Tuesday, August 15, 2017

Procedures and prevention: the challenges of Choosing Wisely

- Kenny Lin, MD, MPH

A 55 year-old woman with chronic low back pain and symptomatic knee osteoarthritis asks your opinion about lumbar fusion surgery and some arthritis walking shoes she saw advertised on television. She is prescribed long-acting oxycodone and physical therapy for back pain, and her orthopedist recently began a series of hyaluronic acid injections for her knees. She is up-to-date on cervical and breast cancer screening, but also desires screening for ovarian cancer.

Next, you see this patient's husband, a 60 year-old man with stable coronary artery disease. He was recently hospitalized for an episode of chest pain, and although tests did not show a myocardial infarction, a cardiac catheterization found an 80% stenosis in the left anterior descending artery. He already takes a baby aspirin daily, but his cardiologist has advised adding clopidogrel and having a coronary stent placed. Last year, he quit smoking after going through a pack of cigarettes a day for 40 years, and he is interested in screening for lung cancer. Also, since his brother was diagnosed with colorectal cancer at age 50, he has undergone screening colonoscopies at ages 40, 45, 50, and 55. These have all been normal, and he wonders if it is necessary for him to continue having them every 5 years.

Although both of these patients are fictitious, they represent common clinical scenarios in family medicine that contain enormous potential for overdiagnosis and overtreatment. In the August 15 issue of American Family Physician, Drs. Roland Grad and Mark Ebell present this year's edition of the "Top POEMs Consistent with the Principles of the Choosing Wisely Campaign," which includes the following suggested clinical actions:
As with last year's Top POEMs list, questioning unnecessary procedures or non-beneficial treatments is an effective way to protect patients from harm. But it's important to take a critical approach to preventive care as well to avoid overscreening. For example, as Dr. Jennifer Middleton noted in a previous blog post, one high-profile screening test for ovarian cancer still has big gaps in the evidence regarding its effect on mortality. Drs. Grad and Ebell advise against screening for ovarian cancer and carefully weighing the risks and benefits of lung and colorectal cancer screening:
It is challenging, and sometimes uncomfortable, to question long-accepted practices that feel like "old friends," AFP assistant medical editor Allen Shaughnessy wrote in a 2016 editorial. He suggested that clinicians keep in mind that the purpose of these evidence-based recommendations, and all of those from the Choosing Wisely campaign, is to improve care and reduce harm:

Every aspect of patient care—every word we say, every test or exam we perform, every treatment or procedure we employ—carries with it the possibility of harm as well as the opportunity for benefit. Although eliminating overuse is often perceived as a way of cutting medical costs, it is really about decreasing wasteful, unnecessary testing and treatment that offer only the potential of harm without the corresponding possibility of benefit. Sometimes, we need to leave our old friends behind.

Monday, July 31, 2017

Asking patients about herbal dietary supplements

- Jennifer Middleton, MD, MPH

The world of herbal dietary supplements can feel murky to physicians, as many supplements have limited rigorous data to back their efficacy and safety. Despite physicians' common reservations, though, an estimated 40.6 million US adults used these supplements in 2012. The authors of a current AFP article on Common Herbal Dietary Supplement-Drug Interactions cite studies showing that only 1 in 3 patients taking a supplement have informed their physician. If we are to help patients navigate the world of supplements safely, we first must know what they are taking.

Several studies have attempted to categorize which patients are more and less likely to discuss their supplement use with physicians. Women are more likely to inform their physicians of supplement use than men, and adults aged 45-64 are more likely to inform than adults aged 18-24. Asian Americans and Hispanic Americans are less likely to inform their physicians than other US ethnic groups. Patients who believe that supplements are safer than conventional medicine and/or not do consider them "medications"  are unlikely to report their use as well. Unfortunately, patients are often unaware of the risks that may exist with supplements.

Knowledge of herbal dietary supplements among physicians is varied, as are attitudes about their use. Physicians with negative views are more likely to advise patients against supplement use. Unfortunately, this advice can discourage patients from further disclosing supplement use at future visits. Physicians may also hesitate to broach the subject with patients because of their own limited knowledge, and, in general, physicians are willing to learn more about supplements and other complimentary medicine therapies given the opportunity.

Several potential solutions exist. Raising awareness of the prevalence of supplement use, and many patients' reticence to discuss it, is a necessary first step. Improving our knowledge of common therapies' safety and efficacy is another; the AFP article mentioned above includes a table (Table 3) with several useful resources, and there's also an AFP By Topic on Complimentary and Alternative Medicine. Since less than half of physicians ask patients about their supplement use, simply asking our patients at every visit is also important as most patients prefer for their physician to ask rather than bring up supplement use themselves. Demonstrating a nonjudgmental attitude may encourage patients to give us honest responses. Communication and cultural competence training may also help physicians more deeply understand and discuss varied health traditions with patients.

How do you discuss supplement use with patients? Are there resources that you have found especially useful?

Monday, July 24, 2017

How family physicians can push back against overpriced drugs

- Kenny Lin, MD, MPH

Sometimes missed in the headlines about the stratospheric costs of new specialty drugs is the contribution of price hikes for older, established drugs, including generics, to prescription spending increases. In an editorial in the July 1 issue of AFP, Dr. Allen Shaughnessy described several situations that drug manufacturers exploit to raise prices excessively (also known as price gouging):

- Limited to no alternatives
- Older products with few producers
- Same product, different use
- Single producer, no generic available
- Evergreening (minor changes to gain patent exclusivity)
- Pay for delay (paying generics manufacturers not to sell a generic version of an off-patent drug)

In the United States, Dr. Shaughnessy observed, "The biggest driver of the cost hike is, simply put, that pharmaceutical companies can charge whatever they want. Drugs cost what the market will bear. Many medications could be a lot less expensive, but because an insurance company, the government, or a patient is willing to pay the asking price, there is no push to lower the costs."

Price gouging has become such a problem for patients and insurers that the Maryland General Assembly recently passed legislation to discourage price gouging on essential off-patent or generic drugs. As explained by Drs. Jeremy Greene and William Padula in the New England Journal of Medicine:

The law authorizes Maryland’s attorney general to prosecute firms that engage in price increases in noncompetitive off-patent–drug markets that are dramatic enough to “shock the conscience” of any reasonable consumer. ... To establish that a manufacturer or distributor engaged in price gouging, the attorney general will need to show that the price increases are not only unjustified but also legally unconscionable. ... A relationship between buyer and seller is deemed unconscionable if it is based on terms so egregiously unjust and so clearly tilted toward the party with superior bargaining power that no reasonable person would freely agree to them. This standard includes cases in which the seller vastly inflates the price of goods.

The scope of the Maryland law is limited. It restricts action to off-patent drugs that are being produced by three or fewer manufacturers, and requires that manufacturers be given an opportunity to justify a price increase before legal proceedings are initiated. It is too early to know if the law will be effective against price gouging, or if it will be copied by other states that are also struggling to contain prescription drug cost increases in their Medicaid programs.

In the meantime, what can family physicians do to help patients lower their medication costs? In a 2016 editorial on the why and how of high-value prescribing, Dr. Steven Brown recommended five sound strategies: be a healthy skeptic, and be cautious when prescribing new drugs; apply STEPS and know drug prices; use generic medications and compare value; restrict access to pharmaceutical representatives and office samples; and prescribe conservatively.

Monday, July 17, 2017

Counseling families about social media

- Jennifer Middleton, MD, MPH

Counseling at well child visits about media use can easily fall by the wayside with so many other important topics to discuss. Our office's electronic health record (EHR) has several template options to choose from for well child exams that each include age-appropriate anticipatory guidance topics, but none of them, at any age, include media use. Adding that prompt may become imperative, especially given the American Academy of Pediatrics' (AAP) Use of Media by School-Aged Children and Adolescents guideline. A recent AFP issue reviewed this new guideline and reminds us of the importance of making time to discuss media use with families.

The AAP encourages physicians to screen for problems related to media use, such as sexting, cyberbullying, problematic internet use, and Internet gaming disorder, in children and adolescents. A recent survey of Texas high schoolers found that 28% of adolescents had texted a naked picture of themselves ("sexting"); in this study, teen girls who sexted were at higher risk of engaging in high risk sexual behavior. The authors of this study suggest asking all teens if they have ever sent, received, or been asked to text a naked picture and also note that the majority of teens are quite uncomfortable with participating in sexting.

The AFP review of this guideline notes that cyberbullying can bring "social, academic, and health concerns" for both the victim and the bully. Several validated scales for screening both bullying victims and perpetrators can be found in this CDC document; although none explicitly mention social media use, several questions are vague enough to potentially include cyberbullying.

Validated scales do exist for screening for problematic internet use and Internet gaming disorder. The 18-item Problematic and Risky Internet Use Screening Scale (PRIUSS) can help identify adolescents and adults with problematic internet use. Many adolescents and young adults with problematic internet use also have depression, social anxiety, and/or attention deficit disorder, so a positive PRIUSS should prompt exploration of these other possible diagnoses. The Internet Gaming Disorder Test (IGDT-10) is a 10 question screen for Internet gaming disorder.

Besides screening for these 4 conditions, the AAP encourages physicians to discuss boundary setting regarding places and times where media use is and is not appropriate. Parents should role model appropriate media use, such as keeping electronic devices (including televisions) outside of the bedroom. Parents also should discuss online safety with their children, though some parents feel unprepared to do so; the AAP has a list of tips for parents here. There's also an AFP By Topic on Health Maintenance and Counseling that includes additional resources for well child (and adult) visits.

No data yet exists showing that screening for these conditions positively influences any patient-centered outcomes, but their associations with mental illness and risky behaviors is convincing enough for me to incorporate them into my well child visits. I'm going to get started by asking our EHR leadership to add "media use" to our anticipatory guidance templates. What step will you take to facilitate conversations about media use with families?

Tuesday, July 11, 2017

Self-monitoring doesn't improve control of type 2 diabetes

- Kenny Lin, MD, MPH

"Have you been checking your sugars?" I routinely ask this question at office visits involving a patient with type 2 diabetes, whether the patient is recently diagnosed or has been living with the disease for many years. However, the necessity of blood glucose self-monitoring in patients with type 2 diabetes not using insulin has been in doubt for several years.

A 2012 Cochrane for Clinicians published in AFP concluded that "self-monitoring of blood glucose does not improve health-related quality of life, general well-being, or patient satisfaction" (patient-oriented outcomes) and did not even result in lower hemoglobin A1C levels (a disease-oriented outcome) after 12 months. In their article "Top 20 Research Studies of 2012 for Primary Care Physicians," Drs. Mark Ebell and Roland Grad discussed a meta-analysis of individual patient data from 6 randomized trials that found self-monitoring improved A1C levels by a modest 0.25 percentage points after 6 and 12 months of use, with no differences observed in subgroups. Based on these findings, the Society of General Internal Medicine recommended against daily home glucose testing in patients not using insulin as part of the Choosing Wisely campaign.

Still, the relatively small number of participants in trials of glucose self-monitoring, and the persistent belief that it could be useful for some patients (e.g., recent type 2 diabetes diagnosis, medication nonadherence, changes in diet or exercise regimen), meant that many physicians have continued to encourage self-monitoring in clinical practice. In a 2016 consensus statement, the American College of Endocrinology stated that in patients with type 2 diabetes and low risk of hypoglycemia, "initial periodic structured glucose monitoring (e.g., at meals and bedtime) may be useful in helping patients understand effectiveness of medical nutrition therapy / lifestyle therapy."

In a recently published pragmatic trial conducted in 15 primary care practices in North Carolina, Dr. Laura Young and colleagues enrolled 450 patients with type 2 non-insulin-treated diabetes with A1C levels between 6.5% and 9.5% and randomized them to no self-monitoring, once-daily self-monitoring, or once-daily self-monitoring with automated, tailored patient feedback delivered via the glucose meter. Notably, about one-third of participants were using sulfonylureas at baseline. After 12 months, there were no significant differences in A1C levels, health-related quality of life, hypoglycemia frequency, health care utilization, or insulin initiation. This study provided further evidence that although glucose self-monitoring may make intuitive sense, it improves neither disease-oriented nor patient-oriented health outcomes in patients with type 2 diabetes not using insulin.

Monday, July 3, 2017

Adding an antibiotic to uncomplicated I&Ds may improve outcomes

- Jennifer Middleton, MD, MPH

Adding an oral antibiotic after incision and drainage of an uncomplicated skin abscess has been found, to date, to not improve clinical outcomes. The American College of Emergency Physicians (ACEP) even has a Choosing Wisely recommendation to this effect. A study published last week, however, found differently: adding an antibiotic after incision and drainage (I&D) of small skin abscesses resulted in better clinical healing.

The study authors prospectively enrolled 505 adults and 281 children at several sites across the United States who presented to urgent care clinics, Emergency Departments (EDs), and outpatient care sites with small skin abscesses (no greater than 5 cm in diameter for adults, no larger than 3 cm for children under 1 year of age, no larger than 4 cm for children aged 1-8 years) and randomized them to receive, after incision and drainage, either 10 days of clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX), or placebo. 81.7% and 83.1% of the participants who received clindamycin or TMP/SMX, respectively, had a clinical cure 10 days after completing antibiotics, compared with only 68.9% of participants who received a placebo (95% confidence intervals 78.3-87.9, 76.8-86.7, and 62.9-74.9, respectively). When analyzed separately, the researchers found that clindamycin was more effective in the pediatric participants compared to TMP/SMX, while the difference between cure rates for adults for these 2 antibiotics was not significant.

New infections in the 30 days following treatment were more common in the placebo group than either antibiotic group; clindamycin was more effective than TMP/SMX in preventing recurrent infection, especially in pediatric participants. Adverse events were more common in the clindamycin group, though, and most commonly consisted of diarrhea and nausea; these were described as "mild or moderate and resolved without sequelae." 1 hypersensitivity reaction to TMP/SMX was described.

This study's findings contradict common practice and the ACEP's Choosing Wisely recommendation. A closer look at the references cited in the ACEP's Choosing Wisely recommendation, however, demonstrate that the evidence to date regarding treatment of uncomplicated skin abscesses has been a bit meager. They include a smaller randomized control trial (RCT) from 2010 that found placebo equivalent to TMP/SMX in 161 pediatric patients treated in EDs for uncomplicated abscesses; an RCT from 1985 that enrolled 50 adults and found no difference in clinical improvement between those treated with cephradine (a first-generation cephalosporin) and placebo; and, a 2011 cross-sectional study that examined differences in antibiotic prescribing habits across 3 separate pediatric EDs but did not examine clinical outcomes.

Additionally, the Infectious Diseases Society of America's 2014 Practice Guideline for the Diagnosis and Management of Skin and Soft Tissue Infections includes a "strong" recommendation against using antibiotics in uncomplicated skin abscesses but describes the quality of the evidence supporting this recommendation as "low." The more robust design of this new study, with its large number of participants and breath of geographic sites, makes its findings difficult to dismiss. It also builds on a 2016 RCT which found that, in care sites with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA), adding TMP/SMX to incision and drainage improved clinical cure rates in adults and teens with uncomplicated skin abscesses compared to placebo.

Given all of the attention on inappropriate antibiotic use these last few weeks on the blog, it's admittedly a bit tough to digest a study that suggests adding antibiotic treatment to a condition that didn't previously warrant it. It will be interesting to see if other researchers attempt to replicate this result or, perhaps, perform a systematic review of all of the data on this topic.

Will this study change how you care for patients after incision and drainage of an uncomplicated skin abscess?

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 afpedit@aafp.org.

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, healthdecision.org, 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?