Monday, October 16, 2017

Interview with AFP's incoming editor-in-chief

- Jennifer Middleton, MD, MPH

On February 1, 2018, AFP will have its first new editor-in-chief in 29 years. In an interview this past week, Dr. Sumi Sexton shared some of her ideas with me about the journal's online presence (hyperlinks below are my additions):

How do AFP's online platforms (Facebook, Twitter, Community Blog, podcast, website) fit into your overall goals for the journal going forward?
I'd like to engage readers through the various platforms to generate discussion ranging from comments on various articles or AFP features to feedback on what we can do to improve.  We don't always have room to include everything we want on a topic in print, so it is nice to be able to include some of these online. I love the concept of Twitter chats, and how the most recent one on antibiotic prescribing incorporated an AFP editorial, a Cochrane for Clinicians, an AHRQ review, and was mentioned on the Community Blog. I look forward to seeing more of that.
AFP's Facebook page, Twitter feed, podcast, and Community Blog offer several different ways for readers to connect with us online, but the number of readers who engage with us on those platforms is a relatively small proportion of total AFP subscribers. How might AFP encourage more readers to connect with these platforms?
I intend to brainstorm with the AFP team on how we can enhance an article on a clinical topic through these platforms. For example, the "Diabetes Self-Management" article in the September 15 issue could be enhanced by a more personal story akin to Diary from a Week in Practice which I used to edit and dearly miss. Another example would be to provide information to family docs on what their colleagues are doing; in the September 1 issue, for example, the article on "Aseptic and Bacterial Meningitis" mentions the meningococcal type B vaccines. How many of our readers are giving this vaccine and why or why not?
In your recent AAFP news interviewyou mentioned wanting to speak with readers "in person and online to see how we can better meet their needs." How do you envision connecting with readers online? What information would you like to learn from them?
It would be interesting to see responses from readers to online polling for certain features like editorials (for example, Controversies in Family Medicine) or articles on more controversial topics (like the article and editorial on "Testosterone Therapy" in the October 1 issue). While it may take a little time to post a comment, it is easy to click on a link to answer a quick yes or no on Twitter or Facebook. In addition to knowing what our readers think about medical topics, I'd like to know how they like to receive information. How could AFP be more accessible at the point of care? Is there anything we can do to make CME through the journal easier for them?
AFP's online presence will certainly continue to grow under Dr. Sexton's leadership, and we'll keep you updated about new tools and ways to connect. In the meantime, what additions would you like to see in AFP's online content? 

Monday, October 9, 2017

Key updates in preventive services from the USPSTF

Kenny Lin, MD, MPH

In the third installment of a series that began in 2015 and continued with last year's one-page Preventive Health Care schedule, American Family Physician recently published "USPSTF Recommendations: New and Updated in 2016," authored by Deputy Editor and former U.S. Preventive Services Task Force (USPSTF) member Mark Ebell, MD, MS. Dr. Ebell's editorial summarized 15 recommendations released by the USPSTF in 2016 and provided more details about several key updates.

1) Colorectal cancer screening: "the USPSTF now recommends that physicians offer any one of seven options for colorectal cancer screening:

- Annual fecal immunochemical testing (FIT);
- Colonoscopy every 10 years;
- FIT plus fecal DNA (Cologuard) every one to three years;
- Computed tomographic colonography every five years;
- The combination of flexible sigmoidoscopy and FIT;
- Flexible sigmoidoscopy alone every five years; or
- Annual guaiac-based fecal occult blood testing."

The recommended duration of routine screening remains from ages 50-75, with selective screening advised for adults aged 76-85 years, based on the patient's overall health, prior screening history, and personal preferences.

2) Aspirin for primary prevention of cardiovascular (CV) disease and colorectal cancer: "the USPSTF now recommends aspirin use only in adults 50 to 69 years of age who have a 10-year risk of a CV event of at least 10%, are willing to take aspirin for at least 10 years, and are not at increased risk of bleeding."

3) Statins for prevention of CV disease: "Like the [2013 ACC/AHA guidelines], the USPSTF recommendations for statin use base the decision on the patient's 10-year CV risk and do not identify specific low-density lipoprotein targets. They differ from the ACC/AHA guidelines in that they give a B rating for a low- or moderate-dose statin for patients with a 10-year CV risk event of 10% or greater, but a C rating for those with a 7.5% to 10% risk."

4) Depression screening in adults: "The recommendation ... now explicitly includes pregnant and postpartum women. The Edinburgh Postnatal Depression Scale is the recommended screening tool."

5) Screening for autism spectrum disorder (ASD): "Although there have been several small clinical trials showing the benefit of treatment in children with ASD, all trials were conducted in children who were identified by parents or caregivers and who have relatively severe symptoms. The USPSTF [insufficient evidence] recommendation covers screening in asymptomatic children whose parents and teachers have not identified any concerns."

For a complete list of Task Force recommendations on clinical preventive services, family physicians can consult the USPSTF's website or the Agency for Healthcare Research and Quality's Electronic Preventive Services Selector (ePSS) tool. For easy reference, AFP and the American Academy of Family Physicians have also collected USPSTF recommendations for children, adolescents/young adults (ages 11-26), and adults (ages 18 and older).

Monday, October 2, 2017

Learning about our patients via their pets

- Jennifer Middleton, MD, MPH

A Close-up on Pet Therapy in the October 1 issue of AFP shares one patient's benefit from caring for her dog through the challenges of an abusive relationship and subsequent homelessness. The patient's family physician helped her find low-cost veterinary care and allowed the dog to accompany the patient to visits; the patient's appreciation of these acts is clear in her narrative. Asking about pets as part of the social history can not only provide family physicians with important information about our patients' personal health but may also help us develop meaningful wellness strategies with patients that incorporate their pets.

Pet ownership correlates with several health benefits; pets can provide meaningful social support, encourage regular physical activity, and possibly even improve cardiovascular health. Pets may help children develop compassion and enjoy a higher quality of life. Similar to the Close-up mentioned above, the homeless youth who own pets report that they help them to not only feel safe but also help to attenuate loneliness.

Knowing about our patients' pets may help us understand their health better, but we can also incorporate our patients' pets into treatment plans for mental health conditions and cardiovascular disease. Regular time with pets can increase anxious individuals' willingness to engage with themselves and others in treatment. Creating an exercise routine that involves a pet may appeal to some patients. Discussing the risk to pets of second-hand tobacco smoke may motivate some patients to quit.

We can also work with our veterinary colleagues to ensure that pet ownership is healthy for pets and humans alike. This 2016 AFP editorial about the One Health initiative describes this partnership between veterinary and human medicine to reduce the prevalence of zoonotic infections such as rabies, ringworm, and toxoplasmosis. Here's a link to AFP articles that include the keyword Animal-Related Diseases if you'd like to read more.

Encouraging our patients who don't have pets to consider obtaining one, however, may be ill-advised; it's likely beyond our scope to investigate whether patients have the resources and ability to care adequately for a pet. If we feel interacting with animals might benefit a patient without a pet, we could suggest opportunities to interact with animals such as volunteering at a shelter or caring for a friend or family member's pet. Animal-assisted therapy may also be available in your community; this Curbside Consultation from 2016 describes animal-assisted therapy and its benefits in more detail.

What have you learned about your patients by asking about their pets? Have you incorporated patients' pets into their wellness strategies?

Tuesday, September 26, 2017

Medication-assisted treatment for opioid addiction: the family physician's role

- Kenny Lin, MD, MPH

Millions of Americans suffer from a potentially fatal disease that has become so common over the past decade that it has lowered the average life expectancy and has particularly devastated vulnerable populations, such as adults with mental health disorders. Although effective medications exist to treat this national health emergency, only a small fraction of family physicians can prescribe them, and even certified physicians face numerous obstacles to providing treatment where their services were most needed. Instead, most efforts have focused on disseminating guidelines to prevent this condition, mostly by reducing known risk factors. Unfortunately, most of what we know about prevention is only supported by low-quality evidence on patient outcomes.

I am writing, of course, about the epidemic of opioid use disorder and overdoses. In an editorial in the Sept. 15 issue of AFP, Dr. Jennifer Middleton argued that while reducing the risk of addiction through the selective and responsible prescribing of opioid medications for pain is important, it is not sufficient to turn the tide. Observing that there is a critical shortage of substance abuse subspecialists, she encouraged family physicians to obtain a Drug Abuse Treatment Act of 2000 (DATA 2000) waiver to prescribe buprenorphine:

Family physicians ... are already adept at combining behavioral interventions with medication management for chronic diseases such as diabetes, cardiovascular disease, and chronic obstructive pulmonary disease; addiction treatment requires a similar combination of lifestyle coaching and prescription oversight. ... 

Buprenorphine is no more complex or difficult to manage than many other treatments routinely used in primary care. Additionally, our specialty has historically embraced the needs of populations labeled as difficult or challenging, such as homeless persons, refugees, and those with developmental disabilities or mental illness. Patients who are struggling with addiction are no less deserving of our attention.

Whether or not medication-assisted treatment (MAT) for opioid use disorder should become part of every family physician's scope of practice is a subject of intense debate, most recently in a pair of Point/Counterpoint editorials in the Annals of Family Medicine. Echoing Dr. Middleton, Dr. David Loxtercamp wrote about his "conversion experience" - the 19 year-old patient with whom he realized that he needed to be able to prescribe MAT to provide adequate care to her and so many others like her. "I am still involved [in MAT]," he wrote, "because I am a doctor and this is the epidemic of our time, a social tsunami that can be traced to my prescription - and yours. ... Addiction is a chronic disease that is decimating our communities. We need no other reason to embrace its treatment within every primary care practice."

Taking the opposite view that not every family physician can "be at the front lines" of the fight against the opioid epidemic, Dr. Richard Hill outlined several other factors that weigh against most family physicians prescribing MAT: specialized treatment required, comorbid psychiatric illness, methods shortcomings of emerging models of care, and the risk that taking on this additional responsibility would create more job dissatisfaction and burnout. "Even if further research establishes an 'optimal' model of care for use in primary care," he asserted, "the nature of the disease [opioid use disorder] itself will place undue clinical burden on an already overextended clinical workforce. Perhaps future efforts and funding should be directed toward the development of readily accessible referral networks of mental health/addiction centers, both public and private."

Both sides of the debate make compelling points. What do you think the family physician's role should be in MAT for opioid addiction?

Monday, September 18, 2017

Prompting physicians and patients increases colorectal cancer screening

- Jennifer Middleton, MD, MPH

Despite multiple available options for colorectal cancer screening, a significant portion of adults aged 50-74 in the United States do not get screened as frequently as recommended by the United States Preventive Services Task Force (USPSTF). A pair of studies this past week describe moderately successful outreach strategies to patients and physicians, respectively, to boost rates.

The first study randomized nearly 6000 US adults aged 50-64 who were not up to date on their colon cancer screening into 3 groups: a colonoscopy outreach group, a fecal immunochemical test (FIT) outreach group, and a usual care group. Participants in the colonoscopy outreach group received mailings encouraging them to call to schedule a colonoscopy; if they didn't within 2 weeks, research staff called them. Participants in the FIT outreach group received mailings with a FIT kit and accompanying instructions. 38.4% of the colonoscopy outreach group and 28.0% of the FIT outreach group completed screening compared to only 10.7% of the usual care group. In the discussion section, the authors note some disappointment that "screening process completion for both outreach groups remained below 40%, highlighting the potential for further improvement."

The second study randomized nearly 1500 general practitioners in France into 3 groups: physicians in the first group received a personalized letter listing all of their patients who were not up to date on colorectal cancer screening, physicians in the second group received a letter describing their region's overall screening rate, and physicians in the third group received no communication at all. The researchers found a small increase in colorectal cancer screening rates in the physician group that received personalized letters (24.8% versus 21.7% for the regional screening information group versus 20.6% for the usual care group) that was statistically significant compared to the other 2 groups. In the discussion section, these authors note that this increase was "modest" and that they, similar to the study described above, also expected a higher screening rate than their results found.

Dr. Lin has written previously on the blog about the various methods available to screen for colorectal cancer in the US and the USPSTF's lack of guidance regarding which method to choose. The USPSTF states that, in addition to colonoscopy and FIT, fecal DNA testing and CT colonography are also options, and the task force encourages physicians to choose the test "that would most likely result in completion." You can read more about these methods in this 2015 AFP article and in the AFP By Topic on Colorectal Cancer.

I'd like to see a study that combines outreach efforts to physicians and patients; it would be interesting to see if the effect is additive in terms of increasing rates. In the meantime, perhaps your own office might create or review a registry of patients not up to date on their colorectal cancer screening, while also providing physicians with a list of these patients. Perhaps you might implement a standard script to discuss colorectal cancer screening with patients at appointments. Or, perhaps you might hire or train an existing staff member to serve as a care coordinator to manage these lists and reach out to patients.

With so many methods to choose from, which one will your office try next to improve colorectal cancer screening rates?

Monday, September 11, 2017

Blood pressure goals in patients with CKD: how low should we go?

- Kenny Lin, MD, MPH

In 2013, the Eighth Joint National Committee (JNC 8) recommended that adults with hypertension and chronic kidney disease (CKD) be treated to a blood pressure (BP) goal of lower than 140/90, after finding no evidence that treating to lower BP goals showed the progression of CKD. At the same time, the American College of Physicians published a guideline on screening, monitoring, and treatment of Stage 1 to 3 CKD that suggested pharmacologic therapy with an ACE inhibitor or angiotensin II receptor blocker, but noted "no difference in end-stage renal disease or mortality between strict blood pressure control (128 to 133/75 to 81 mm Hg) and standard control (134 to 141/81 to 87 mm Hg)."

Less than two years later, however, findings from the Systolic Blood Pressure Intervention Trial (SPRINT) suggested that some older adults at high risk of cardiovascular disease, including those with CKD, may experience additional benefits if treated to a systolic BP goal of 120. After reviewing SPRINT and other recent studies, the American Academy of Family Physicians and the American College of Physicians decided in a new guideline for adults aged 60 years or older to stick with a systolic BP goal of 140 for adults at high cardiovascular risk.

Two systematic reviews and meta-analyses published recently in JAMA Internal Medicine ensure that debate about BP goals for adults with CKD will continue. The first study, by Dr. Wan-Chuan Tsai and colleagues, identified 9 randomized trials (n=8127) that compared intensive BP control (less than 130/80 mm Hg) with standard BP control (less than 140/90 mm Hg) in nondiabetic patients with chronic kidney disease. They found no significant differences between the groups in annual rate of change in glomerular filtration rate (GFR), doubling of serum creatinine level, a composite renal outcome, or all-cause mortality over a median follow-up of 3.3 years.

The second study, by Dr. Rakesh Malhotra and colleagues, extracted data from 18 randomized trials that included 15,924 participants with CKD to determine if more intensive (mean systolic BP 132 mm Hg) compared with less intensive (mean systolic BP 140 mm Hg) control reduced mortality risk in persons with CKD stages 3 to 5. The authors found that more intensive BP control was associated with a statistically significant 14% lower relative risk of all-cause mortality.

An accompanying editorial by Dr. Csaba Kovesdy did a good job of putting these findings into perspective. Dr. Kovesdy pointed out that the benefits of a systolic BP goal of 120 for persons with CKD remain uncertain, and that the meta-analysis could have low external validity because trials had much lower absolute mortality rates than those in observational cohorts of adults with CKD. Finally, he observed that any incremental mortality benefit from intensive BP control is small in comparison to that already achieved by standard BP control:

We must remember that the highest risks of hypertension occur in those with extremely elevated BP levels, and the benefits accrued with treating systolic BP to levels below about 140 mm Hg are much smaller. ... More intensive vs less intensive BP lowering resulted in a [number needed to treat] to prevent 1 death of 167 based on the absolute risk reduction estimated in the meta-analysis by Malhotra et al and an NNT to prevent 1 composite renal failure event of 250 based on the results of another meta-analysis. These diminishing absolute benefits have to be weighed against the increased likelihood of adverse effects and the higher costs associated with more intensive BP lowering.

Bottom line: if family physicians choose to devote more resources to patients with CKD or other cardiovascular risk factors who might benefit from lower-than-usual BP goals, they should not lose focus on improving care for the 46% of U.S. adults with hypertension whose BPs are not adequately controlled by any standard.

Tuesday, September 5, 2017

Using clinical risk scores wisely

- Jennifer Middleton, MD, MPH

Physicians have several clinical calculator apps to choose from, but guidance about choosing the right score and interpreting its results isn't always as readily available. Busy family physicians looking to enhance their use of clinical risk scores will find several discussed among the articles in the current issue of AFP; understanding the nuances of each may help physicians choose the best ones to "favorite" in their calculator app of choice.

A practice guideline on "Newly Detected Atrial Fibrillation" and an editorial on the "Differences Between the AAFP Atrial Fibrillation Guideline and the AHA/ACC/HRS Guideline" both include a discussion on risk scores to predict stroke and bleeding risk in these patients. Using the CHA2DS2-VASc score increases the number of persons recommended to receive anticoagulation compared to the CHADS2 score, but the authors of both articles argue that these risk scores' ability to predict stroke risk is identical. Interestingly, neither of the clinical calculator apps that I have on my smartphone include the CHA2DS2-VASc score. The practice guideline does describe the HAS-BLED score's ability to predict bleeding risk as "slightly better" than other bleeding risk scores for patients on anticoagulation.

"Pleuritic Chest Pain: Sorting Through the Differential Diagnosis" discusses the importance of ruling out pulmonary embolism (PE), the most common life-threatening cause of pleuritic chest pain. The authors advocate for using a validated risk score in patients presenting with pleuritic chest pain to guide decisions about testing for PE; one of the reference articles describes several available validated risk scores but lists the Wells rule as "widely validated and commonly used;" regardless of the score used, a negative D-dimer test in a patient with a low pre-test probability score usually negates the need for further testing.

Similarly, "Exercise Stress Testing: Indications and Common Questions" discusses the use of the Diamond and Forrester score to calculate the pre-test probability of coronary artery disease (CAD) in patients with chest pain. Exercise stress testing provides the highest diagnostic utility in patients with an intermediate pre-test probability for CAD; low risk patients with negative cardiac enzymes typically require no further testing, and high risk patients should receive prompt intervention.

The AFP By Topic on Point-of-Care Guides provides not only numerous risk scores to use with patients but also an evidence-based summary of how to use them each in practice. You can bookmark this department collection and also save your most-used clinical calculator websites under your AAFP "Favorites" tab for easy future reference.

Tuesday, August 29, 2017

Taking stock of a new guideline for hypertension in children

- Kenny Lin, MD, MPH

Last week, the American Academy of Pediatrics (AAP) published a new practice guideline on screening, evaluation and management of high blood pressure in children and adolescents, updating a 2004 guideline from the National Heart, Lung, and Blood Institute. The new guideline includes 30 evidence-informed "key action statements" and 27 other recommendations based on consensus opinion. The AAP recommends that blood pressure be measured annually in every child starting at 3 years of age, and at every health care encounter in children with obesity, renal disease, diabetes, aortic arch obstruction or coarctation, or who are taking medications known to increase blood pressure. Notably, the guideline's blood pressure tables lower previous thresholds for abnormal blood pressure in children by several mmHg because they are based on normal weight children only.

The American Academy of Family Physicians (AAFP) currently supports the U.S. Preventive Services Task Force's (USPSTF) 2013 statement that "current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood." According to the USPSTF, the accuracy and reliability of blood pressure screening protocols in children has not been well studied; a sizable percentage of persons with high blood pressure in childhood will have normal blood pressure as adults; and there is inadequate evidence that lifestyle modification or pharmacotherapy results in sustained blood pressure decreases in children or prevents cardiovascular events. Also, abnormal blood pressure thresholds in the AAP guideline are based on a normal population distribution (with 3 different readings >95th percentile defined as hypertensive) rather than on patient-oriented evidence of improved outcomes, as in the JNC-8 guidelines for hypertension management in adults.

How can family physicians know if a new guideline is trustworthy and applicable to their patients? In a 2009 AFP article, Dr. David Slawson and I proposed several attributes of good practice guidelines:
  • Comprehensive, systematic evidence search with end date noted
  • Evidence linked directly to recommendations via strength of recommendation grading system
  • Recommendations based on patient-oriented rather than disease-oriented outcomes
  • Transparent guideline development process
  • Potential conflicts of interest identified and addressed
  • Prospectively validated (i.e., guideline use has been shown to improve patient-oriented outcomes)
  • Recommendations offer flexibility in various clinical situations
Subsequently, the Institute of Medicine (IOM; now the National Academy of Medicine) published a report, "Clinical Practice Guidelines We Can Trust," that recommended many similar criteria. The IOM report informed the American Academy of Family Physicians' current processes for developing and endorsing clinical practice guidelines from other organizations. The AAP guideline will undergo a structured quality assessment by AAFP staff and members of the Commission on the Health of the Public and Science, who will recommend to the Board of Directors if the guideline should be fully endorsed, receive an Affirmation of Value, or not endorsed. So stay tuned for more news and analysis of this guideline in future issues of AFP.

Monday, August 21, 2017

STEADI-ing our older patients against falls

- Jennifer Middleton, MD, MPH

Falls can feel like an inevitable part of aging, but with just a little effort and teamwork we can help keep our older patients safe. The current issue of AFP reviews several evidence-based resources at our disposal in a feature article and an accompanying editorial, including the Centers for Disease Control's (CDC) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program.

The authors of the feature article, Preventing Falls in Older Persons, review the prevalence and risk factors for falls in the United States along with relevant Choosing Wisely recommendations. They provide an algorithm from the STEADI toolkit to identify patients at risk for falls using a patient checklist and the Timed Up and Go (TUG) test. Incorporating these 2 screening instruments into the Welcome to Medicare Visit fulfills the requirement to review functional ability and level of safety. Recommending physical therapy, reviewing medications, and ensuring home safety, visual correction, and appropriate footwear have been found to benefit patients at moderate to high risk of falling. Prescribing vitamin D is also recommended for some older adults, though Dr. Lin has written previously on the blog about the limited benefit of vitamin D supplementation for community-dwelling elders.

The accompanying editorial discussing the STEADI initiative reviews the costs for caring for older adults after a fall ($31 billion a year from Medicare alone) along with the development and components of the STEADI initiative: screen, assess, and intervene. A 2016 Community Blog guest post by Dr. Stephen Hargarten of the CDC reviewed each of these STEADI components. Plans to integrate STEADI screens and interventions in electronic health records (EHR) should assist physicians with incorporating falls assessment into our everyday workflow; while waiting for these build updates to arrive, creating a macro or template of the STEADI checklist within your own EHR might be useful.

Besides the printed materials available at the CDC's STEADI website, a quick search of your smartphone's app store will turn up an app or two for administering the TUG test; although I could not find any that were rigorously evaluated, the test is simple enough that a quick practice run using the app should demonstrate its utility. Family Practice Management has a topic collection on Medicare Annual Wellness Visits with tools for incorporating fall prevention into your practice, and there's an AFP By Topic on Geriatric Care that includes articles on gait and balance disorders as well as writing exercise prescriptions. Your office team might want to measure its progress with implementing these changes with a plan-do-study-act (PDSA) cycle, and the Institute for Healthcare Improvement has a video reviewing PDSA cycles along with a worksheet for charting the outcomes of your chosen intervention. You can obtain continuing medical education (CME) credit by completing the CDC's STEADI online course and/or by completing a Knowledge Self-Assessment (KSA) for the American Board of Family Medicine on Care of Vulnerable Elders.

Which of these resources have you and your office team found useful for helping reduce your elderly patients' fall risk? Which new resource are you eager to investigate?

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.