low; about 20% of the 11,000+ eligible patients began a module, and only 7.9% completed a module. Of that 7.9%, though, about half felt that it enabled them to have a more helpful conversation with their physician.

The second is a review of shared decision making techniques and resources in the current issue of Family Practice Management. The article reviews clinical circumstances when shared decision making is relevant and also reminds readers that shared decision making is an integral part of the United States Preventive Services Task Force's (USPSTF's) recommendations on breast cancer screening for women aged 40-49 and lung cancer screening. It describes the 6 general steps of shared decision making along with 3 tools for using shared decision making with patients: SHARE, the 5 As, and IAIS. The article also includes a table with online resource aids for patients; the first,, provides neat graphics that may make concepts like "prevalence" and "false positive" easier to discuss using lay language.

You can read about these and other controversies in the AFP Department Collection on Editorials: Controversies in Family Medicine that also includes a search engine. You can also read more about cancer screening, diagnosis, and treatment in the AFP By Topic on Cancer.

What shared decision making techniques and/or tools have you found useful?

Tuesday, May 30, 2017

CA-MRSA coverage is unnecessary for uncomplicated cellulitis

- Kenny Lin, MD, MPH

Cephalexin has long been my oral antibiotic of choice for a patient with uncomplicated cellulitis and no cephalosporin allergy. However, the increasing prevalence of skin and soft tissue infections (SSTIs) caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), often mistaken by patients and clinicians for spider bites, has raised the question of whether it makes sense to also prescribe an antibiotic such as trimethoprim/sulfamethoxazole for empiric CA-MRSA coverage for immunocompetent patients with cellulitis that is not purulent or severe enough for inpatient therapy.

A 2009 case-control study found that children with SSTIs who received empiric monotherapy with trimethoprim/sulfamethoxazole had higher rates of treatment failure than those who received beta-lactam antibiotics. Although helpful, this study did not measure outcomes in adults or in children who were prescribed more than one antibiotic. Despite the lack of evidence of benefit, national data suggest that up to 3 in 4 patients presenting to the emergency department with skin infections are prescribed antibiotics active against CA-MRSA. Potential downsides of "double coverage" include higher rates of adverse effects, cost, and increasing antibiotic resistance.

In a recent paper in JAMA, Dr. Gregory Moran and colleagues reported the results of a multicenter randomized, controlled trial of 500 adolescents and adults with diagnosed in the emergency department with cellulitis and no wound, purulent drainage, or abscess (verified by soft tissue ultrasound) who received 7 days of therapy with either cephalexin plus trimethoprim/sulfamethoxazole or cephalexin plus placebo. They found no differences in clinical cure rates in either the modified intention-to-treat or per-protocol analyses.

Based on this study's results, I will continue to restrict my use of trimethoprim/sulfamethoxazole to patients whose cellulitis fails to respond to cephalexin and patients with purulent infections. Of note, the American College of Emergency Physicians recommends against sending wound cultures or prescribing antibiotics in persons who undergo successful incision and drainage of skin and soft tissue abscesses and who have adequate medical follow-up. A 2015 AFP article provides more information on the management of SSTIs, including inpatient treatment and other special considerations.

Monday, May 22, 2017

2017 Family Medicine Day of Action #staywellsoon

- Jennifer Middleton, MD, MPH

AFP provides content on a variety of issues that may compel a larger call to social justice. Articles on caring for the homeless, victims of intimate partner violence, and ethnic minorities demonstrate our specialty's mission to care for all. Promoting breastfeedinggun safety, and oral health can help patients avoid potentially catastrophic outcomes. Our generalist's perspective can provide expertise on issues such as debated cancer screenings (breast, prostate, and lung) and unnecessary interventions (antibiotics, imaging). We are also well-suited to comment on public health issues such as obesity, opioid misuse, and even global warming.

We may recognize, however, that knowing these medical facts is only the first step to meeting our patients' and communities' needs. Sharing our perspective as family physicians is another important way that we can care for our communities.

Every year, the AAFP's Family Medicine Advocacy Summit takes a group of interested family physicians, trains them in political advocacy, and takes them to Capitol Hill to meet with their elected officials. This opportunity is undoubtedly valuable for those able to participate, but family physicians unable to make this trip now have other ways to get involved. Joining the Family Physician Action Network is a great first step; signing up will provide you with resources to be an effective advocate for your patients. An overview is available on the Family Physician Action Center website, including a primer on the legislative process and tips to maximize your engagement over social media as well as conduct an effective telephone or in-person conversation with your elected officials. Speaking up doesn't have to take a lot of time, and it can have a powerful impact. AFP's Graham Center One-Pagers Department Collection provides succinct talking points on a variety of topics.

The AAFP has also decreed tomorrow the first "Family Medicine Day of Action." You can post a "Stay Well Soon" e-postcard to your Facebook, Twitter, and/or Tumblr contacts by clicking here. AAFP's goal is to have 1000 people post with a goal of 1,000,000 views. It's an easy way to promote Family Medicine and all we have to offer our patients and communities.

Whether it's attending the Advocacy Summit, getting involved in the Action Network, or posting a #staywellsoon e-postcard, all of us can find a way to speak up. What will yours be?

Tuesday, May 16, 2017

Should patients with first syncopal episodes be evaluated for PE?

- Kenny Lin, MD, MPH

The evaluation of patients with syncope has changed minimally over the years, with considerable continuity between recommendations in American Family Physician reviews published in 2005, 2011, and most recently, in the March 1, 2017 issue. But the field received an unexpected jolt last October, when Dr. Paolo Prandoni and colleagues published a cross-sectional study in the New England Journal of Medicine that calculated a surprisingly high prevalence of pulmonary embolism (PE) of 17.3% in patients hospitalized for a first episode of syncope. In this study, 230 of 560 patients at 11 Italian hospitals who did not have a low pretest probability of PE by the Wells rule and negative D-dimer assay underwent computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion lung scans. 97 of these patients had evidence of PE. Overall, the investigators identified PE in 25% of patients with no alternative explanation for syncope and 13% of patients with an alternative explanation.

Standard algorithms for syncope evaluation focus on identifying cardiac and neurally mediated causes and do not include routine testing for PE. The question raised by the Italian study is if all inpatients with syncope warrant an evaluation, since nearly 1 in 6 patients may have PE. There are good reasons to think twice about doing so. First, we don't know if the prevalence of PE in this study was representative of the general population of adults hospitalized for syncope, as it only included patients admitted from emergency departments (and not patients initially evaluated in primary care settings). Second, the study did not determine if PE was the etiology of syncope, as opposed to an incidental finding. This is important because evidence suggests that the enhanced sensitivity of CTPA for detecting small, subsegmental PE is increasing overdiagnosis and overtreatment of clinically insignificant clots. Finally, the absence of a comparison group means that it is not known if the systematic workup for PE affected the patients' prognosis, if at all.

A retrospective cross-sectional study in JAMA Internal Medicine recently addressed the generalizability question by using clinical and administrative data from 4 hospitals in Toronto to estimate the prevalence of PE in 1305 patients with a first episode of syncope who were not receiving anticoagulation at the time of admission. 120 of these patients received CTPA, ventilation-perfusion scan, and/or compression ultrasonography, resulting in the diagnosis of PE in 18 patients. As opposed to the Italian study, where all persons received at least a D-dimer test, the decision to evaluate for PE was driven by clinical judgment. Nonetheless, of 146 patients in the Toronto study who received any test for PE (presumably those with the highest pretest probability), only 12% were positive, and the overall prevalence of PE was a mere 1.4%. The authors concluded that "there is little, if any, justification for routine testing for [venous thromboembolism] in all patients hospitalized for a first episode of syncope."

Based on both studies, I agree that evidence does not support routine testing in patients with syncope. In those with signs or symptoms of PE, another clinical decision rule may be used to confidently rule out the diagnosis without resorting to the less sensitive Wells rule or less specific D-dimer test, where a positive result often leads to unnecessary CTPA.

Monday, May 8, 2017

Counseling postmenopausal women on exercise

- Jennifer Middleton, MD, MPH

Exercise has many benefits for older women. In the current issue of AFP, "Health Maintenance in Postmenopausal Women" describes exercise's benefits regarding cardiovascular disease prevention and fall prevention. Exercise may also reduce the risk of cognitive decline in older women; one meta-analysis found that both aerobic and resistance training may help preserve executive function in women to a greater degree than either exercise modality does in men. Unfortunately, many older women do not regularly exercise, and knowledge of both common barriers and some strategies to overcome them may improve the effectiveness of our counseling.

Most studies examining barriers to regular exercise in older adults include both men and women; identified barriers include concerns about damaging joints, falling, and sustaining injuries. Older adults referred to aquatic therapy often feel uncomfortable wearing a bathing suit in public. Inclement weather is a commonly cited barrier, as is spending significant time caring for an ill partner. Some older women believe, too, that exercise is unnecessary at their age.

Older patients are often receptive to counseling about exercise, but physicians frequently don't initiate these conversations, possibly due to a lack of knowledge about how to do so. Exploring which of the above barriers might keep a patient from exercising is a good first step. Communicating the benefits of exercise to postmenopausal women and brainstorming how to incorporate it into their everyday lives can help with motivation and planning. Reassuring women that it can take some time to develop physical fitness, and that some initial muscle discomfort is normal, may help. Local exercise programs targeted to older adults may be more appealing to patients than attending classes with younger participants.

Providing an exercise prescription is another useful strategy. Last month's AFP article on "Exercise Prescriptions in Older Adults" reviews how to compose one: identify exercises and/or modalities of interest and provide specifics regarding frequency and intensity. A balanced exercise prescription should include aerobic, flexibility, and balance exercises. Including short- and long-term goals of an exercise program may increase patient engagement. This 2010 AFP article on "Physical Activity Guidelines for Older Adults" provides several examples of exercise modalities to consider along with a sample exercise prescription in Table 3. Cardiac stress testing is only needed for patients with established cardiovascular disease who wish to participate in vigorous activities. There are AFP By Topics on Geriatric Care (certainly not all postmenopausal women are geriatric, but some are) and Health Maintenance and Counseling if you'd like to read more.

Monday, May 1, 2017

Three ways AFP translates research for practice

- Kenny Lin, MD, MPH

The May 1 issue of American Family Physician features the latest installment of the "Top 20 Research Studies" series of articles that Drs. Mark Ebell and Roland Grad have been writing annually since 2012. What sets this particular set of study summaries apart from other journals' "best of the year" studies lists? Dr. Jay Siwek explains in his editor's note:

Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.

The research studies from 2016 rated most primary care relevant, valid, patient-oriented, and practice changing include patient-oriented evidence that matters (POEMs) on hypertension; respiratory conditions; musculoskeletal conditions; diabetes mellitus and obesity; and miscellaneous items. The complete POEMs are available in AFP's Evidence-Based Medicine toolkit. Also, Canadian Medical Association members identified four important guidelines published in 2016: the U.S. Preventive Services Task Force (USPSTF) on screening for colorectal cancer and interventions for tobacco cessation in adults; the American College of Physicians on management of chronic insomnia; and the Centers for Disease Control and Prevention on opioid prescribing for chronic pain.

During Dr. Ebell's past membership on the USPSTF, the panel voted to recommend one-time screening for hepatitis C virus (HCV) in every adult born between 1945 and 1965 (also known as birth cohort screening). On the other hand, as a member of the Canadian Task Force on Preventive Health Care, Dr. Grad recently developed a recommendation against screening for HCV in asymptomatic adults without risk factors, including baby boomers. AFP previously presented both sides of this complicated debate in a pair of editorials that outlined the case for birth cohort screening and the case against it. You can find other Pro-Con editorials on controversial family medicine topics in this online collection.

Finally, readers should be aware that essential concepts from AFP Journal Club, a popular journal feature that analyzed key research studies from 2007 to 2015, have been incorporated into our EBM toolkit. This annotated collection of evidence-based medicine pointers provides useful information for clinicians, teachers, and learners at all levels.

Monday, April 24, 2017

Rethinking how we use office blood pressure measurements

- Jennifer Middleton, MD, MPH

The accuracy of medical office blood pressure (BP) measurements is coming under increased scrutiny, possibly affecting how we treat our patients. Basing hypertension diagnosis and treatment on the BP values we obtain in our offices is routine for many of us as family physicians, but checking BP several times during an office visit may more appropriately guide diagnosis and treatment decisions.

In its March/April issue, the Annals of Family Medicine includes a study on "Thirty-Minute Office Blood Pressure Monitoring in Primary Care." The researchers examined every patient over a six-month period who received automated office BP monitoring over a 30 minute period (OBP30) in a practice in the Netherlands. This method has been previously studied there and was found to yield more useful BP data than a single measurement. The researchers then compared the OBP30 readings to these same patients' previously obtained single BP measurements and asked their physicians if they found a clinically meaningful difference: did they make different diagnosis and treatment decisions because of the OBP30 readings?

There were clinically significant differences in both systolic and diastolic BP comparing the single office BP measurement with the OBP30 measurements; the mean systolic OBP30 measurement was 22.8 mmHg lower than the single office BP measurement (95% CI, 19.8–26.1 mm Hg), and the mean diastolic OBP30 measurement was 11.6 mmHg lower (95% CI, 10.2–13.1 mm Hg). The physicians stated that they would have initiated or intensified BP treatment in 79% of patients based on the single office BP measurement, compared to only initiating or intensifying treatment in 25% of these same patients once they had their OBP30 measurements.

These sizable differences imply that we are at risk of overtreating, and possibly incurring undesirable medication side effects, if we base decisions only on single office BP measurements. SPRINT already encourages more aggressive BP goals in some patients; if aiming for a BP of less than 120/80, the risk of over-treatment could be magnified if medication increases are made solely based on solitary BP readings. Additionally, a study reviewed in the current AFP article on "Severe Asymptomatic Hypertension: Evaluation and Treatment" cites a study finding that "[i]n more than 30% of patients with severe asymptomatic hypertension, blood pressure lowers to an acceptable level (mean of 160/89 mm Hg) without intervention following a 30-minute rest period." Even when BPs are first alarmingly high, waiting and rechecking can prevent over-treatment.

An editorial accompanying the above Annals article reviews the challenges of changing our office workflow to accommodate improved BP measurements. Allowing a patient to sit for even 5 minutes before a single BP measurement can be a challenge, let alone keeping them there for 30 minutes. Dr. Lin has written previously on the blog about the usefulness of home BP measurements in adjusting treatment in patients with established hypertension, so that might be an alternative. Either way, if our goal is to treat the patients who need treatment - and not treat those who don't - expanding beyond a single office BP measurement to guide our decisions may help.

There's an AFP By Topic on Hypertension which includes several resources to assist with diagnosis and treatment if you'd like to read more. This recent Family Practice Management article on "Improving Blood Pressure Control with Strategic Workflows" might also be of interest.

Monday, April 17, 2017

Safety net doesn't shield patients from low-value care

- Kenny Lin, MD, MPH

During my residency training and for parts of my career, I practiced in several "safety net" clinics, defined as clinics that serve a patient population where at least 25% have no health insurance or are insured with Medicaid. As family physicians who work in these settings well know, resources are often limited, and arranging for patients to receive necessary care at an affordable price can be a major challenge.

While on telephone hold one day for the umpteenth prior authorization request for a medication my patient had been taking for years, I remember consoling myself that at least these maddening financial constraints provided protection against low-value care. Unlike the concierge practice on the other side of town, I couldn't get patients with acute low back pain into a magnetic resonance imaging (MRI) scanner the next day or order huge panels of unnecessary laboratory tests at health maintenance exams.

As it turned out, my perception was more myth than reality. In a recent cross-sectional analysis of national survey data on nearly 200,000 office visits from 2005 to 2013, Dr. Michael Barnett and colleagues examined performance on quality measures for low- and high-value care among uninsured patients, patients with Medicaid, and privately insured patients. Sample low-value care measures included computed tomography (CT) for sinusitis, screening electrocardiogram during a general medical examination, and CT or MRI for headache. High-value care measures included aspirin, statin, and beta-blocker use in patients with coronary artery disease and tobacco cessation and weight reduction counseling in eligible patients. The authors analyzed the data by insurance type and by physicians classified as practicing in a safety net population. They found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.

This study's findings underline the importance of involving clinicians and patients in underserved practices in the Choosing Wisely campaign against medical overuse. For example, the Connecticut Choosing Wisely Collaborative used a foundation grant to study patient-clinician communication about care experiences and incorporate the Choosing Wisely "5 Questions" at two federally qualified health centers. Lessons learned from these pilot projects included providing patients with context for the "5 Questions" materials and offering ongoing role-specific training and support for everyone on the care team.

Monday, April 10, 2017

More information on NSAIDs & CV risk

- Jennifer Middleton, MD, MPH

Have your patients been asking about non-steroidal anti-inflammatory drug (NSAID) safety? I've seen several lay press articles recently regarding a couple of new NSAID safety studies, and they are definitely prompting patients to ask questions in my office. Both studies reinforce the cardiovascular risks we already know about NSAIDs.

The first study scrutinized four European countries' population health registries for an association between current oral NSAID use and risk of admission to a hospital for acute heart failure. The authors matched individuals in these databases who were admitted with heart failure and had been using an NSAID in the last 14 days ("current" use) to individuals of a similar age, gender, and health risk who were not admitted and had used NSAIDs previously ("past" use, defined by use at least 183 days prior). Those individuals with "current" use of any NSAID were more likely to be admitted with heart failure compared to those with "past" use (odds ratio 1.19 [95% confidence interval 1.17-1.22]). Regarding particular NSAIDs, ibuprofen, naproxen, indomethacin, and diclofenac all increased the risk of heart failure admission while celecoxib, etodolac, and meloxicam did not.

The second study, conducted in Denmark, examined the association between out of hospital cardiac arrest and oral NSAID use in the 30 days prior. All cases of cardiac arrest in Denmark are entered into a registry, and the researchers excluded individuals with obvious non-cardiac causes of arrest (trauma, overdose, etc). Every prescription in Denmark is tracked via another registry, and most NSAIDs used there are prescribed; over the counter NSAID availability in Denmark is quite limited (only small quantities of low dose ibuprofen may be purchased without a prescription). The researchers found the use of any NSAID to increase the risk of out of hospital cardiac arrest (OR 1.31, 95% confidence interval 1.17-1.46), which was mostly driven by ibuprofen and diclofenac's effect - by far the most commonly prescribed NSAIDs there.

NSAID safety concerns are nothing new; this 2009 AFP article advises us to be cautious before prescribing NSAIDs to patients at increased risk of bleeding along with chronic heart, liver, and/or kidney problems. I've written previously on the blog about a large meta-analysis published in 2013 showing that long term NSAID use increased the risk of heart failure. These two new studies, however, may cast even short term safety of NSAIDs in a questionable light. Neither set of researchers commented on how long patients had been taking NSAIDs who were "current" users, but it seems possible that at least some of the individuals in these cohorts were not using them long-term.

These studies provide us with more information to discuss with patients when considering options for acute or chronic pain relief. Although oral NSAID use increased cardiovascular risks in both of these studies, the odds ratios in each study were not terribly high; this increase in risk might be more acceptable to many patients - and physicians - than the risks of opioids. With the ever-growing awareness of opioid misuse, we'll have to decide with each patient which set of risks and benefits are the most acceptable. Topical NSAIDs may also be worth including in conversations about treating acute musculoskeletal pain.

Will these new studies change how you discuss NSAIDs with patients?

Tuesday, April 4, 2017

AAFP and ACP confront the opioid epidemic

- Kenny Lin, MD, MPH

Although I rarely initiate opioid therapy, my practice has inherited an increasing number of patients for whom previous physicians have prescribed potentially dangerous doses of opioids for chronic musculoskeletal or neuropathic pain. What is the best approach to take to this situation? As Dr. Jennifer Middleton discussed in an earlier AFP blog post, I could follow the Centers for Disease Control and Prevention guideline and try to reduce their pain prescriptions to safer levels by substituting alternative treatments, such as cognitive behavioral and physical therapy. I could choose to stop prescribing opioids for chronic pain, as one federally qualified health center did with notable success. I could also seek out additional training to become certified to treat opioid addiction with buprenorphine.

Last year, Surgeon General Vivek Murthy called on every physician in the U.S. to pledge to work with him to "turn the tide" on the opioid epidemic. Writing in New York Magazine, columnist Andrew Sullivan recently called it "this generation's AIDS crisis" - an epidemic that, by being highly concentrated in one demographic (AIDS in urban gay men, opioids in rural, white working-class persons), was invisible to most Americans:

For many of us, ... it’s quite possible to live our daily lives and have no connection to this devastation. And yet its ever-increasing scope, as you travel a few hours into rural America, is jaw-dropping: 52,000 people died of drug overdoses in 2015. That’s more deaths than the peak year for AIDS, which was 51,000 in 1995, before it fell in the next two years. The bulk of today’s human toll is related to opioid, heroin, and fentanyl abuse. And unlike AIDS in 1995, there’s no reason to think the worst is now over.

The April 1 issue of AFP featured a Practice Guidelines summary of the American Academy of Family Physicians' position paper on management of chronic pain and opioid misuse, which noted that "in addition to physicians, there are opportunities to help at the practice, community, education, and advocacy levels." In an accompanying editorial, two family physician authors of the position paper argued that family physicians should take a leading role in responding to the opioid crisis:

Family physicians are committed to advancing population and community health, and we must take the lead in reducing opioid misuse and overdose before outside entities mandate practice strategies that may not be patient-centered. Substance abuse disorders remain a stigma, and physician offices must be safe places for nonjudgmental diagnosis and treatment. Although we certainly cannot tackle this challenge alone, we have a clear opportunity to combat the problem of opioid misuse.

Similarly, the American College of Physicians recently published a position paper on prevention and treatment of substance use disorders that observed that only 18% of people in the U.S. with a substance use disorder are receiving treatment, far short of treatment rates for other chronic conditions in primary care: hypertension (77%), diabetes (73%), or major depression (71%). The authors concurred with the AAFP that multi-pronged efforts will be required to reduce the rising toll of opioid misuse:

Multiple stakeholders should cooperate to address the epidemic of prescription drug misuse, including the following strategies: implementation of evidence-based guidelines for pain management; expansion of access to naloxone to opioid users, law enforcement, and emergency medical personnel; expansion of access to medication-assisted treatment of opioid use disorders; improved training in the treatment of substance use disorders, including buprenorphine-based treatment; establishment of a national prescription drug monitoring program (PDMP); and improvement of existing monitoring programs.

Monday, March 27, 2017

Simplifying treatment of acute asthma

- Jennifer Middleton, MD, MPH

A 2 day course of oral dexamethasone emerged as an alternative to a 5 day prednisone course for acute asthma treatment in adults a few years ago, and now a POEM (patient-oriented evidence that matters) reviewed in the current issue of AFP suggests that just one dose of dexamethasone might also be an option.

The study researchers enrolled 465 adults between the ages of 18-56 who were diagnosed with acute asthma in an emergency department (ED). The participants were randomized to either 60 mg of prednisone for 5 days or 12 mg of oral dexamethasone once (followed by four days of placebo). This study used a noninferiority design; the researchers wanted to see if both regimens were equally efficacious regarding the reduction of relapses requiring additional days of steroid treatment. 9.8% of the prednisone group had a relapse compared with 12.1% of the single dose dexamethasone group, which was a statistically significant difference. There was no difference in hospitalization rates or adverse treatment effects between the two groups. Although 5 days of prednisone was more effective at preventing relapse, the researchers felt that the difference between the two treatment arms was small enough, and the benefits of better compliance high enough (since the dexamethasone was given in the ED), to still make it a viable option.

Shorter courses of dexamethasone may also be an option for our patients under the age of 18 with acute asthma. A meta-analysis published last year found that short courses (1-2 days) of dexamethasone were equivalent to longer courses of oral prednisone or prednisolone for children presenting to the ED with acute asthma in preventing relapse. 1-2 day treatment courses are likely easier for children and parents to adhere to, and children may additionally find oral dexamethasone to be more palatable than oral prednisolone. Inhaled anticholinergics are also a useful adjunctive treatment for children with acute asthma (and possibly for adults with severe exacerbations) as reviewed in this 2011 AFP article on the Management of Acute Asthma Exacerbations. The article mentions a 2008 study that found 3 days of prednisone to be equivalent to 5 days for outpatient treatment of acute asthma.

A 2016 Cochrane review on corticosteroid options for acute asthma in adults and children found that existing evidence was insufficient to state whether one type of oral corticosteroid therapy - regardless of specific medication or treatment duration - was superior to another for outpatient treatment of acute asthma, calling for larger, more rigorous trials. It is reassuring, at least, that they did not find any "convincing evidence" that one type of treatment was worse than another regarding rates of relapse, hospitalization, and adverse drug effect. For the time being, we'll need to use patient-centered decision making to arrive at the best treatment plan for each patient with acute asthma, though it certainly seems reasonable to consider shorter durations of oral corticosteroids in uncomplicated pediatric and adult patients. There's an AFP By Topic on Asthma if you'd like to read more.

Having a reliable source for potential practice-changers, like this 1-dose dexamethasone study, can help busy family physicians stay up to date. At the bottom of this most recent AFP POEM are links to several such resources. There's an archive of AFP's published POEMs, complete with a tool to quickly search them by discipline, topic, and/or keyword. The AFP Podcast regularly reviews the POEMs published in AFP like the one above, often adding additional information, angles, and/or resources along the way. The POEM of the Week Podcast with AFP Editor Dr. Mark Ebell is another audio resource that provides concise, thoughtful reviews of studies relevant to primary care.

How do you decide which corticosteroid to prescribe - and for how long - in acute asthma treatment?

Tuesday, March 21, 2017

The influence of residency training on high-value care

- Kenny Lin, MD, MPH

The American Academy of Family Physicians last week celebrated the results of the 2017 Match, which saw a record 3,237 medical students and graduates fill first-year positions in family medicine residency programs. Although there is ample evidence that providing primary care improves population health, it is less clear how residency training specialty or location influences future health care quality and spending.

As Dr. Jennifer Middleton and I mentioned in prior posts, the AAFP was an early adopter of the American Board of Internal Medicine Foundation's Choosing Wisely campaign against questionable or unnecessary medical interventions, but so far, studies have shown limited effects of the campaign in primary care. Since an estimated 30 percent of health care spending is wasted on unnecessary services, and a recent case study in JAMA suggested that "excessive resource utilization" may be considered an adverse event, it is worth studying if residency training spending patterns persist in clinical practice.

In a research paper in this month's Annals of Family Medicine, Dr. Robert L. Phillips, Jr. and colleagues at the American Board of Family Medicine and the Robert Graham Center analyzed spending patterns of a nationally representative sample of 3,075 family physicians and general internists who graduated from residency between 1992 and 2010 and who cared for a total of more than 500,000 Medicare patients. The physicians' residency program locations were matched with Hospital Service Areas (HSAs) and categorized by spending per patient into low-, average-, and high-cost groups. The researchers found that the "imprint" of residency training spending patterns persisted regardless of where physicians ended up providing primary care:

Physicians trained in high-cost HSAs spent significantly more per patient than those trained in low-cost HSAs, no matter what the spending category of the practice HSA. Averaged across all practice HSAs, this difference was $1,644. ... This relationship held true for family physicians and general internists in our multivariable analysis; general internists, however, made up two-thirds of sample physicians trained in high-cost HSAs, and family physicians made up two-thirds of those trained in low-cost HSAs. [Residency] graduates were significantly more likely to be low-cost physicians if their sponsoring institution produced fewer total physicians, more rural physicians, or more primary care physicians.

The researchers found no relationship between spending patterns and diabetes quality measures, suggesting that lower spending did not lead to worse health outcomes. And it is important to note that family physicians who trained in high-cost HSAs were as likely to be big health care spenders as general internists from high-cost programs; in other words, there did not appear to be anything inherent in family medicine training that caused graduates to spend less. However, more general internists provided costlier care by virtue of having trained in high-cost areas - most likely, those with tertiary academic medical centers. I agree with Dr. Phillips and colleagues' conclusion that their study "supports efforts to test interventions in residency training that may bend imprinting toward teaching and modeling behaviors that improve value in health care." One intervention has borne fruit for the past 8 years in a row: attracting more medical students to the specialty of family medicine.

Monday, March 13, 2017

Supporting our LGBT adolescents

- Jennifer Middleton, MD

Well care at all stages of life is an important part of many family physicians' practices, but perhaps our visits with adolescents are among the most crucial. Discussing sexual health and risk behaviors in all adolescents can help teens avoid serious health sequelae. These discussions are especially critical for lesbian, gay, bisexual, and transgendered (LGBT) youth, as Drs. Knight and Jarrett remind us in the current issue of AFP.  In their article "Preventive Health Care for Women Who Have Sex with Women" (WSW), they assert that "sexual minority adolescents face unique developmental challenges." Providing a supportive environment for sexual minority youth to discuss their sexuality allows us to provide counseling and care regarding these health concerns.

Adopting gender-neutral language with all of our adolescent patients indicates our willingness to provide a safe space for LGBT youth to tell their story. Asking "Is there someone special in your life?" instead of "Do you have a boyfriend/girlfriend?", for example, avoids assumptions regarding sexual orientation. Confidentiality during adolescent visits is especially important to LGBT teens, who may not have disclosed their sexual identity to family and friends. Protecting confidentiality is appropriate unless the adolescent's safety is immediately at risk (such as disclosure of ongoing abuse or intent to commit suicide). Inquiring about bullying is also a must for LGBT adolescents, as they are at higher risk of peer violence compared to their heterosexual peers. Connecting adolescents, and their families, with organizations such as Parents, Friends, and Families of Lesbians and Gays (PFLAG) and the Gay, Lesbian, and Straight Education Network (GLSEN) may help sexual minority teens find support that may be lacking in school or other social environments.

Establishing rapport and a safe environment allows physicians the opportunity to screen for common adolescent risk-taking behaviors. Drs. Knight and Jarrett discuss the health concerns that are disproportionately increased in adolescent WSW, including eating disorders, depression, social anxiety disorders, sexually transmitted infections (STIs), and substance abuse. Asking specifically about each of these issues can help family physicians uncover risk behaviors and provide counseling and treatment. The authors provide helpful language and prompts for obtaining a sexual and social history in WSW (table 4) along with safer sex recommendations particular to WSW (table 6). You can review counseling recommendations for men who have sex with men (MSM) in this 2015 AFP article; highlights include ensuring that hepatitis and meningitis vaccinations are up to date for MSM who meet criteria and offering pre- and post-exposure prophylaxis when warranted to reduce the risk of human immunodeficiency virus (HIV) infection.

Having awareness of these recommendations and using these techniques as physicians is only a first step; our offices must also reflect our commitment to provide care for all. In an accompanying editorial to Drs. Knight and Jarrett's AFP article, Dr. Stumbar reminds us to "create an inclusive office environment that features photos of same-sex and opposite-sex couples, the rainbow flag, and office staff who are comfortable with nontraditional family structures."  The AFP By Topic on Care of Special Populations includes a subheading on Gay, Lesbian, Bisexual, and Transgendered Persons if you'd like to read more.

Monday, March 6, 2017

Prioritizing effective clinical preventive services: an update

- Kenny Lin, MD, MPH

In a widely cited 2003 study, Dr. Kimberly Yarnall and colleagues estimated that in order for a family physician to provide all U.S. Preventive Services Task Force-recommended services to a patient panel of 2500 with an age and sex distribution similar to that of the U.S. population, he or she would need to spend 7.4 hours per working day, leaving little time to address acute or chronic medical problems. Although the subsequent rise of the patient-centered medical home model has allowed physicians to share this work load with other primary care team members, it remains difficult to meet all preventive care needs. In 2006, the National Commission on Prevention Priorities (NCPP) ranked 25 preventive health services recommended by the USPSTF and the Advisory Commission on Immunization Practices (ACIP) based on clinically preventable burden (health impact) and cost-effectiveness. The three services that received the highest score were aspirin use to prevent cardiovascular disease (CVD), the childhood immunization series, and tobacco use screening and brief interventions in adults.

In the January/February Annals of Family Medicine, the NCPP published an updated ranking of effective clinical preventive services, using similar methods as in their 2006 study. The childhood immunization series and adult tobacco use screening and counseling remained the most highly prioritized services, joined by counseling to prevent initiation of tobacco use in children and adolescents, first recommended by the USPSTF in 2013. Although low-dose aspirin for primary prevention remained important, the more targeted 2016 USPSTF recommendation to discuss use with high-risk adults lowered the estimated population health impact of this service. In a recent editorial in AFP, former USPSTF member Douglas Owens explained the rationale for focusing on persons 50 to 59 years of age with a 10% or greater 10-year CVD risk:

The decision to initiate aspirin should be based on a discussion of potential benefits and harms. ... Persons who value avoiding long-term medication use may benefit less from taking aspirin. Cardiovascular risk is also important: the higher a person's risk of CVD, the more potential benefit aspirin provides. The most favorable balance of benefits and harms occurs in persons who are at substantially elevated CVD risk but are not predisposed to bleeding complications. Finally, although older age increases the risk of cardiovascular events, it also increases the risk of bleeding complications.

Dr. Jennifer Middleton discussed the nuances of this recommendation statement, including aspirin's benefits for reducing colorectal cancer risk, in a previous post on the AFP Community Blog.

Finally, clinicians should be aware that the Affordable Care Act (ACA) mandated that in addition to the USPSTF and ACIP, preventive services recommended by the Bright Futures guidelines and the Women's Preventive Services Initiative be fully covered by private insurance plans without cost-sharing. The methods of these groups differ significantly, and unlike the NCPP, none of them review cost-effectiveness. Although political uncertainty surrounding possible repeal of the ACA makes it unlikely that this process will change in the near future, a 2016 editorial in JAMA Internal Medicine proposed improving the consistency of the groups' evidence review methodologies and forming a separate advisory committee "to integrate economic considerations into the final selection of free preventive services." Or, perhaps the NCPP itself could take on that role?

Monday, February 27, 2017

Meaningful practice change: less "top-down," more "copy-improve"

- Jennifer Middleton, MD, MPH

I recently wrote about the slow uptake in practice changes in response to the Choosing Wisely recommendations. Understanding the potential challenges to implementing change is an important prerequisite for success, and the current issue of Family Practice Management describes these challenges in the article Why Best Practices Fail to Spread. Drs. Toussaint and Elmer discuss 4 common reasons that practice changes fail; although their discussion centers on workflow changes, the obstacles they discuss can certainly pertain to clinical change as well.

  1. A top-down approach: organizational leaders mandating how change must happen even though every practice is different
  2. A lack of compelling data: physicians won’t buy into making changes unless there is some proof those changes will provide benefit
  3. Standard work for everyone but providers: requiring standardization of everyone in an office except the physicians
  4. Lack of management: office managers must routinely audit compliance with the change plan

The authors suggest one key solution:
[O]rganizations need to include a bottom-up aspect to their change effort; that is, give clinics a playbook not to simply copy but to “copy-improve.” …. Each clinic took the standard work and adapted it to its own environment and specific needs.
Implementing office workflow changes that support Choosing Wisely could follow a similar pattern. As Dr. Lin and colleagues discussed in an FPM article last year, “Many of the recommendations can become the focus of quality improvement projects, performance metrics, and pay-for-performance measures.” Each office could choose a Choosing Wisely recommendation that is especially pertinent to their patient population’s needs and initiate a quality improvement (QI) cycle. The initial point of change could come from within the office itself. Presenting staff and physicians in the office with the evidence base behind the recommendation may increase buy-in, and standardizing the new process for everyone - including physicians - may increase the likelihood of success. Office managers must then commit to auditing workflows and charts to ensure ongoing compliance with the change plan.

FPM is an excellent source of ideas about how to implement these kinds of changes. Family physicians can also find useful articles there about partnering with insurance companies on quality efforts, using pre-visit planning to your advantage, and conducting meaningful audits. AFP has several useful tools to consider as well, including the Choosing Wisely recommendation search tool and articles such as this review of the evidence consistent with several Choosing Wisely recommendations.

Tuesday, February 21, 2017

Guest Post: On the front lines of the opioid epidemic

- Catherine Shafts, DO and Mort Glasser, MD

As a Federally Qualified Health Center in northeastern Connecticut, our mission is to improve the health of the towns we serve. In 2007, we were known as a place where one could easily get prescription opioids. At the same time, opioid abuse, addiction and overdoses were being recognized as a national epidemic. We decided to make a change. All chronic pain management plans were reviewed. Medications were not benefiting patients and often being diverted. This led to a complete reversal of prescribing practices and overhaul of how we managed chronic pain.

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. It was difficult at first. Patients complained to the medical staff, administration, chief medical officer, and Department of Public Health that their needs were not being met. Everyone realized we were not abandoning our patients but rather offering better, healthier treatments. Our efforts were supported.

Since much of our population is transient, including homeless persons, migrant farm workers, former prisoners, and patients with mental health and substance abuse disorders, we wanted a system in place that did not discriminate based on appearance or history. The policy is the same for a 70-year-old woman with osteoarthritis as a 35-year-old man with chronic low back pain.

Patients were offered help at addiction treatment centers, referred to pain management, and given non-addictive options to treat pain. It led to a cultural shift. In time, we experienced less staff stress, fewer irate phone calls, and fewer calls to police. A variety of patients began to come to the community health center instead of only those desiring opiates. Newborns, seniors and families began seeking care. Our child patient population increased significantly. We became a true Family Medicine practice.

Many patients ultimately have been thankful for the changes. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus. Each patient is screened for substance abuse. ACE (Adverse Childhood Experience) scores are being used and discussed. Consistently addressing opioids with preteen and teen patients to prevent use is paramount. With this policy and these new practices, we hope to continue to impact opioid abuse and overdoses and make our small part of the world healthier.

Wednesday, February 15, 2017

Vaccines in the news: controversies & updated recommendations

- Jennifer Middleton, MD, MPH

Vaccine safety concerns continue to make headlines, with another physician garnering attention for voicing his opinions in the last few weeks. Although his healthcare system has vehemently disavowed his statements, some physicians may fear that his claims will complicate the discussions we have with patients about vaccination. It's within this context that AFP's current issue reviews the Advisory Committee on Immunization Practices' (ACIP) updated recommendations for 2017, with articles focusing on children and adults. There are several changes for physicians to be aware of - and having strategies at the ready to respond to concerns evoked by current events may prove useful when discussing them with patients.

Some highlights from the ACIP recommendations:

* Live attenuated influenza vaccine is no longer recommended following studies showing its relative ineffectiveness. This change unfortunately eliminates what was an attractive influenza vaccine option for our needle-phobic patients.

* Only 2 doses of human papillomavirus (HPV) vaccine are now needed for healthy adolescents as long as the series is started before age 15; if started at or after age 15, then 3 doses are still required.

* Pregnant adolescents and women should receive a tetanus toxoid, reduced diptheria toxoid, and acelluar pertussis (Tdap) vaccine between 27 and 36 weeks gestation, regardless of when they last received Tdap vaccination.

* Speaking of infants, ACIP changed their language regarding the first hepatitis B vaccination to emphasize that it should be given "within 24 hours of birth."

* The new vaccine for serotype B meningococcal disease is available for adolescents between ages 16-23.

* Everyone with chronic liver disease - including non-alcoholic fatty liver disease - should receive the hepatitis B vaccine series.

It's likely that, in the course of discussing these changes with patients, that some patients will share their hesitancy to receive a vaccination themselves and/or vaccinate their children. Several techniques may be useful in overcoming vaccine hesitancy. I've written on the blog before about how eliciting our patients' specific concerns and then tailoring our message accordingly can be successful. Dr. Lin has previously provided recommendations about discussing HPV vaccination with parents. A recent editorial in AFP shared "Strategies for Addressing and Overcoming Vaccine Hesitancy," and this excellent article provides useful information about vaccinations and common concerns to share with patients as well. There are AFP By Topics on Immunizations (excluding influenza) and another on Influenza with editorials, patient information, and review articles at your fingertips. If you have concerns about reimbursement related to providing vaccines in your office, check out this 2015 article from Family Practice Management.

Recent outbreaks in the United States of measles and pertussis serve as vivid reminders of how dangerous these diseases can be. Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.

Monday, February 6, 2017

Guest Post: Innovating connections in family medicine

- Brian Champagne, MD

Two years ago I chose family medicine not only to develop a diverse skill set and knowledge to handle almost any patient concern, but also to build a connection with numerous patients of different ages to learn from them as they learn from me.

Fast-forward to now. I’m in the depths of a busy clinic, stabilizing a crying baby’s ear and desperately searching for a reflective hue amid a narrow tunnel of earwax. I’m not finding it. I glimpse for 2 seconds before the child’s war cries rattle my own tympanic membranes and I abort the mission. On my third try, I hit the jackpot and visualize a reflective drum. My job is done. I instill some confidence in the mom that her baby will do fine without a goodie bag of antibiotics. We share a bonding laugh at the absurdity of spending over an hour out of her day for a one-second examination with a magnifying glass.

I scamper to my computer and slam in some orders for vaccines, glance at my schedule, and then briskly walk to the next room down the hall. Behind the door is a 70-year-old woman seated in the infamous tripod pose, hunched over with retracting neck muscles, swollen legs and appearing worried. She was discharged just 2 weeks ago for heart failure. I examine her and order 40 mg of IV Lasix. A half of an hour later she’s still retracting. I kneel to tell her she’s going to get through this and she nods appreciatively, hoping I’m right. I send her to the hospital for more diuretics as I tap on the door of my next patient.

It’s a wiry 60-year-old man who describes brief spouts of right upper quadrant pain so severe that he swears it’s worse than childbirth. I examine him and explain the possibility of a problem in his liver or gallbladder. After ordering some labs and a right upper quadrant ultrasound, he thanks me for my care. Days later, my suspicion is confirmed. Gallstones are present and off to surgery he goes.

While I enjoy these hectic days and the meaningful connections I find through them, I also understand that in 10 years, my family medicine clinic will likely run differently.

For the screaming baby with possible otitis media, if mom had sent in photos of her baby’s eardrum with a smartphone, perhaps a 10-minute video call would have provided all information that supportive care is appropriate.

For the 70-year-old woman with persistent CHF exacerbations, perhaps if she were plugged into a system of communicating nurses trained in heart failure management, maybe she wouldn’t be in need of another hospitalization.

For the 60-year-old man with right upper quadrant pain, if a quick bedside ultrasound by the physician were possible, perhaps he could have been referred to surgery that day.

With small improvements in patient care, we have the opportunity to develop a more efficient and inexpensive health care system with better health outcomes. While I delight in new technology that enhances our care for patients, some aspects of family medicine won’t change. Technology won’t change the reassuring words we can offer to a worried parent or acutely ill patient. It won’t alter the power of our receptive ears being present for a scared patient. And it definitely won’t replace the wisdom, laughs, perspectives, and connections we encounter with our patients each day. And that’s a good thing.


This post won first place in the Society of Teachers of Family Medicine 2016 Resident/Fellow Blog competition. It was originally published on the STFM Blog.

Tuesday, January 31, 2017

Obstructive sleep apnea: screening and home testing news

- Kenny Lin, MD, MPH

According to a recent article in AFP, obstructive sleep apnea (OSA) is present in 2 to 14 percent of the general adult population, with a higher prevalence in older and obese persons. Most people are unaware of their diagnoses, either because they do not recognize symptoms or do not report them to physicians. Since it is hard to make an asymptomatic person feel better, is there any good reason to screen for OSA in asymptomatic adults? Screening advocates suggest that treating patients with moderate to severe OSA with continuous positive airway pressure (CPAP) reduces hypoxic episodes that could trigger cardiovascular events in patients with known vascular disease. A POEM in the January 15th issue summarized a randomized trial that seemed to refute this hypothesis. After almost 4 years of follow-up, the group that received CPAP reported slightly less daytime sleepiness, but had the same frequency of cardiovascular events as the control group.

The U.S. Preventive Services Task Force (USPSTF) considered this study and others in issuing a new recommendation statement on January 24th that concluded "the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults." The USPSTF found inadequate evidence that validated questionnaires (such as STOP-BANG) accurately identify who will benefit from polysomnography (PSG) in asymptomatic populations (as opposed to those with suspected OSA). The Task Force also could not determine if CPAP or mandibular advancement devices improve health outcomes (mortality, cognitive impairment, motor vehicle crashes, and cardiovascular or cerebrovascular events) other than sleep-related quality of life.

Although an insufficient evidence statement is not necessarily a recommendation to not screen, Drs. Sachin Pendharkar and Fiona Clement argued in an editorial in JAMA Internal Medicine that the costs of screening for OSA (not considered by the Task Force) warrant clinicians doing just that. Based on the sensitivity and specificity of one widely used screening tool, and an OSA prevalence of 26% in the Medicare population, the authors estimate that $21 billion would be wasted on negative PSG tests, or $4.4 billion if less expensive home-based sleep studies were used instead.

On a related note, the comparative accuracy of home-based tests versus laboratory PSG in diagnosing OSA has been an actively studied topic. A 2014 practice guideline from the American College of Physicians recommended that portable sleep monitors (limited-channel sleep studies) only be used to diagnose OSA when PSG was not available. However, a randomized non-inferiority trial published last week in Annals of Internal Medicine found that patient outcomes after limited-channel studies were similar to those after PSG. This finding may be a blow to the for-profit sleep testing industry, but it is undoubtedly good news for our patients.

Saturday, January 21, 2017

After emergency contraception: what next?

- Jennifer Middleton, MD, MPH

Developing a regular, ongoing contraception plan when women request emergency contraception (EC) makes intuitive sense, and the updated Centers for Disease Control and Prevention (CDC)'s Practice Recommendations for Contraceptive Use, as described in the January 15 issue of AFP, includes several points for physicians to consider when doing so. One important discussion point involves the risks and benefits of simultaneously providing a ulipristal (ella) prescription and initiating long-acting hormonal contraceptive methods.

Women desiring EC in the U.S. currently have three oral medication options, in addition to the copper IUD, to choose from: the Yupze method and levonorgestrel are approved up to 72 hours after unprotected intercourse, and ulipristal is approved up to 120 hours after unprotected intercourse. Patients requesting EC are often willing to initiate a regular contraceptive method at the same visit. Initiating hormonal contraception at the same time as levonorgestrel or the oral contraceptives used in the Yupze method poses no drug-drug interaction risk, but how ulipristal's antiprogestin effect might impact outcomes is less clear.

Hormonal contraceptive methods, regardless of delivery mode (oral, implant, or IUD) may decrease ulipristal's efficacy, and, conversely, ulipristal may also decrease the initial efficacy of a regular hormonal method. The CDC recommends waiting at least 5 days after taking ulipristal before beginning a hormonal contraceptive method. This delay, however, can be inconvenient for women and can increase the risk of them not initiating a regular contraceptive method at all. Discussing these risks and benefits with patients at the time of providing EC is a must.

Ulipristal has definite positives; it's the most effective oral medication for EC, it only requires one dose, and it works up to 5 days after unprotected intercourse. The potential negative of these interaction risks, however, drives the CDC to encourage transparent discussion with patients. Patient-centered decision making is one framework well-suited to such conversations:
The health care provider's role includes provision of information, facilitating the identification of patient preferences, ensuring that preferences are not based on misinformation, helping patients to think about how their preferences relate to the available options, and coming to a mutually acceptable decision.
Women want their preferences included in discussions of contraceptive choice, and they also want to have the final decision in what method they will use. Discussions about EC should include options for initiating a regular form of contraception along with information about ulipristal's effectiveness and possible interactions. 

Family physicians should not dismiss ulipristal as an option for EC given its convenience and efficacy, but considering the possible decreased effectiveness of both ulipristal and whatever new contraceptive method patients choose is important. Providing this information to women in the context of patient-centered decision making will allow them to choose both an EC method and a regular contraceptive method that best fit their priorities and wishes. If you'd like to read more about ulipristal, there's an AFP STEPS article that outlines its use, and this Update on Emergency Contraception describes use of the Yupze method, levonorgestrel, and the copper IUD. There's also an AFP By Topic on Family Planning and Contraception that contains in-depth information about a variety of contraceptive methods.

How do you counsel women about EC?

Tuesday, January 10, 2017

What's in a name? Obesity, ABCD, and prediabetes

- Kenny Lin, MD, MPH

A recent position statement from the American Association of Clinical Endocrinologists and the American College of Endocrinology proposed replacing obesity with the term "adiposity-based chronic disease," or ABCD for short. The authors argued that this new term emphasizes that most persons with obesity will struggle with weight gain for their entire lives; encourages a complications-centric as opposed to body mass index-based management approach; and "avoids the stigmata [sic] and confusion" associated with obesity in popular culture. They also asserted that ABCD is more amenable to interventions based on the Chronic Care Model, which explicitly recognizes that screening and office-based management need to be adapted to the patient's unique environment.

None of these concepts should surprise family physicians, though, and after reading through the AACE/ACE statement, I was not sold on the benefits of the new term. Some patients with body mass indexes above 30 don't like the obesity label, but would they respond any more positively to the disease acronym ABCD? There are potential harms to consider, too. One of my AFP physician colleagues felt that the new term was "intimidating" and "not at all patient centered," while another thought that it "only hides the issue [of obesity] instead of confronting it."

This discussion brought to mind another medical term often associated with overweight and obese patients: prediabetes. On one hand, being classified as "prediabetic" or at risk for this exceptionally common diagnosis may motivate obese patients to lose weight through improved diet and physical activity. On the other, the term prediabetes is misleading: many of these patients will not develop diabetes, and the diagnostic accuracy of the most common screening tests (hemoglobin A1c and fasting glucose levels) is poor, according to a systematic review published in the BMJ. Due to the tests' low sensitivity and specificity, some persons are incorrectly diagnosed with prediabetes, and others who might actually benefit from interventions to prevent diabetes are falsely reassured. Therefore, the review authors concluded, "'screen and treat' policies alone are unlikely to have substantial impact on the worsening epidemic of type 2 diabetes."

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.

Tuesday, January 3, 2017

Guest Post: I have a new patient

- Donna J. Schue, MD

I've been in a busy rural private practice for 15 years. Outside of new obstetrical patients, the children I deliver, and the occasional close relative or close friend of an existing patient, my practice has been full.

I received a phone call on a Saturday from one of our Emergency Department physicians. Our practice was listed that day to provide an ED follow-up visit for those patients who were seen and had no physician. My colleague had just seen a delightful and independent 80 year-old woman who had come to the ED, not having seen a physician for over 25 years. She had discovered a breast lump about two years before. She had witnessed her husband die of cancer 15 years before despite all attempts at treatment, and had decided that she would continue to have good days until she wasn't having good days anymore. The ED evaluation had revealed an obvious large breast cancer, extensive ascites, and a large pleural effusion. A CT scan showed scattered bony metastases. She did not want to see an oncologist and did not want to be admitted to the hospital, but knew she would need care in the months to come. I told him I would accept her as a patient and saw her in my office on Monday.

Now, four months later, my new patient has undergone a thoracentesis and several paracenteses. She is beginning to have discomfort related to metastases, and we are managing her pain. She has completed a Medical Order for Life-Sustaining Treatment form and prepared her legal affairs. She has also continued to live independently, attend daily Mass, volunteer at a hospice home and a clothing donation center, and has visited out of town family three times. She has told no one of her diagnosis. She does not want those around her to worry. She tells me repeatedly that she is grateful that it is winter and her sweaters can hide the changes to her body that would be more obvious otherwise.

The clinician in me wonders what might have been the outcome if she had presented to care earlier. However, having had two patients die in the last year from opportunistic infections while immunocompromised due to chemotherapy, I remind myself that treatment does not guarantee longer survival.

We talk at each visit about telling her family. As I lost my own mother due to side effects of cancer treatment a few years ago, I share with her that as a daughter I would want to know that this was happening to my mother. She agrees that at some point she will tell them, but not yet. She mentions that she may need help with that when the time comes.

I remain impressed by her fortitude to continue her daily routines. I realize, again, that sometimes we family physicians are called to comfort and not cure. I see how filling her remaining days by helping others continues to bring her a sense of purpose. I have learned a great deal from her in a short time and am grateful that I accepted a new patient.