- Kenny Lin, MD, MPH
After moving into our current home nine years ago, my wife and I purchased a basic security system - the kind with a programmable keypad, multiple door alarms and a motion sensor. The alarm has sounded about a dozen times since then. None of these times was a burglary actually in progress. On several particularly windy days, one of us forgot to lock the back door after leaving, and it blew open. Two or three other times, departing early for work, I accidentally hit "Away" on the keypad (arming the motion detector at the foot of the stairs) rather than "Stay," causing the klaxon to sound when my unsuspecting son came down the stairs later in the morning. We've also set off the fire alarm a few times while cooking. Although our security system cost little to purchase, by now we've spent more money in monitoring fees than the value of what we might conceivably have lost in an actual burglary.
There are intangible benefits to having a home security system - peace of mind being the most important. But our peace of mind has been achieved at the cost of temporarily diverting multiple municipal police and fire units, disturbing our neighbors, receiving inconvenient cellular phone calls from the monitoring company, and terrifying a 5 year-old on his way to breakfast.
I think about my home security system every time I do a physical examination on an apparently healthy adult. Although the general health check is an established medical tradition, a Cochrane for Clinicians review in the October 1st issue of AFP concluded that health checks increase the number of diagnoses but don't reduce morbidity or mortality. So are these visits a waste of time? Not necessarily, argued Dr. Krishnan Narasimhan:
Although the general health check has not been shown to decrease morbidity or mortality, there is some evidence that designating a specific visit for the provision of preventive services may increase the likelihood that patients will receive them. ... Adding preventive services to other patient visits, sending reminders to patients to use these services, and using community linkages, such as screening at job sites or schools, could be potential avenues for effective delivery of preventive services. Evaluating better models for the delivery of evidence-based preventive services is an area for further research.
Unfortunately, a 2012 study in the Annals of Family Medicine found that patients often overestimate the benefits of preventive interventions that primary care physicians commonly provide at health checks: breast cancer screening, colorectal cancer screening, and medications to prevent hip fractures and cardiovascular disease. In most cases, patients' "minimum acceptable benefit" (the lowest level of benefit that in their mind was required to justify the preventive intervention) far exceeded the actual benefit of the service established in randomized trials. Further, the study considered only the benefits of these services, and not the false alarms, which occur, for example, in more than 60 percent of women receiving annual mammography after 10 years.
Senin, 30 September 2013
Senin, 23 September 2013
Small Effect of Inhaled Steroids on Height in Children with Asthma
- Jennifer Middleton, MD, MPH
Childhood asthma is a frequent diagnosis in many Family Medicine offices, and inhaled corticosteroids are often the mainstay of treatment for kids with moderate or severe persistent disease. Previous retrospective studies were reassuring regarding how these inhaled medications might affect height; children may not grow quite as fast when they're using inhaled steroids for asthma - but these studies suggested that, once the steroids are stopped, children catch up without any lifelong loss of height.
A recent randomized controlled trial, reviewed in this month's Journal of Family Practice (JFP), challenges this notion. The researchers found that children (ages 5-13 years at the beginning of the study) on long-term budesonide treatments for moderate persistent asthma did lose about half-an-inch (actually 0.47 inches or 1.2 cm, to be precise) of height during the 4-6 year trial that was sustained when they were followed up in their mid-20s.
The JFP authors point out that the enrolled children were on the same dose of budesonide throughout this lengthy study, which may be a bit atypical. The Expert Panel Review 3 (EPR-3) recommends that physicians consider tapering down chronic asthma therapy for adults and children if their symptoms have been controlled for three months (see page 288 of this document). This trial does add a bit of additional weight to that recommendation; we don't know whether intermittent use of these medications would mitigate this height loss, but it's probably still reasonable to limit their use when possible.
On the flip side, I wouldn't like to see 0.47 inches of height get in the way of adequately treating a child with moderate persistent asthma, either. (The researchers intentionally didn't include children with severe persistent asthma, assuming that the benefit of inhaled steroids for them would absolutely outweigh the risk of a few millimeters of height.) Like so many things in medicine, our discussion of this trial's finding with parents and families should include both the risks and benefits of these medications. But this trial is a good example of how important it is to follow-up assumptions from retrospective studies with more rigorous, prospective trials.
AFP By Topic has a rich collection of resources on asthma which includes several articles related to the care of children with asthma.
Will this trial affect how you prescribe inhaled corticosteroids to children and adolescents?
Minggu, 15 September 2013
Managing progressive disability in older adults
- Kenny Lin, MD, MPH
One in seven Americans suffer from disability, which an article by Dr. Cathleen Colon-Emeric and colleagues in the September 15th issue of AFP defines as "limitation in the ability to carry out basic functional activities." Progressive disability, or functional decline, commonly affects older adults with multiple chronic health conditions. First steps in the evaluation of an older adult with a new or progressive disability include characterizing the time course, associated symptoms, effects on specific tasks (including activities of daily living), and compensatory strategies. The authors then recommend that clinicians identify potentially modifiable health conditions, comorbid impairments, and contextual factors. All of this information should be considered and integrated into a treatment plan that enhances the patient's capacity and/or reduces task demands.
A Close Ups in the same issue of the journal provides insight on the perspective of a patient and family member who benefited from a comprehensive evaluation for functional decline. C.W. writes about her late mother's positive experience:
Twenty-minute visits were inadequate to address all of the diagnoses and medications, let alone her falls, constipation, insomnia, and cognitive decline. It seemed no one was appreciating the big picture. ... With full support from her family physician at home, we arranged for her to undergo a comprehensive assessment [that] focused on mom's primary goal—the ability to continue the activities she loved. She was evaluated by a geriatrician, a nurse, and a social worker. My family was also interviewed, and the appointment concluded with a meeting involving the whole team. We were given recommendations to consolidate and simplify her regimens for pain, insomnia, and constipation; initiate medication for depression; and make sure she exercised and socialized regularly, with concrete recommendations for overcoming barriers to these goals, such as transportation. Additionally, we received referrals for physical therapy and low vision rehabilitation.
One in seven Americans suffer from disability, which an article by Dr. Cathleen Colon-Emeric and colleagues in the September 15th issue of AFP defines as "limitation in the ability to carry out basic functional activities." Progressive disability, or functional decline, commonly affects older adults with multiple chronic health conditions. First steps in the evaluation of an older adult with a new or progressive disability include characterizing the time course, associated symptoms, effects on specific tasks (including activities of daily living), and compensatory strategies. The authors then recommend that clinicians identify potentially modifiable health conditions, comorbid impairments, and contextual factors. All of this information should be considered and integrated into a treatment plan that enhances the patient's capacity and/or reduces task demands.
A Close Ups in the same issue of the journal provides insight on the perspective of a patient and family member who benefited from a comprehensive evaluation for functional decline. C.W. writes about her late mother's positive experience:
Twenty-minute visits were inadequate to address all of the diagnoses and medications, let alone her falls, constipation, insomnia, and cognitive decline. It seemed no one was appreciating the big picture. ... With full support from her family physician at home, we arranged for her to undergo a comprehensive assessment [that] focused on mom's primary goal—the ability to continue the activities she loved. She was evaluated by a geriatrician, a nurse, and a social worker. My family was also interviewed, and the appointment concluded with a meeting involving the whole team. We were given recommendations to consolidate and simplify her regimens for pain, insomnia, and constipation; initiate medication for depression; and make sure she exercised and socialized regularly, with concrete recommendations for overcoming barriers to these goals, such as transportation. Additionally, we received referrals for physical therapy and low vision rehabilitation.
In a related editorial, Dr. V.S. Periyakoil observes that progressive frailty that does not respond to optimal management of reversible conditions is in fact a terminal illness, even if it is often not recognized as such. He criticizes a recent decision by the Centers for Medicare and Medicaid Services to stop accepting the ICD codes for "debility not otherwise specified" and "adult failure to thrive" as principal hospice diagnoses, arguing that "these older adults may be subjected to ineffective interventions, including repeated emergency department visits and hospitalizations that are burdensome and expensive, and erode their quality of life."
Do you have the time and resources to evaluate functional decline in older adults in your practice, or do you refer these patients to other health professionals? How do you recognize when a patient is transitioning from a reversible state of frailty to a potentially terminal one? Will the information in these articles change your approaches to disability and end-of-life care, and if so, how?
Selasa, 10 September 2013
Ruling out DVT: doppler or D-dimer?
- Jennifer Middleton, MD, MPH
Yesterday I saw an older patient with a swollen leg. Although I was reasonably confident that the swelling and pain was due to an early cellulitis, I still felt compelled to rule out a deep venous thrombosis (DVT). I ordered a stat ultrasound doppler of the leg, which was negative for DVT. I was left wondering if I shouldn't have wasted the patient's time and his insurance dollars on this test; I wasn't terribly worried about a DVT, but I also knew that I couldn't afford to miss one.
One of the POEMs in AFP last week reviewed a recent article from the Annals of Internal Medicine regarding testing for DVT. The researchers evaluated the use of Wells' criteria to determine whether ultrasound (doppler) or a D-dimer was used first to evaluate for possible DVT. The researchers divided the patients into two groups; one group consisted of outpatients with a low or moderate pre-test probability according to their Wells' score, and one group consisted of outpatients with a high pre-test score along with inpatients. The patients in the first group with a positive D-dimer went on to ultrasound. They found that stratifying patients by pre-test probability decreased the use of both D-dimer and ultrasound but did not negatively affect patient outcomes.
I know I should use clinical decision rules like the Wells criteria more often to help me eliminate unnecessary testing; there are a few rules that I do use regularly, but for less frequent diagnoses like this one, I often forget to look for an applicable rule. There are many inexpensive smartphone apps that can make this process easier for clinicians, too. I suspect that my patient yesterday would have preferred a quick blood test in the office instead of having to trek over to the hospital's vascular lab. It seems, though, when I'm in the middle of a busy office session, that I often only think about using these tools after the day is done. This POEM was an excellent reminder to me to think about incorporating these tools more into my everyday decision-making process.
There is a useful AFP by Topic about DVT and Pulmonary Embolism if you'd like more information about this topic. And, here's the original study that validated Wells' criteria for DVT.
How are you currently working up possible DVTs? Is it realistic to integrate the use of clinical calculators into your day-to-day practice?
Yesterday I saw an older patient with a swollen leg. Although I was reasonably confident that the swelling and pain was due to an early cellulitis, I still felt compelled to rule out a deep venous thrombosis (DVT). I ordered a stat ultrasound doppler of the leg, which was negative for DVT. I was left wondering if I shouldn't have wasted the patient's time and his insurance dollars on this test; I wasn't terribly worried about a DVT, but I also knew that I couldn't afford to miss one.
One of the POEMs in AFP last week reviewed a recent article from the Annals of Internal Medicine regarding testing for DVT. The researchers evaluated the use of Wells' criteria to determine whether ultrasound (doppler) or a D-dimer was used first to evaluate for possible DVT. The researchers divided the patients into two groups; one group consisted of outpatients with a low or moderate pre-test probability according to their Wells' score, and one group consisted of outpatients with a high pre-test score along with inpatients. The patients in the first group with a positive D-dimer went on to ultrasound. They found that stratifying patients by pre-test probability decreased the use of both D-dimer and ultrasound but did not negatively affect patient outcomes.
I know I should use clinical decision rules like the Wells criteria more often to help me eliminate unnecessary testing; there are a few rules that I do use regularly, but for less frequent diagnoses like this one, I often forget to look for an applicable rule. There are many inexpensive smartphone apps that can make this process easier for clinicians, too. I suspect that my patient yesterday would have preferred a quick blood test in the office instead of having to trek over to the hospital's vascular lab. It seems, though, when I'm in the middle of a busy office session, that I often only think about using these tools after the day is done. This POEM was an excellent reminder to me to think about incorporating these tools more into my everyday decision-making process.
There is a useful AFP by Topic about DVT and Pulmonary Embolism if you'd like more information about this topic. And, here's the original study that validated Wells' criteria for DVT.
How are you currently working up possible DVTs? Is it realistic to integrate the use of clinical calculators into your day-to-day practice?
Selasa, 03 September 2013
Why do clinical questions go unanswered?
- Kenny Lin, MD, MPH
What do you do when you have a clinical question that ideally requires an answer before the patient leaves your office? Do you flip through a textbook or a back issue of American Family Physician? Look up the topic in a online reference? Consult an smartphone app? Ask a colleague in the office or curbside a specialist by telephone?
Family physicians take many approaches to answering clinical questions, some more efficient and effective than others. For example, using AFP By Topic or the journal website search function is more likely to yield relevant results than hunting through a stack of print issues for that article on community-acquired pneumonia that you remembered reading at some point. Unfortunately, Deputy Editor Mark Ebell, MD, MS reported in a 2009 article that on average, 15-20 clinical questions come up each day, and most of these go unanswered.
A recent study published in JAMA Internal Medicine examined barriers to answering clinical questions at the point of care. Researchers affiliated with the Mayo Clinic conducted several focus groups with a total of 50 family and internal medicine physicians in academic medical center and community settings. Not surprisingly, the barrier most commonly mentioned by physicians was insufficient time. Some physicians with convenient access to computers and online references complained of not knowing which resource to search, and having doubts about whether the search was likely to yield an answer. Others were concerned that looking up information while in the examination room might diminish a patient's confidence in them. Finally, some physicians found that available resources simply did not contain the answers they needed.
The editors of AFP are interested in learning more about how you use our journal - in its print, online, and mobile versions - to answer your clinical questions. Are you able to find current, relevant answers at the point of care, or do you prefer to browse AFP at home and subsequently incorporate what you learn into practice? What could we do to improve your searching and reading experiences?
What do you do when you have a clinical question that ideally requires an answer before the patient leaves your office? Do you flip through a textbook or a back issue of American Family Physician? Look up the topic in a online reference? Consult an smartphone app? Ask a colleague in the office or curbside a specialist by telephone?
Family physicians take many approaches to answering clinical questions, some more efficient and effective than others. For example, using AFP By Topic or the journal website search function is more likely to yield relevant results than hunting through a stack of print issues for that article on community-acquired pneumonia that you remembered reading at some point. Unfortunately, Deputy Editor Mark Ebell, MD, MS reported in a 2009 article that on average, 15-20 clinical questions come up each day, and most of these go unanswered.
A recent study published in JAMA Internal Medicine examined barriers to answering clinical questions at the point of care. Researchers affiliated with the Mayo Clinic conducted several focus groups with a total of 50 family and internal medicine physicians in academic medical center and community settings. Not surprisingly, the barrier most commonly mentioned by physicians was insufficient time. Some physicians with convenient access to computers and online references complained of not knowing which resource to search, and having doubts about whether the search was likely to yield an answer. Others were concerned that looking up information while in the examination room might diminish a patient's confidence in them. Finally, some physicians found that available resources simply did not contain the answers they needed.
The editors of AFP are interested in learning more about how you use our journal - in its print, online, and mobile versions - to answer your clinical questions. Are you able to find current, relevant answers at the point of care, or do you prefer to browse AFP at home and subsequently incorporate what you learn into practice? What could we do to improve your searching and reading experiences?
Senin, 26 Agustus 2013
You don't snooze, you lose
- Jennifer Middleton, MD, MPH
The consequences of insufficient sleep can be significant. Children and teens who don't get enough sleep not only get worse grades in school but are also more likely to have parents who worry about their mood and behavior. Sleep-deprived adults are more likely to be involved in a motor vehicle or work accident, are more likely to have hypertension, and are more likely to be obese (even controlling for changes in diet patterns). Perhaps logically, then, sleep-deprived adults incur higher health care costs than adults who get at least 6 hours of sleep a night.
The August 15, 2013 AFP featured an article regarding the Management of Common Sleep Disorders. The first section of this article dealt with insomnia; I don't know about you, but I see a lot of patients in the office who are struggling with falling and staying asleep at night. The authors wisely suggest reframing patients' thoughts about sleep using Cognitive Behavioral Therapy (CBT), and Table 4 contains most of the advice that I routinely dispense to patients: limit caffeine and stop nicotine, only use the bedroom for sleep and sex, get up if you haven't fallen asleep within 20 minutes, etc. I liked how the authors cited evidence showing that these simple physician interventions can be quite effective.
Decreasing time with electronics (TV, computers, tablets, mobile phones) may also help. The American Sleep Foundation's annual poll in 2011 found that use of a smartphone, computer, and/or television the in hour before falling asleep correlated with lower quality sleep. They also reported that the average number of caffeinated beverage servings among adolescents and adults was around 3 a day - perhaps to make up for the fatigue from decreased sleep quality?
I recommend that patients get television sets and other electronics out of the bedroom if at all possible, and spend the last hour of the day disconnected from technology. You can probably imagine how my patients often respond to that advice; smartphones, computers, and televisions seem to be ubiquitous in the US, and certainly have many positives regarding inter-connectivity and just plain old entertainment.
But, as the above studies demonstrate, helping our patients to get restful sleep may help prevent a lot of problems. There are AFP by Topics on sleep disorders for both adults and children if you'd like to check out more resources about this issue.
Do you have any special advice for your patients regarding sleep?
The consequences of insufficient sleep can be significant. Children and teens who don't get enough sleep not only get worse grades in school but are also more likely to have parents who worry about their mood and behavior. Sleep-deprived adults are more likely to be involved in a motor vehicle or work accident, are more likely to have hypertension, and are more likely to be obese (even controlling for changes in diet patterns). Perhaps logically, then, sleep-deprived adults incur higher health care costs than adults who get at least 6 hours of sleep a night.
Decreasing time with electronics (TV, computers, tablets, mobile phones) may also help. The American Sleep Foundation's annual poll in 2011 found that use of a smartphone, computer, and/or television the in hour before falling asleep correlated with lower quality sleep. They also reported that the average number of caffeinated beverage servings among adolescents and adults was around 3 a day - perhaps to make up for the fatigue from decreased sleep quality?
I recommend that patients get television sets and other electronics out of the bedroom if at all possible, and spend the last hour of the day disconnected from technology. You can probably imagine how my patients often respond to that advice; smartphones, computers, and televisions seem to be ubiquitous in the US, and certainly have many positives regarding inter-connectivity and just plain old entertainment.
But, as the above studies demonstrate, helping our patients to get restful sleep may help prevent a lot of problems. There are AFP by Topics on sleep disorders for both adults and children if you'd like to check out more resources about this issue.
Do you have any special advice for your patients regarding sleep?
Senin, 19 Agustus 2013
The most popular posts of January - July 2013
- Kenny Lin, MD, MPH
Following up on our successful previous collection of the most popular posts of 2012 (which has been viewed more than 1300 times), here are the AFP Community Blog's top 5 most viewed posts from the first seven months of 2013.
1. Are IUDs a reasonable option for birth control in adolescents? (May 21)
What are your thoughts about the intrauterine device for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?
2. Pros and cons of vitamin D screening (April 29)
No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone.
The increasing diversity of the U.S. population has made it more likely that family physicians will care for many patients with cultural backgrounds, beliefs, and practices that are dissimilar to their own.
Given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is something more than just counseling necessary to effect behavior change?
5. Is routine stress testing necessary for resolved chest pain? (May 29)
Are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?
Following up on our successful previous collection of the most popular posts of 2012 (which has been viewed more than 1300 times), here are the AFP Community Blog's top 5 most viewed posts from the first seven months of 2013.
1. Are IUDs a reasonable option for birth control in adolescents? (May 21)
What are your thoughts about the intrauterine device for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?
2. Pros and cons of vitamin D screening (April 29)
No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone.
3. Providing culturally competent health care (January 25)
The increasing diversity of the U.S. population has made it more likely that family physicians will care for many patients with cultural backgrounds, beliefs, and practices that are dissimilar to their own.
Given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is something more than just counseling necessary to effect behavior change?
5. Is routine stress testing necessary for resolved chest pain? (May 29)
Are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?
Senin, 12 Agustus 2013
Does acetaminophen help nasal congestion from the common cold?
- Jennifer Middleton, MD, MPH
I don't know about you, but when I get a upper respiratory tract infection (URI or "cold"), one of the first things that I reach for is acetaminophen. I've never thought that it did much for the nasal congestion, but it at least seems to take the edge off of the headache, muscle aches, and fever.
Cold and flu season is right around the corner - except for my household, where it unfortunately arrived this weekend. So, I am finding Cochrane's recent review of acetaminophen for the common cold rather timely. The reviewers only found 4 small studies of "low to moderate quality," but 2 of these studies did show that acetaminophen reduced nasal congestion, and 1 showed that it reduced rhinorrhea.
I had never thought of acetaminophen as a treatment for nasal symptoms before, but the Cochrane reviewers wisely recommend caution in interpreting these small studies, stating that they are insufficient "to reach a conclusion."
Does this mean that I will be less likely to use and recommend acetaminophen for cold symptoms? Nope. A lack of high-quality studies supporting its efficacy isn't the same as a high-quality study showing that it doesn't work. I still like recommending acetaminophen for headache, myalgias, and fever, and if it gets some of those nasal symptoms, that'd be a nice bonus. What this review will hopefully spark, though, is some higher-quality prospective studies to more precisely define acetaminophen's utility for URI symptoms.
So, we'll keep on using acetaminophen in our house until this current virus runs its course. AFP also recently reviewed "Treatment of the Common Cold in Children and Adults" with pragmatic evidence-based recommendations for patients (and doctors) with URIs. And, when all of those over-the-counter options for colds get overwhelming, this AFP Cochrane for Clinicians article can provide guidance. We're also drinking plenty of fluids, resting when possible, and my husband is taking zinc lozenges (though the taste isn't worth it to me, given zinc's only modest effect on URIs).
Will Cochrane's review change your recommendations for acetaminophen use in the common cold?
I don't know about you, but when I get a upper respiratory tract infection (URI or "cold"), one of the first things that I reach for is acetaminophen. I've never thought that it did much for the nasal congestion, but it at least seems to take the edge off of the headache, muscle aches, and fever.
Cold and flu season is right around the corner - except for my household, where it unfortunately arrived this weekend. So, I am finding Cochrane's recent review of acetaminophen for the common cold rather timely. The reviewers only found 4 small studies of "low to moderate quality," but 2 of these studies did show that acetaminophen reduced nasal congestion, and 1 showed that it reduced rhinorrhea.
I had never thought of acetaminophen as a treatment for nasal symptoms before, but the Cochrane reviewers wisely recommend caution in interpreting these small studies, stating that they are insufficient "to reach a conclusion."
Does this mean that I will be less likely to use and recommend acetaminophen for cold symptoms? Nope. A lack of high-quality studies supporting its efficacy isn't the same as a high-quality study showing that it doesn't work. I still like recommending acetaminophen for headache, myalgias, and fever, and if it gets some of those nasal symptoms, that'd be a nice bonus. What this review will hopefully spark, though, is some higher-quality prospective studies to more precisely define acetaminophen's utility for URI symptoms.
So, we'll keep on using acetaminophen in our house until this current virus runs its course. AFP also recently reviewed "Treatment of the Common Cold in Children and Adults" with pragmatic evidence-based recommendations for patients (and doctors) with URIs. And, when all of those over-the-counter options for colds get overwhelming, this AFP Cochrane for Clinicians article can provide guidance. We're also drinking plenty of fluids, resting when possible, and my husband is taking zinc lozenges (though the taste isn't worth it to me, given zinc's only modest effect on URIs).
Will Cochrane's review change your recommendations for acetaminophen use in the common cold?
Senin, 05 Agustus 2013
Is prevention or treatment the heart of family medicine?
- Kenny Lin, MD, MPH
The comprehensive scope of family medicine has always made it a challenge to describe, in a nutshell, what family physicians do. Unlike subspecialists or general internists, surgeons, or pediatricians, family physicians do not define their patient populations by age, gender, or organ system. A series of editorials published a few years ago in the Annals of Family Medicine argued that family physicians practice a "science of connectedness" that includes a distinct approach to clinical problem-solving. A more recent study in Family Medicine asserted that the training and attitudes of family physicians make them uniquely qualified to provide cost-effective health care. The emergence of the Patient-Centered Medical Home model has emphasized the role of the family physician as a facilitator and leader of care teams for patients with multiple preventive and chronic care needs.
Dr. John Hickner, editor of The Journal of Family Practice, worries that well-intentioned initiatives to improve family physicians' skills at providing screening tests and facilitating behavioral change may come at the cost of neglecting patients' acute concerns. He wrote in a recent editorial:
At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”
Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.
At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”
Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.
As a family physician who teaches public health and preventive medicine, I appreciate the tension between prevention and treatment in my own practice. Previous studies concluded that paying exclusive attention to providing guideline-recommended preventive and chronic disease services would leave literally no time to address the many other reasons that patients come into the office. As Dr. Hickner noted, "The 'number needed to treat' to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!" So is prevention or treatment the heart of family medicine? Is the answer to this question different today than it would have been a generation ago, and is it likely to be different a generation from now?
Senin, 29 Juli 2013
Is all substance misuse really abuse?
- Jennifer Middleton, MD, MPH
I appreciated AFP's article last week about "A Primary Care Approach to Substance Misuse" and its practical review of screening and treatment options for patients struggling with this issue. The article appropriately included discussion about prescription drug abuse.
Prescription painkiller deaths have been on the rise in the United States. Drug overdose (60% of which are pharmaceutical drug overdoses) is now the number 1 cause of injury-related death in the U.S. The Centers for Disease Control and Prevention (CDC) states that every 3 minutes a middle-aged woman presents to the Emergency Department for prescription opioid "misuse or abuse." Every single one of those prescription medications originated from a doctor's prescription pad (paper or virtual).
I continue to ruminate, though, about the word "misuse" in the AFP article. Usually, when I think about problems with inappropriate substance use, I think of the word "abuse," not "misuse." Clearly these words share a similar meaning, but, for me at least, the connotation of "misuse" is a bit gentler than "abuse." "Misuse" sounds more like a mistake than the intentional impropriety of "abuse."
I have previously thought of the substance "abusers" as those who are inappropriately requesting prescription painkillers. My office, as I'm sure many others do, has a controlled substance policy that supports frequent urine drug screens, and we discontinue prescribing for patients with discordant results.
But what about the "misusers?" What about the patients who have some legitimate pain source but don't always use their prescription opioids as prescribed? Or the patients who never tell me that they're borrowing someone else's prescription medications? After all, the CDC found that 55% of the people misusing or abusing prescription pain medications obtain them for free from a friend or relative. Only 11% buy their pills from friends or family, and only 4% purchase their meds from a dealer. Learning that most of my patients using these medications inappropriately are getting them at no cost from friends and family changes how I think about who those patients might be.
What I appreciate about the term "misuse" is its reminder that, as a prescriber of these medications, I need to be on the alert for more than just the "abusers." I should probably be asking all of my patients the single question screen for substance disorders outlined in last week's AFP article (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) on a regular basis. I need to broaden who I think of as at risk from problems related to substance misuse and abuse.
How often do thoughts of prescription medication misuse and abuse occur during your practice day? Does the term "misuse" help you to think more widely about prescription medication problems, or is it an unnecessary term?
I appreciated AFP's article last week about "A Primary Care Approach to Substance Misuse" and its practical review of screening and treatment options for patients struggling with this issue. The article appropriately included discussion about prescription drug abuse.
Prescription painkiller deaths have been on the rise in the United States. Drug overdose (60% of which are pharmaceutical drug overdoses) is now the number 1 cause of injury-related death in the U.S. The Centers for Disease Control and Prevention (CDC) states that every 3 minutes a middle-aged woman presents to the Emergency Department for prescription opioid "misuse or abuse." Every single one of those prescription medications originated from a doctor's prescription pad (paper or virtual).
I have previously thought of the substance "abusers" as those who are inappropriately requesting prescription painkillers. My office, as I'm sure many others do, has a controlled substance policy that supports frequent urine drug screens, and we discontinue prescribing for patients with discordant results.
But what about the "misusers?" What about the patients who have some legitimate pain source but don't always use their prescription opioids as prescribed? Or the patients who never tell me that they're borrowing someone else's prescription medications? After all, the CDC found that 55% of the people misusing or abusing prescription pain medications obtain them for free from a friend or relative. Only 11% buy their pills from friends or family, and only 4% purchase their meds from a dealer. Learning that most of my patients using these medications inappropriately are getting them at no cost from friends and family changes how I think about who those patients might be.
What I appreciate about the term "misuse" is its reminder that, as a prescriber of these medications, I need to be on the alert for more than just the "abusers." I should probably be asking all of my patients the single question screen for substance disorders outlined in last week's AFP article (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) on a regular basis. I need to broaden who I think of as at risk from problems related to substance misuse and abuse.
How often do thoughts of prescription medication misuse and abuse occur during your practice day? Does the term "misuse" help you to think more widely about prescription medication problems, or is it an unnecessary term?
Kamis, 18 Juli 2013
Estimating osteoporosis risk in older men
- Kenny Lin, MD, MPH
According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."
Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.
In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.
Will the results of this study make you more likely to use MORES to assess the risk of osteoporosis in older men in your practice? Or would you prefer to screen all men older than a certain age with DXA to avoid missing any patients with osteoporosis?
According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."
Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.
In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.
Will the results of this study make you more likely to use MORES to assess the risk of osteoporosis in older men in your practice? Or would you prefer to screen all men older than a certain age with DXA to avoid missing any patients with osteoporosis?
Senin, 15 Juli 2013
Steroids for pharyngitis?
- Jennifer Middleton, MD, MPH
This month, The Journal of Family Practice (JFP) published a review of a recent Cochrane meta-analysis regarding the use of steroids for patients with "exudative or severe sore throat." The Cochrane researchers found that even one dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4). The Cochrane researchers included studies of patients with both viral and bacterial pharyngitis.
Despite evidence-based tools such as the modified Centor score, which can determine the pre-test probability of streptococcal pharyngitis and guide treatment (described nicely in this AFP article), physicians still overprescribe antibiotics for upper respiratory infections, including pharyngitis. This AFP by Topic on Upper Respiratory Infections provides a useful review of current treatment guidelines for these prevalent conditions; several articles in that grouping advise caution regarding overuse of antibiotics. It may be that patients with painful pharyngitis don't necessarily want antibiotics, though, but just something to control their pain. This new Cochrane meta-analysis, with that excellent NNT regarding improvement of pain after only one day of treatment with a steroid, suggests that steroids may be another useful tool in our pharyngitis treatment kit.
Do you already prescribe steroids for patients with severe pharyngitis (viral or bacterial)? If not, would this Cochrane meta-analysis encourage you to try it?
This month, The Journal of Family Practice (JFP) published a review of a recent Cochrane meta-analysis regarding the use of steroids for patients with "exudative or severe sore throat." The Cochrane researchers found that even one dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4). The Cochrane researchers included studies of patients with both viral and bacterial pharyngitis.
Despite evidence-based tools such as the modified Centor score, which can determine the pre-test probability of streptococcal pharyngitis and guide treatment (described nicely in this AFP article), physicians still overprescribe antibiotics for upper respiratory infections, including pharyngitis. This AFP by Topic on Upper Respiratory Infections provides a useful review of current treatment guidelines for these prevalent conditions; several articles in that grouping advise caution regarding overuse of antibiotics. It may be that patients with painful pharyngitis don't necessarily want antibiotics, though, but just something to control their pain. This new Cochrane meta-analysis, with that excellent NNT regarding improvement of pain after only one day of treatment with a steroid, suggests that steroids may be another useful tool in our pharyngitis treatment kit.
The JFP reviewers are quick to point out that these corticosteroids weren't used alone; the studies in the meta-analysis used them in addition to either antibiotics or analgesics. Hopefully we will see some randomized controlled trials (RCTs) in the next few years that determine whether steroids are useful by themselves for patients not needing an antibiotic. In the meantime, since the RCTs in the Cochrane meta-analysis used varying methods, we don't have a clear guideline about which patients might benefit or what dose and administration route of corticosteroid to use.
Do you already prescribe steroids for patients with severe pharyngitis (viral or bacterial)? If not, would this Cochrane meta-analysis encourage you to try it?
Senin, 08 Juli 2013
Medicating mild hypertension: is more evidence needed?
- Kenny Lin, MD, MPH
In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood pressure of 90 to 99 mm Hg) on cardiovascular outcomes or mortality. However, the randomized trials' relatively small number of participants (fewer than 9000) and short follow-up periods (five years or less) left open the possibility that a significant benefit could still exist. Therefore, Dr. Guirguis-Blake concluded: "Larger double-blinded RCTs in this population of patients with stage 1 hypertension are needed to clarify the potential long-term benefits of pharmacologic therapy."
When existing research does not adequately answer an important clinical question - in this case, are medications superior to lifestyle modifications or no treatment for mild hypertension? - researchers invariably recommend collecting more evidence. But is performing a large randomized trial of mild hypertension management feasible, given that the standard of care set in 2003 by the Seventh Report of the Joint National Committee (JNC-7) (and reflected in this AFP Point-of-Care Guide) is to routinely identify and treat blood pressures in this range? The U.S. Preventive Services Task Force apparently thinks so; after previously declaring that the benefits of screening were "well established," the USPSTF has released an extensive draft research plan to reevaluate benefits, harms, best methods, and recommended intervals for screening for high blood pressure in adults.
With the next USPSTF statement at least a few years down the road, current evidence-based guidance on hypertension management is limited. The U.S. National Heart, Lung, and Blood Institute, which convened the previous JNC panels, recently announced in a cardiology journal its intention to stop producing guidelines. Instead, it says it will partner with outside medical groups to release its long-delayed JNC-8 hypertension guideline. Since guidelines sponsored by subspecialty societies are less likely to adhere to Institute of Medicine standards for producing unbiased guidelines, family physicians and other primary care clinicians should advocate for their organizations to participate in this process.
In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood pressure of 90 to 99 mm Hg) on cardiovascular outcomes or mortality. However, the randomized trials' relatively small number of participants (fewer than 9000) and short follow-up periods (five years or less) left open the possibility that a significant benefit could still exist. Therefore, Dr. Guirguis-Blake concluded: "Larger double-blinded RCTs in this population of patients with stage 1 hypertension are needed to clarify the potential long-term benefits of pharmacologic therapy."
When existing research does not adequately answer an important clinical question - in this case, are medications superior to lifestyle modifications or no treatment for mild hypertension? - researchers invariably recommend collecting more evidence. But is performing a large randomized trial of mild hypertension management feasible, given that the standard of care set in 2003 by the Seventh Report of the Joint National Committee (JNC-7) (and reflected in this AFP Point-of-Care Guide) is to routinely identify and treat blood pressures in this range? The U.S. Preventive Services Task Force apparently thinks so; after previously declaring that the benefits of screening were "well established," the USPSTF has released an extensive draft research plan to reevaluate benefits, harms, best methods, and recommended intervals for screening for high blood pressure in adults.
With the next USPSTF statement at least a few years down the road, current evidence-based guidance on hypertension management is limited. The U.S. National Heart, Lung, and Blood Institute, which convened the previous JNC panels, recently announced in a cardiology journal its intention to stop producing guidelines. Instead, it says it will partner with outside medical groups to release its long-delayed JNC-8 hypertension guideline. Since guidelines sponsored by subspecialty societies are less likely to adhere to Institute of Medicine standards for producing unbiased guidelines, family physicians and other primary care clinicians should advocate for their organizations to participate in this process.
Senin, 01 Juli 2013
Another strike against NSAIDs?
- Jennifer L. Middleton MD, MPH
One of the issues family docs deal with on a daily basis is pain control. I usually think about pain medication as falling into one of three categories: acetaminophen, NSAIDs, and opioids. I frequently recommend acetaminophen, but patients often tell me "it's not strong enough for me" (maybe an unintentional consequence of those commercials touting Tylenol's gentleness?). And, of course, I defer opioid regimens if possible given the risks of addiction and diversion.
Perhaps you've already heard about The Lancet's NSAID meta-analysis article from about a month ago. The authors performed a robust literature search and included hundreds of trials with several outcome measures, one of which was the rate of "major coronary events" (a composite of non-fatal myocardial infarction and coronary death). The authors found that long-term use of all non-steroidal anti-inflammatory drugs (NSAIDs), selective COX-2 or non-selective, doubled the risk of heart failure. I'd like to focus on two non-selective NSAIDs, ibuprofen and naproxen, for the rest of this post.
I found this meta-analysis unsettling, as I like having an option in between acetaminophen and opioids to offer my patients. True, the authors only examined patients taking high dose NSAIDs (2400 mg ibuprofen/day and 1000 mg naproxen/day) for at least 4 weeks. Is it safe, then, to extrapolate that lower doses and/or shorter periods of time are safer?
AFP had a nice article about osteoarthritis treatment last year that discussed the pros and cons of all of these medication classes. Rereading that article this past week reminded me that every 12th patient taking an NSAID, even short-term, will experience a gastrointestinal (GI) bleed, kidney problem, or elevated blood pressure (number needed to harm [NNH] = 12 for that composite outcome). As NNHs go, that's a pretty impressive number.
For now, at least, NSAIDs probably should be off the table for patients at an increased risk of heart disease. Myself, I will probably continue recommending NSAIDs in patients without a history of GI bleed, with normal kidney function, and without a history of heart disease, but I will recommend more modest doses and shorter periods of use. I will probably spend more time counseling patients, too, about the risks of ibuprofen and naproxen.
I encourage you to take a look at these related AFP By Topic collections:
Heart Failure
Pain: Chronic
Arthritis and Joint Pain (includes this AHRQ-EHC review's discussion of NSAID risks)
How frequently have you been recommending NSAIDs? Will this meta-analysis change your NSAID prescribing?
One of the issues family docs deal with on a daily basis is pain control. I usually think about pain medication as falling into one of three categories: acetaminophen, NSAIDs, and opioids. I frequently recommend acetaminophen, but patients often tell me "it's not strong enough for me" (maybe an unintentional consequence of those commercials touting Tylenol's gentleness?). And, of course, I defer opioid regimens if possible given the risks of addiction and diversion.
Perhaps you've already heard about The Lancet's NSAID meta-analysis article from about a month ago. The authors performed a robust literature search and included hundreds of trials with several outcome measures, one of which was the rate of "major coronary events" (a composite of non-fatal myocardial infarction and coronary death). The authors found that long-term use of all non-steroidal anti-inflammatory drugs (NSAIDs), selective COX-2 or non-selective, doubled the risk of heart failure. I'd like to focus on two non-selective NSAIDs, ibuprofen and naproxen, for the rest of this post.
I found this meta-analysis unsettling, as I like having an option in between acetaminophen and opioids to offer my patients. True, the authors only examined patients taking high dose NSAIDs (2400 mg ibuprofen/day and 1000 mg naproxen/day) for at least 4 weeks. Is it safe, then, to extrapolate that lower doses and/or shorter periods of time are safer?
AFP had a nice article about osteoarthritis treatment last year that discussed the pros and cons of all of these medication classes. Rereading that article this past week reminded me that every 12th patient taking an NSAID, even short-term, will experience a gastrointestinal (GI) bleed, kidney problem, or elevated blood pressure (number needed to harm [NNH] = 12 for that composite outcome). As NNHs go, that's a pretty impressive number.
For now, at least, NSAIDs probably should be off the table for patients at an increased risk of heart disease. Myself, I will probably continue recommending NSAIDs in patients without a history of GI bleed, with normal kidney function, and without a history of heart disease, but I will recommend more modest doses and shorter periods of use. I will probably spend more time counseling patients, too, about the risks of ibuprofen and naproxen.
I encourage you to take a look at these related AFP By Topic collections:
Heart Failure
Pain: Chronic
Arthritis and Joint Pain (includes this AHRQ-EHC review's discussion of NSAID risks)
How frequently have you been recommending NSAIDs? Will this meta-analysis change your NSAID prescribing?
Senin, 24 Juni 2013
Social media guidance for family physicians
- Kenny Lin, MD, MPH
How do you use social media for professional purposes? An increasing number of family physicians use channels such as blogs, Facebook, and Twitter to keep up with the medical literature, network with other health professionals, and provide health education to current and prospective patients and their communities. When AFP launched its Community Blog and Facebook and Twitter accounts in 2010, there was little published guidance for physicians on how to get started in social media. Guidelines from the American Medical Association focused on avoiding unprofessional behavior, while the American Academy of Pediatrics reviewed the risks of social media use in children and adolescents, including cyberbullying and sexting. The author of a 2011 Curbside Consultation on whether physicians should be "friends" with their patients on social networking websites remarked: "In terms of universally accepted standards for interacting with patients using social media, it is kind of like the Wild West."
The Wild West got a little bit tamer last week, when the American Academy of Family Physicians released "Social Media for Family Physicians: Guidelines and Resources for Success." Designed to meet the needs of family physicians with varying levels of social media experience, this 15-page document offers a valuable road map that includes a concise orientation to major social media channels; a suggested initial approach; guidance on protecting patient privacy; and commonsense recommendations for social media policies in private and employed physician practices.
How do you use social media for professional purposes? An increasing number of family physicians use channels such as blogs, Facebook, and Twitter to keep up with the medical literature, network with other health professionals, and provide health education to current and prospective patients and their communities. When AFP launched its Community Blog and Facebook and Twitter accounts in 2010, there was little published guidance for physicians on how to get started in social media. Guidelines from the American Medical Association focused on avoiding unprofessional behavior, while the American Academy of Pediatrics reviewed the risks of social media use in children and adolescents, including cyberbullying and sexting. The author of a 2011 Curbside Consultation on whether physicians should be "friends" with their patients on social networking websites remarked: "In terms of universally accepted standards for interacting with patients using social media, it is kind of like the Wild West."
The Wild West got a little bit tamer last week, when the American Academy of Family Physicians released "Social Media for Family Physicians: Guidelines and Resources for Success." Designed to meet the needs of family physicians with varying levels of social media experience, this 15-page document offers a valuable road map that includes a concise orientation to major social media channels; a suggested initial approach; guidance on protecting patient privacy; and commonsense recommendations for social media policies in private and employed physician practices.
Senin, 17 Juni 2013
USPSTF: Diet and exercise counseling not routinely recommended for healthy adults
- Jennifer Middleton, MD, MPH
I was surprised to come across the United States Preventive Services Task Force (USPSTF) update in the June 15 AFP this weekend regarding nutrition and physical activity counseling for healthy adults:
[E]xisting evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small.
And, they listed a potential harm to providing this counseling:
Harms may include the lost opportunity to provide other services that have a greater health effect.
As a family physician, I want to help my patients to live the best lives they can, and I feel strongly that good nutrition and exercise are both critical to doing so. So, this is a difficult USPSTF recommendation for me to absorb.
Of course, to clarify, the USPSTF only said that counseling regarding these matters is not effective. They did not make any value statements about diet and exercise. But given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is it that we just don't counsel well? Or, is something more than just counseling necessary to effect behavior change?
A review article from 1999 and a more recent systematic review suggest that individual, computerized nutrition counseling may result in positive changes. Telephone interventions may also be effective for improving nutrition and exercise habits. Targeting counseling about nutrition that focuses on two concepts from health behavior theory, self-efficacy ("I believe I have what I need to make the change") and outcome expectations ("Making this change will result in a good outcome") also can make a difference.
Perhaps we need to both 1) make our counseling more effective, and 2) employ a more interdisciplinary approach to help our patients make sustainable changes.
This AFP USPSTF update is included in the AFP By Topic for Health Maintenance and Counseling. There is a lot of nice information there about health counseling in general (I especially like this Family Practice Management article on motivational interviewing).
Will this USPSTF update change your approach to diet and exercise counseling in the office?
I was surprised to come across the United States Preventive Services Task Force (USPSTF) update in the June 15 AFP this weekend regarding nutrition and physical activity counseling for healthy adults:
[E]xisting evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small.
And, they listed a potential harm to providing this counseling:
Harms may include the lost opportunity to provide other services that have a greater health effect.
As a family physician, I want to help my patients to live the best lives they can, and I feel strongly that good nutrition and exercise are both critical to doing so. So, this is a difficult USPSTF recommendation for me to absorb.
Of course, to clarify, the USPSTF only said that counseling regarding these matters is not effective. They did not make any value statements about diet and exercise. But given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is it that we just don't counsel well? Or, is something more than just counseling necessary to effect behavior change?
A review article from 1999 and a more recent systematic review suggest that individual, computerized nutrition counseling may result in positive changes. Telephone interventions may also be effective for improving nutrition and exercise habits. Targeting counseling about nutrition that focuses on two concepts from health behavior theory, self-efficacy ("I believe I have what I need to make the change") and outcome expectations ("Making this change will result in a good outcome") also can make a difference.
Perhaps we need to both 1) make our counseling more effective, and 2) employ a more interdisciplinary approach to help our patients make sustainable changes.
This AFP USPSTF update is included in the AFP By Topic for Health Maintenance and Counseling. There is a lot of nice information there about health counseling in general (I especially like this Family Practice Management article on motivational interviewing).
Will this USPSTF update change your approach to diet and exercise counseling in the office?
Selasa, 11 Juni 2013
Rosiglitazone for diabetes: helpful, harmful, or neither?
- Kenny Lin, MD, MPH
Last week, an advisory panel convened by the U.S. Food and Drug Administration (FDA) voted to relax safety restrictions on the diabetes drug rosiglitazone (Avandia) that were put in place in response to previous evidence that rosiglitazone may increase the risk of heart attacks and cardiovascular deaths. American Family Physician first highlighted these safety concerns in its March 15, 2008 Tips From Other Journals, which Dr. Kenneth Moon concluded:
There is substantial circumstantial evidence that rosiglitazone is associated with higher risks of heart failure and myocardial infarction. Despite the awkwardness of persuading a patient to use a drug that may provide similar benefits but pose greater risks than other proven agents, the legitimate concerns raised by these studies make this a serious issue. Until there is conclusive evidence about the safety of rosiglitazone, many physicians and their patients may be more comfortable using alternative treatments.
Last week, an advisory panel convened by the U.S. Food and Drug Administration (FDA) voted to relax safety restrictions on the diabetes drug rosiglitazone (Avandia) that were put in place in response to previous evidence that rosiglitazone may increase the risk of heart attacks and cardiovascular deaths. American Family Physician first highlighted these safety concerns in its March 15, 2008 Tips From Other Journals, which Dr. Kenneth Moon concluded:
There is substantial circumstantial evidence that rosiglitazone is associated with higher risks of heart failure and myocardial infarction. Despite the awkwardness of persuading a patient to use a drug that may provide similar benefits but pose greater risks than other proven agents, the legitimate concerns raised by these studies make this a serious issue. Until there is conclusive evidence about the safety of rosiglitazone, many physicians and their patients may be more comfortable using alternative treatments.
Subsequent AFP articles on management of blood glucose in type 2 diabetes and rosiglitazone vs. pioglitazone reinforced cautionary messages about rosiglitazone. However, the results of a large randomized trial published in 2009 found similar risks for cardiovascular hospitalizations and death in patients using rosiglitazone compared to patients taking other oral diabetes drugs. This trial, which was sponsored by rosiglitazone's manufacturer GlaxoSmithKline, was criticized for methodological problems, but an independent re-analysis of the trial's data persuaded the FDA advisory panel that the drug's safety risks had been exaggerated in previous studies.
If the FDA acts on the advisory panel's recommendations and makes rosiglitazone more widely available, should family physicians prescribe it? It is worth noting that the panel considered only the drug's safety, not its effectiveness. A previous AFP Journal Club reminded readers that the disease-oriented outcome of improved glycemic control does not necessarily lead to patients living longer or better. Rosiglitazone causes more weight gain and congestive heart failure than metformin, and is more expensive than metformin and sulfonylureas. For those reasons, it should be a second- or third-line drug choice for patients with type 2 diabetes.
Senin, 03 Juni 2013
The safety risks of backyard trampolines
- Jennifer Middleton, MD, MPH
I've been watching trampolines sprout up in backyards all over our neighborhood this spring, and seeing them has resurrected some memories from residency. Like many family physicians, I spent time in a children's emergency department (ED) as a resident.
What I saw during my rotation made me wonder about the safety of these bouncy backyard devices. I saw an injury related to backyard trampolines during nearly every shift that summer. These children typically either fell off the trampoline onto the ground or got caught in the gap between the mat and the metal support. Some of these injuries were just contusions and sprains, but I also helped evaluate several broken bones and a couple of head injuries.
It turns out that my ED experiences were not atypical. The American Academy of Pediatrics (AAP) has been advising against recreational backyard trampoline use since 1977, with their most recent update last fall. (1) Similarly, the American Academy of Orthopedic Surgeons also has a position statement against backyard trampoline use. (2) Despite these recommendations, trampoline use and trampoline injuries in the US are on the rise, from an average of about 41,000/year in the early 1990s to about 88,000/year in the early 2000s. (3) More children are injured directly on the mat, though around a third of injuries are from falls to the ground. (4,5)
I could find no rigorous evidence base to demonstrate that counseling against backyard trampoline use reduces injuries, but at least one literature review suggests that physician counseling about other childhood safety issues does reduce injuries. (6) And, here's a recent AFP article about unintentional childhood injury prevention: http://www.aafp.org/
My suspicion is that many parents remain unaware of these dangers (perhaps like this mother was), and a brief question about trampoline use would be a simple addition to our safety counseling at well child visits.
Is this topic worth discussing with families in the office? I welcome your thoughts.
(1) Trampoline Safety in Childhood and Adolescence. Council on Sports Medicine and Fitness. Pediatrics; originally published online September 24, 2012. http://pediatrics.aappublications.org/content/early/2012/09/19/peds.2012-2082.full.pdf+html
(2) http://www.aaos.org/about/papers/position/1135.asp
(3) Linakis et al. Emergency department visits for pediatric trampoline-related injuries: an update. Acad Emerg Med. 2007 Jun;14(6):539-44. Epub 2007 Apr 20. http://www.ncbi.nlm.nih.gov/pubmed/17449791
(4) Black and Amadeo. Orthopedic injuries associated with trampoline use in children. Can J Surg. 2003 June; 46(3): 199–201. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211739/
(5) McDermitt, Quinlin, Kelly. Trampoline injuries in children. J Bone Joint Surg Br. 2006 Jun;88(6):796-8. http://www.ncbi.nlm.nih.gov/pubmed/16720776
(6) Bass et al. Childhood injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics. 1993 Oct;92(4):544-50. http://www.ncbi.nlm.nih.gov/pubmed/8414825
I've been watching trampolines sprout up in backyards all over our neighborhood this spring, and seeing them has resurrected some memories from residency. Like many family physicians, I spent time in a children's emergency department (ED) as a resident.
What I saw during my rotation made me wonder about the safety of these bouncy backyard devices. I saw an injury related to backyard trampolines during nearly every shift that summer. These children typically either fell off the trampoline onto the ground or got caught in the gap between the mat and the metal support. Some of these injuries were just contusions and sprains, but I also helped evaluate several broken bones and a couple of head injuries.
It turns out that my ED experiences were not atypical. The American Academy of Pediatrics (AAP) has been advising against recreational backyard trampoline use since 1977, with their most recent update last fall. (1) Similarly, the American Academy of Orthopedic Surgeons also has a position statement against backyard trampoline use. (2) Despite these recommendations, trampoline use and trampoline injuries in the US are on the rise, from an average of about 41,000/year in the early 1990s to about 88,000/year in the early 2000s. (3) More children are injured directly on the mat, though around a third of injuries are from falls to the ground. (4,5)
I could find no rigorous evidence base to demonstrate that counseling against backyard trampoline use reduces injuries, but at least one literature review suggests that physician counseling about other childhood safety issues does reduce injuries. (6) And, here's a recent AFP article about unintentional childhood injury prevention: http://www.aafp.org/
My suspicion is that many parents remain unaware of these dangers (perhaps like this mother was), and a brief question about trampoline use would be a simple addition to our safety counseling at well child visits.
Is this topic worth discussing with families in the office? I welcome your thoughts.
(1) Trampoline Safety in Childhood and Adolescence. Council on Sports Medicine and Fitness. Pediatrics; originally published online September 24, 2012. http://pediatrics.aappublications.org/content/early/2012/09/19/peds.2012-2082.full.pdf+html
(2) http://www.aaos.org/about/papers/position/1135.asp
(3) Linakis et al. Emergency department visits for pediatric trampoline-related injuries: an update. Acad Emerg Med. 2007 Jun;14(6):539-44. Epub 2007 Apr 20. http://www.ncbi.nlm.nih.gov/pubmed/17449791
(4) Black and Amadeo. Orthopedic injuries associated with trampoline use in children. Can J Surg. 2003 June; 46(3): 199–201. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211739/
(5) McDermitt, Quinlin, Kelly. Trampoline injuries in children. J Bone Joint Surg Br. 2006 Jun;88(6):796-8. http://www.ncbi.nlm.nih.gov/pubmed/16720776
(6) Bass et al. Childhood injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics. 1993 Oct;92(4):544-50. http://www.ncbi.nlm.nih.gov/pubmed/8414825
Rabu, 29 Mei 2013
Is routine stress testing necessary for resolved chest pain?
- Kenny Lin, MD, MPH
Last week, the family medicine residency inpatient service that I supervise admitted several patients from the emergency department with acute chest pain that had resolved. Most of them had no history of cardiovascular disease, but were deemed to have enough risk factors to undergo pre-discharge cardiac stress testing after they had "ruled out" for acute coronary syndrome with normal cardiac enzymes. Rationales for the American Heart Association's recommendation for routine stress testing in patients with resolved chest pain include reducing malpractice liability, improving cardiac risk stratification, and initiating appropriate interventions earlier in high-risk patients. Although this practice is widely accepted, there is no evidence that it improves patient-oriented outcomes compared to outpatient management, and some researchers have argued that randomized trials are needed to prove that the benefits actually exceed the harms.
A recent study published in JAMA Internal Medicine adds fuel to this debate by presenting prospectively collected outcomes of adult patients evaluated in the emergency department chest pain unit of Mount Sinai Medical Center from 2004 to 2010. A total of 4181 patients underwent stress testing (512 with exercise ECG tests and the rest with nuclear perfusion imaging), and 470 tests suggested potential myocardial ischemia. 123 patients underwent cardiac catheterizations; 60 of these patients were found to have normal coronary arteries. Of the 63 patients whose catheterizations showed obstructive coronary artery disease, only 28 had lesions that warranted stenting or coronary artery bypass grafting according to expert consensus guidelines.
There are at least two ways to view this study's results. A positive interpretation is that cardiac stress testing led to in the presumptive diagnosis of coronary artery disease in more than 10 percent of patients, who could then have received medical interventions shown to improve outcomes. On the other hand, the high false positive rates on coronary angiography suggest that up to half of these diagnoses were incorrect (and, consequently, that more than 150 patients would have received therapy inappropriately). Nearly 90 percent of patients were exposed to significant radiation doses through nuclear imaging, but less than 1 percent had coronary artery lesions that warranted revascularization. So are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?
Last week, the family medicine residency inpatient service that I supervise admitted several patients from the emergency department with acute chest pain that had resolved. Most of them had no history of cardiovascular disease, but were deemed to have enough risk factors to undergo pre-discharge cardiac stress testing after they had "ruled out" for acute coronary syndrome with normal cardiac enzymes. Rationales for the American Heart Association's recommendation for routine stress testing in patients with resolved chest pain include reducing malpractice liability, improving cardiac risk stratification, and initiating appropriate interventions earlier in high-risk patients. Although this practice is widely accepted, there is no evidence that it improves patient-oriented outcomes compared to outpatient management, and some researchers have argued that randomized trials are needed to prove that the benefits actually exceed the harms.
A recent study published in JAMA Internal Medicine adds fuel to this debate by presenting prospectively collected outcomes of adult patients evaluated in the emergency department chest pain unit of Mount Sinai Medical Center from 2004 to 2010. A total of 4181 patients underwent stress testing (512 with exercise ECG tests and the rest with nuclear perfusion imaging), and 470 tests suggested potential myocardial ischemia. 123 patients underwent cardiac catheterizations; 60 of these patients were found to have normal coronary arteries. Of the 63 patients whose catheterizations showed obstructive coronary artery disease, only 28 had lesions that warranted stenting or coronary artery bypass grafting according to expert consensus guidelines.
There are at least two ways to view this study's results. A positive interpretation is that cardiac stress testing led to in the presumptive diagnosis of coronary artery disease in more than 10 percent of patients, who could then have received medical interventions shown to improve outcomes. On the other hand, the high false positive rates on coronary angiography suggest that up to half of these diagnoses were incorrect (and, consequently, that more than 150 patients would have received therapy inappropriately). Nearly 90 percent of patients were exposed to significant radiation doses through nuclear imaging, but less than 1 percent had coronary artery lesions that warranted revascularization. So are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?
Selasa, 21 Mei 2013
Are IUDs a reasonable option for birth control in adolescents?
- Jennifer Middleton, MD, MPH
What kind of contraception options do you discuss with adolescents?
A study by Rubin, Davis, and McKee from the Annals of Family Medicine's last issue explored the views of family physicians, pediatricians, and OB/GYNs on this issue. Some might be tempted to dismiss this study because the n only equaled 28 docs, but this study was a qualitative study, not a numbers-crunching quantitative study. The researchers used a semi-structured interview guide and interviewed as many physicians as it took to reach saturation, or the point where they were not recording any new themes. (Low ns are fairly typical of qualitative studies.)
Although this study discussed both the intrauterine device (IUD) and implantable contraception (Implanon), I'm going to focus on the IUD findings for today's post.
It turns out that only about half of these physicians were recommending IUDs to their teenage patients. The researchers found that this was due to "knowledge gaps" and "limited access to the device."
The "knowledge gaps" mostly related to the suitability of an IUD for a teen. We know that 1 in 4 teens get a sexually transmitted infection (STI) each year. IUDs were previously thought to increase the risk for pelvic inflammatory disease following an STI, but more recent research disputes that assumption with the current IUD devices available in the US.(1,2) And, despite all of the levonorgestrel-releasing intrauterine system (Mirena) commercials stating that it's only for women who have "had at least one child," the American College of Obstetrics and Gynecology reasonably asserts that IUDs are safe and reasonable to use in nulliparous women of all ages.
The "limited access to the device" is exactly what it sounds like; only 60% of the family docs, and none of the pediatricians, were providing this service in their offices. Pediatricians, especially, were uncomfortable with any type of birth control besides oral contraceptive pills. Long-acting contraception like the IUD, though, is a perfect fit for many teens who may be less than reliable at remembering to pop a pill every day. (Let's face it - many adults aren't any better at remembering to take daily meds.)
A look at the recent evidence regarding IUD use in adolescents shows that IUDs are easily inserted in most teens and nulliparous women, though the insertion process can be more uncomfortable. (3) NSAIDs are a reasonable option for controlling this discomfort. Adolescents may be at slightly higher risk for IUD expulsion than older women, but current data suggests that the difference is probably not very large. (4,5)
There is a useful AFP By Topic collection on family planning and contraception available at http://www.aafp.org/afp/
What are your thoughts about the IUD for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?
What kind of contraception options do you discuss with adolescents?
A study by Rubin, Davis, and McKee from the Annals of Family Medicine's last issue explored the views of family physicians, pediatricians, and OB/GYNs on this issue. Some might be tempted to dismiss this study because the n only equaled 28 docs, but this study was a qualitative study, not a numbers-crunching quantitative study. The researchers used a semi-structured interview guide and interviewed as many physicians as it took to reach saturation, or the point where they were not recording any new themes. (Low ns are fairly typical of qualitative studies.)
Although this study discussed both the intrauterine device (IUD) and implantable contraception (Implanon), I'm going to focus on the IUD findings for today's post.
It turns out that only about half of these physicians were recommending IUDs to their teenage patients. The researchers found that this was due to "knowledge gaps" and "limited access to the device."
The "knowledge gaps" mostly related to the suitability of an IUD for a teen. We know that 1 in 4 teens get a sexually transmitted infection (STI) each year. IUDs were previously thought to increase the risk for pelvic inflammatory disease following an STI, but more recent research disputes that assumption with the current IUD devices available in the US.(1,2) And, despite all of the levonorgestrel-releasing intrauterine system (Mirena) commercials stating that it's only for women who have "had at least one child," the American College of Obstetrics and Gynecology reasonably asserts that IUDs are safe and reasonable to use in nulliparous women of all ages.
The "limited access to the device" is exactly what it sounds like; only 60% of the family docs, and none of the pediatricians, were providing this service in their offices. Pediatricians, especially, were uncomfortable with any type of birth control besides oral contraceptive pills. Long-acting contraception like the IUD, though, is a perfect fit for many teens who may be less than reliable at remembering to pop a pill every day. (Let's face it - many adults aren't any better at remembering to take daily meds.)
A look at the recent evidence regarding IUD use in adolescents shows that IUDs are easily inserted in most teens and nulliparous women, though the insertion process can be more uncomfortable. (3) NSAIDs are a reasonable option for controlling this discomfort. Adolescents may be at slightly higher risk for IUD expulsion than older women, but current data suggests that the difference is probably not very large. (4,5)
What are your thoughts about the IUD for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?
- Faundes A, Telles E, Cristofoletti ML, Faundes D, Castro S, Hardy E. The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998;58:105–9.
- Skjeldestad FE, Halvorsen LE, Kahn H, Nordbo SA, Saake K. IUD users in Norway are at low risk for genital C. trachomatis infection. Contraception 1996;54:209–12.
- Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994;49:56–72.
- Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contraception 2009;79:418–23.
- Lyus R, Lohr P, Prager S. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Board of the Society of Family Planning. Contraception 2010;81:367–71.
Selasa, 14 Mei 2013
How do family physicians provide cost-effective care?
- Kenny Lin, MD
Research studies have documented strong associations between U.S. primary care physician supply, better population health outcomes, and lower health care spending. Among adult primary care specialties, national survey data suggest that family physicians provide more cost-effective care. However, little research has examined how family physicians provide effective care at lower cost than other physicians. Is it because we are more likely to follow evidence-based guidelines? Order fewer inappropriate imaging tests? Are less likely to offer non-beneficial tests and treatments?
In the May issue of Family Medicine, Dr. Richard Young and colleagues reported a qualitative analysis of interviews with 38 Texas family physicians about decision-making practices that may contribute to delivery of cost-effective care. Participants provided examples of experiences that they felt exemplified differences in the ways they approached patients compared to approaches of less cost-effective specialists. Two major themes emerged from these interviews: 1) cost-effective care is an inherent value in family medicine; 2) knowledge of the whole patient through continuous relationships enabled efficient decision-making.
Family physicians in this study emphasized the importance of the history and physical examination, conservative testing strategies in low-risk patients, being comfortable with managing complexity, and assigning less importance to "making the diagnosis" than relieving patients' symptoms. Physicians were also attuned to potential behavioral causes of physical symptoms and placed considerable weight on financial and medical harms that could result from aggressive care.
As the authors point out, these findings are limited by the relatively small number of participants, who may or may not represent the general attitudes of family physicians in other areas of the U.S. Do you think that Dr. Young and colleagues identified all of the important ways that family physicians provide cost-effective care? If not, what other factors would you add from your own patient care experiences?
Research studies have documented strong associations between U.S. primary care physician supply, better population health outcomes, and lower health care spending. Among adult primary care specialties, national survey data suggest that family physicians provide more cost-effective care. However, little research has examined how family physicians provide effective care at lower cost than other physicians. Is it because we are more likely to follow evidence-based guidelines? Order fewer inappropriate imaging tests? Are less likely to offer non-beneficial tests and treatments?
In the May issue of Family Medicine, Dr. Richard Young and colleagues reported a qualitative analysis of interviews with 38 Texas family physicians about decision-making practices that may contribute to delivery of cost-effective care. Participants provided examples of experiences that they felt exemplified differences in the ways they approached patients compared to approaches of less cost-effective specialists. Two major themes emerged from these interviews: 1) cost-effective care is an inherent value in family medicine; 2) knowledge of the whole patient through continuous relationships enabled efficient decision-making.
Family physicians in this study emphasized the importance of the history and physical examination, conservative testing strategies in low-risk patients, being comfortable with managing complexity, and assigning less importance to "making the diagnosis" than relieving patients' symptoms. Physicians were also attuned to potential behavioral causes of physical symptoms and placed considerable weight on financial and medical harms that could result from aggressive care.
As the authors point out, these findings are limited by the relatively small number of participants, who may or may not represent the general attitudes of family physicians in other areas of the U.S. Do you think that Dr. Young and colleagues identified all of the important ways that family physicians provide cost-effective care? If not, what other factors would you add from your own patient care experiences?
Senin, 06 Mei 2013
Skin procedures for the family physician: old and “new”
- Jennifer Middleton, MD, MPH
Are you using the minimal excision technique and/or saucerization in your practice? I welcome comments about when you learned about these techniques and how they're working. Or, if not yet, would these techniques change your practice?
Seeing a skin procedure on my schedule always makes my day. I enjoy providing patients with small epidermal (sebaceous) cysts and worrisome lesions the convenience of removal in the office.
Traditionally, epidermal cysts are removed by making an incision parallel to the skin lines over the widest part of the cyst. The cyst is dissected away from the subcutaneous tissue, and after it’s removed the incision is sutured.
Traditionally, worrisome skin lesions are removed by inking an ellipse (1:3 ratio of width to length ensures optimal closure) around the lesion. The ellipse is then incised and lifted away from the subcutaneous tissue and closed with sutures.
In the last year, I’ve learned about an alternative technique for each of these procedures. They are much faster than the traditional methods above.
Minimal excision technique for epidermal cysts
Make an incision of 2-3 mm over the cyst. Then use a hemostat to keep this incision open and squeeze out all of the cyst’s contents using your thumbs (wear eye protection!). Use the hemostat to lift out the cyst shell. No sutures are necessary given the tiny size of the incision.
(Avoid this technique for cysts that are/were infected or inflamed, as the adhesions surrounding the cyst will make lifting out the cyst shell impossible.)
Thorough technique description and excellent pictures here: http://www.aafp.org/afp/2002/0401/p1409.html
Saucerization (“scoop”) excision for worrisome skin lesions
This procedure uses a common shave biopsy (razor) blade but “scoops” deep into the skin. The blade should enter the skin at a 45-degree angle and penetrate to at least the mid-dermis.
Thorough technique description and excellent pictures here:
When described to me within the last year, both of these procedures were billed as “new,” yet the AFParticles above cite sources that are more than 10 years old. It was a bit disconcerting to find how out of date my surgical techniques were.
Given that the dissemination gap between research-based practice recommendations and the actual implementation into clinical practice is around 20 years, though, perhaps I shouldn’t have been so surprised.
Are you using the minimal excision technique and/or saucerization in your practice? I welcome comments about when you learned about these techniques and how they're working. Or, if not yet, would these techniques change your practice?
Senin, 29 April 2013
Pros and cons of vitamin D screening
- Kenny Lin, MD
The U.S. Preventive Services Task Force recently announced its intent to review the evidence and issue recommendations about screening for vitamin D deficiency, after finding insufficient evidence to recommend routine supplementation for the prevention of fractures in adults. According to a 2009 review published in American Family Physician, up to half of U.S. adults 65 years and older have inadequate vitamin D levels, which places them at increased risk of falls and fractures. Two editorials in the April 15th issue of AFP debate the pros and cons of screening for vitamin D deficiency in asymptomatic persons.
Dr. Leigh Eck makes the case for targeted screening for vitamin D deficiency in at-risk populations, which include, but are not limited to, persons with malabsorption syndromes, persons with chronic kidney disease, pregnant and lactating women, and older persons with a history of falls. "Most of these factors put patients at risk of osteoporosis," Dr. Eck argues. "Given the role of vitamin D in bone mineralization, patients who are at risk of or who have osteoporosis should be considered as candidates for vitamin D screening."
On the other hand, Dr. Colin Kopes-Kerr identifies several problems with measurement of serum vitamin D levels in asymptomatic persons, regardless of risk level: lack of test standardization; disagreement about what constitutes a "normal" vitamin D level; unclear treatment implications; and uncertain cost-effectiveness. Finally, he points out, "No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone."
The Endocrine Society recommends against population-based screening for vitamin D deficiency, and the American Society for Clinical Pathology included this screening test in its list of "Five Things Physicians and Patients Should Question" for the Choosing Wisely campaign.
The U.S. Preventive Services Task Force recently announced its intent to review the evidence and issue recommendations about screening for vitamin D deficiency, after finding insufficient evidence to recommend routine supplementation for the prevention of fractures in adults. According to a 2009 review published in American Family Physician, up to half of U.S. adults 65 years and older have inadequate vitamin D levels, which places them at increased risk of falls and fractures. Two editorials in the April 15th issue of AFP debate the pros and cons of screening for vitamin D deficiency in asymptomatic persons.
Dr. Leigh Eck makes the case for targeted screening for vitamin D deficiency in at-risk populations, which include, but are not limited to, persons with malabsorption syndromes, persons with chronic kidney disease, pregnant and lactating women, and older persons with a history of falls. "Most of these factors put patients at risk of osteoporosis," Dr. Eck argues. "Given the role of vitamin D in bone mineralization, patients who are at risk of or who have osteoporosis should be considered as candidates for vitamin D screening."
On the other hand, Dr. Colin Kopes-Kerr identifies several problems with measurement of serum vitamin D levels in asymptomatic persons, regardless of risk level: lack of test standardization; disagreement about what constitutes a "normal" vitamin D level; unclear treatment implications; and uncertain cost-effectiveness. Finally, he points out, "No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone."
The Endocrine Society recommends against population-based screening for vitamin D deficiency, and the American Society for Clinical Pathology included this screening test in its list of "Five Things Physicians and Patients Should Question" for the Choosing Wisely campaign.
Senin, 22 April 2013
Shared decision making
- Jennifer Middleton, MD, MPH
Let’s say you’re seeing a healthy 21-year-old woman in your office for contraception management. She takes no other medicines, has no personal or family history of blood clots, and has no contraindications to estrogen. She is interested in a long-acting contraceptive that she won’t have to worry about remembering every day. IUD, subdermal progesterone implant, q 3 months injectable progesterone – how do you choose?
Or, how about this: a 45-year-old man presents with frequent migraine headaches. You review the best evidence for migraine prophylaxis in adults and are stuck deciding between propranolol and amitriptyline. Which do you use?
Gray areas like these abound in Family Medicine, even with the ever-growing primary care evidence base. In both of these scenarios, no one option is clearly superior to the other. All of those contraceptive options would be efficacious for the 21-year-old woman, and, likewise, the efficacy of propranolol versus amitriptyline for the migraineur is probably a toss-up.
These types of situations, where multiple reasonable treatment options exist, provide an opportunity to involve the patient in the decision. Shared decision making (SDM) brings the patient’s preferences into the conversation and gives them some ownership over the final choice.
I wish that I could tell you that SDM has a rigorous evidence base behind it, but like many behavioral interventions, few quality studies exist to suggest patient benefit. A study last week in the Annals of Internal Medicine, however, may help to reinforce SDM’s value. Weiner et al engaged patients who surreptitiously recorded their office visits with Internal Medicine residents. The residents who adapted their care plan to meet their specific patient’s preferences had, in return, improved compliance from their patients.
This study was small and needs to be replicated in bigger settings, but its finding makes intuitive sense: patients invited to be involved in treatment decisions tend to have better adherence with those treatments.
You can ease the loss of the extra time it takes to do SDM by billing for the time spent in counseling (10 min = 99212, 15 min = 99213, and 25 min = 99214). Just be sure to document as such in your encounter note.
In 2010, AFP also published a nice SDM review, along with a helpful framework for the office. You can find that Curbside Consultation here: http://www.aafp.org/afp/2010/0301/p645.html.
I welcome your thoughts on the practical use of SDM in the busy family doc’s practice.
Selasa, 16 April 2013
Guidance for Choosing Wisely in diagnostic imaging
- Kenny Lin, MD
In 2006, 380 million radiologic procedures (including 67 million computed tomography [CT] scans) and 18 million nuclear medicine procedures were performed in the United States. To highlight the disproportionate use, U.S. patients received approximately one-half of all nuclear medicine procedures worldwide while making up only 4.6 percent of the global population. The volume represents a sixfold increase (from 0.5 to 3.0 mSv [millisieverts]) in annual per capita radiation exposure from 1980 to 2006. ... Increasing recognition of future cancer risk from radiation exposure was illustrated in a 2009 study showing that 2 percent of all future cancer cases will likely come from previous CT exposure, resulting in approximately 15,000 deaths annually.
This article on the appropriate and safe use of diagnostic imaging goes on to review consensus indications for imaging in the central nervous system, chest, abdomen, and lumbar spine based on American College of Radiology appropriateness criteria. It includes a helpful Table on the average effective radiation doses of medical imaging procedures that clinicians may use to weigh the harm versus the potential benefit of a particular diagnostic imaging test. In general, the authors recommend discouraging patients from undergoing whole body scanning, which is associated with numerous health risks and no proven benefits.
Many of the primary care-relevant recommendations in the Choosing Wisely campaign advise physicians to think twice before reflexively ordering diagnostic imaging tests in certain clinical situations. Inappropriate imaging increases radiation exposure, leads to overdiagnosis and detection of incidentalomas, and increases costs for patients and health systems. In addition, as Drs. Brian Crownover and Jennifer Bepko observe in the April 1st issue of AFP, increasing radiation exposure is likely to lead to higher rates of cancer diagnoses and deaths:
In 2006, 380 million radiologic procedures (including 67 million computed tomography [CT] scans) and 18 million nuclear medicine procedures were performed in the United States. To highlight the disproportionate use, U.S. patients received approximately one-half of all nuclear medicine procedures worldwide while making up only 4.6 percent of the global population. The volume represents a sixfold increase (from 0.5 to 3.0 mSv [millisieverts]) in annual per capita radiation exposure from 1980 to 2006. ... Increasing recognition of future cancer risk from radiation exposure was illustrated in a 2009 study showing that 2 percent of all future cancer cases will likely come from previous CT exposure, resulting in approximately 15,000 deaths annually.
This article on the appropriate and safe use of diagnostic imaging goes on to review consensus indications for imaging in the central nervous system, chest, abdomen, and lumbar spine based on American College of Radiology appropriateness criteria. It includes a helpful Table on the average effective radiation doses of medical imaging procedures that clinicians may use to weigh the harm versus the potential benefit of a particular diagnostic imaging test. In general, the authors recommend discouraging patients from undergoing whole body scanning, which is associated with numerous health risks and no proven benefits.
Senin, 08 April 2013
Meet AFP Community Blog's new contributor
- Jennifer Middleton, MD, MPH
Hello! I’m thrilled to accept AFP’s invitation to join Dr. Lin on this blog. I thought I’d use this first entry to share a little bit about myself and what you can expect from my posts.
Hello! I’m thrilled to accept AFP’s invitation to join Dr. Lin on this blog. I thought I’d use this first entry to share a little bit about myself and what you can expect from my posts.
For about 2 and ½ years, I’ve been blogging at The Singing Pen of Doctor Jen. Many good Family Medicine bloggers were already hard at work when I started in November of 2010, but I thought as a residency educator I might have something different to add to the mix. I did a two-year full time faculty development fellowship in Pittsburgh before starting my career. In my fellowship, I learned how to teach and create curricula, how to write and edit, and how to design and implement research. During my fellowship, I also studied for a Master’s Degree in Public Health (MPH). Between my faculty development background and my MPH training, I see the world of Family Medicine with a detached eye at times.
You can expect musings from me about my experiences as a family doctor, a teacher, and even sometimes, a patient. These stories will hopefully be a backdrop for us to share the challenges and joys of day-to-day Family Medicine. You will also hear me stridently advocating for Family Medicine as the solution to many of our current healthcare woes.
I am grateful for the opportunity to share some of these thoughts with you going forward.
Senin, 25 Maret 2013
New inpatient medicine resource in AFP By Topic
- Kenny Lin, MD
Although some family physicians choose to transfer the primary care of hospitalized patients to other specialists, nearly two-thirds of physicians surveyed by the American Academy of Family Physicians in 2011 reported having hospital admission privileges, with similar proportions among recent residency graduates and physicians with 15 or more years of practice experience. In recognition of the essential role of family medicine in the inpatient setting, our newest AFP By Topic collection features links to key clinical content on 23 common conditions in hospitalized patients.
For example, a clinician managing a patient with diabetic ketoacidosis can consult a review article published in AFP earlier this month, while another recent article provides current information on the evaluation and treatment of patients with acute kidney injury. The Inpatient Medicine collection will be regularly updated with new content as it is published in all areas of the journal.
Senin, 18 Maret 2013
Less is more in preoperative testing
- Kenny Lin, MD
Family physicians are often asked for preoperative consultations prior to elective surgical procedures. Traditionally, the process of "clearing" patients for surgery has included performing an electrocardiogram, chest x-ray, and numerous laboratory tests. However, as Dr. Molly Feely and colleagues point out in the cover article of AFP's March 15th issue, there is little evidence that routine preoperative testing is beneficial: "these tests often do not change perioperative management, may lead to follow-up testing with results that are often normal, and can unnecessarily delay surgery, all of which increase the cost of care." Instead, current guidelines recommend selective testing based on risk factors identified during the history or physical examination.
The following Choosing Wisely campaign recommendations from several medical specialty groups identify unwarranted preoperative tests to reduce waste and prevent harm to patients:
1. Avoid routine preoperative testing for low-risk surgeries without a clinical indication.
2. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
3. Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to noncardiac thoracic surgery.
4. Avoid cardiovascular stress testing for patients undergoing low-risk surgery.
5. Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.
6. Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk.
7. Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.
8. Prior to cardiac surgery there is no need for pulmonary function testing in the absence of respiratory symptoms.
Family physicians are often asked for preoperative consultations prior to elective surgical procedures. Traditionally, the process of "clearing" patients for surgery has included performing an electrocardiogram, chest x-ray, and numerous laboratory tests. However, as Dr. Molly Feely and colleagues point out in the cover article of AFP's March 15th issue, there is little evidence that routine preoperative testing is beneficial: "these tests often do not change perioperative management, may lead to follow-up testing with results that are often normal, and can unnecessarily delay surgery, all of which increase the cost of care." Instead, current guidelines recommend selective testing based on risk factors identified during the history or physical examination.
The following Choosing Wisely campaign recommendations from several medical specialty groups identify unwarranted preoperative tests to reduce waste and prevent harm to patients:
1. Avoid routine preoperative testing for low-risk surgeries without a clinical indication.
2. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
3. Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to noncardiac thoracic surgery.
4. Avoid cardiovascular stress testing for patients undergoing low-risk surgery.
5. Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.
6. Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk.
7. Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.
8. Prior to cardiac surgery there is no need for pulmonary function testing in the absence of respiratory symptoms.
Senin, 04 Maret 2013
Extra diagnostic tests don't reassure: another reason to Choose Wisely
- Kenny Lin, MD
Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality family medicine. The March 1st issue of AFP includes two articles that reflect this philosophy as embodied in the American Board of Internal Medicine Foundation's Choosing Wisely campaign. Four of the American Geriatrics Society's "Five Things Patients and Physicians Should Question" refer to medications that can be harmful to older patients in certain settings: antipsychotics, hypoglycemics, benzodiazepines, and antibiotics. In this issue, Dr. Richard Pretorius and colleagues echo this advice and provide additional guidance and systematic approaches to reducing the risk of adverse drug events in older adults.
Sudden hearing loss is a distressing symptom that may prompt a physician to order a CT scan to look for a brain tumor or other cranial mass lesion. However, the American Academy of Otolaryngology - Head and Neck Surgery Foundation advises against ordering this diagnostic test in patients without focal neurologic findings, since the CT scan provides no useful information and exposes the patient to radiation and an expensive medical bill. More information on the evaluation and management of sudden hearing loss is available in AFP's Practice Guidelines summary of the AAO-HNSF's recent clinical guideline.
One reason that clinicians often give for ordering diagnostic tests in patients with a low pretest probability of serious disease is to "reassure the patient." This rationale is used to justify performing endoscopy in patients with dyspepsia but no alarm symptoms; x-rays or magnetic resonance imaging in patients with uncomplicated low back pain; or electrocardiography in patients with chest pain and a low likelihood of cardiac disease. It turns out, though, that negative tests aren't reassuring at all. A recent systematic review and meta-analysis of 14 randomized trials in JAMA Internal Medicine found that diagnostic tests did not reduce patients' illness worry, nonspecific anxiety, or symptom persistence. The only effect of the tests was a small reduction in subsequent primary care visits. Given the adverse effects of diagnostic testing in general, including false positives and overdiagnosis, this "benefit" does not warrant making unwise choices about non-indicated medical tests.
Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality family medicine. The March 1st issue of AFP includes two articles that reflect this philosophy as embodied in the American Board of Internal Medicine Foundation's Choosing Wisely campaign. Four of the American Geriatrics Society's "Five Things Patients and Physicians Should Question" refer to medications that can be harmful to older patients in certain settings: antipsychotics, hypoglycemics, benzodiazepines, and antibiotics. In this issue, Dr. Richard Pretorius and colleagues echo this advice and provide additional guidance and systematic approaches to reducing the risk of adverse drug events in older adults.
Sudden hearing loss is a distressing symptom that may prompt a physician to order a CT scan to look for a brain tumor or other cranial mass lesion. However, the American Academy of Otolaryngology - Head and Neck Surgery Foundation advises against ordering this diagnostic test in patients without focal neurologic findings, since the CT scan provides no useful information and exposes the patient to radiation and an expensive medical bill. More information on the evaluation and management of sudden hearing loss is available in AFP's Practice Guidelines summary of the AAO-HNSF's recent clinical guideline.
One reason that clinicians often give for ordering diagnostic tests in patients with a low pretest probability of serious disease is to "reassure the patient." This rationale is used to justify performing endoscopy in patients with dyspepsia but no alarm symptoms; x-rays or magnetic resonance imaging in patients with uncomplicated low back pain; or electrocardiography in patients with chest pain and a low likelihood of cardiac disease. It turns out, though, that negative tests aren't reassuring at all. A recent systematic review and meta-analysis of 14 randomized trials in JAMA Internal Medicine found that diagnostic tests did not reduce patients' illness worry, nonspecific anxiety, or symptom persistence. The only effect of the tests was a small reduction in subsequent primary care visits. Given the adverse effects of diagnostic testing in general, including false positives and overdiagnosis, this "benefit" does not warrant making unwise choices about non-indicated medical tests.
Senin, 25 Februari 2013
Choosing Wisely's notable omissions
- Kenny Lin, MD
Last week, the American Board of Internal Medicine Foundation's Choosing Wisely Initiative announced the release of a second round of lists of 5 things that physicians and patients should question, based on evidence that certain tests or procedures are not beneficial in specific clinical situations. AFP will soon be updating our list of primary care-relevant items from the Choosing Wisely campaign, and our Facebook and Twitter accounts will highlight old and new entries daily over the next few months. This AAFP News Now article provides more information about the American Academy of Family Physicians' most recent items, which include elective labor inductions and unnecessary cervical cancer screenings.
Notably absent from the lists of the primary care specialty societies and the American Urological Association is routine prostate-specific antigen (PSA) testing, which both the Cochrane Collaboration and the U.S. Preventive Services Task Force have concluded does not improve men's health outcomes. Even though the American Cancer Society and the AUA still support selective use of the PSA test in older men who have been adequately informed of its potential harms, no medical group supports the still-common practice of ordering PSA screening without first discussing it with the patient.
Another curious omission from the top 5 lists of cardiology and thoracic surgery organizations is angioplasty or coronary artery bypass surgery for stable coronary artery disease, which are frequently performed in the U.S. but have no clinical advantages over initial medical management.
Last week, the American Board of Internal Medicine Foundation's Choosing Wisely Initiative announced the release of a second round of lists of 5 things that physicians and patients should question, based on evidence that certain tests or procedures are not beneficial in specific clinical situations. AFP will soon be updating our list of primary care-relevant items from the Choosing Wisely campaign, and our Facebook and Twitter accounts will highlight old and new entries daily over the next few months. This AAFP News Now article provides more information about the American Academy of Family Physicians' most recent items, which include elective labor inductions and unnecessary cervical cancer screenings.
Notably absent from the lists of the primary care specialty societies and the American Urological Association is routine prostate-specific antigen (PSA) testing, which both the Cochrane Collaboration and the U.S. Preventive Services Task Force have concluded does not improve men's health outcomes. Even though the American Cancer Society and the AUA still support selective use of the PSA test in older men who have been adequately informed of its potential harms, no medical group supports the still-common practice of ordering PSA screening without first discussing it with the patient.
Another curious omission from the top 5 lists of cardiology and thoracic surgery organizations is angioplasty or coronary artery bypass surgery for stable coronary artery disease, which are frequently performed in the U.S. but have no clinical advantages over initial medical management.
Minggu, 17 Februari 2013
Shared decisions in screening for breast cancer
- Kenny Lin, MD
In the February 15th issue of AFP, Dr. Maria Tirona reviews areas of agreement and disagreement in major organizational guidelines on screening for breast cancer. There is widespread consensus that annual or biennial mammography should be offered to women 50 to 74 years of age, and that teaching breast self-examination does not improve health outcomes. For women 40 to 49 years of age, in whom the risks and benefits of mammography are closely balanced on a population level, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommend shared decision making, taking into account individual patient risk and patients' values regarding benefits and harms of screening.
In an accompanying editorial, however, Drs. Russell Harris and Linda Kinsinger argue that shared decision making regarding breast cancer screening need not be limited to younger women:
More and more, the goal for breast cancer screening is not to maximize the number of women who have mammography, but to help women make informed decisions about screening, even if that means that some women decide not to be screened. ... The goal of improving patient decision making should be expanded to all women eligible for breast cancer screening (i.e., those 40 to 75 years of age who are in reasonable health), because the benefits and harms of screening are not very different among these age groups.
This means that for every 2,000 women invited for screening over 10 years, one will have her life prolonged, and 10 healthy women who would not have been diagnosed if there had not been screening will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false-positive findings.
In the February 15th issue of AFP, Dr. Maria Tirona reviews areas of agreement and disagreement in major organizational guidelines on screening for breast cancer. There is widespread consensus that annual or biennial mammography should be offered to women 50 to 74 years of age, and that teaching breast self-examination does not improve health outcomes. For women 40 to 49 years of age, in whom the risks and benefits of mammography are closely balanced on a population level, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommend shared decision making, taking into account individual patient risk and patients' values regarding benefits and harms of screening.
In an accompanying editorial, however, Drs. Russell Harris and Linda Kinsinger argue that shared decision making regarding breast cancer screening need not be limited to younger women:
More and more, the goal for breast cancer screening is not to maximize the number of women who have mammography, but to help women make informed decisions about screening, even if that means that some women decide not to be screened. ... The goal of improving patient decision making should be expanded to all women eligible for breast cancer screening (i.e., those 40 to 75 years of age who are in reasonable health), because the benefits and harms of screening are not very different among these age groups.
The primary benefit of screening mammography is an estimated 15 percent relative reduction in deaths from breast cancer; harms of mammography include false positive results, overdiagnosis, and overtreatment. A recent study published in BMJ explored the impact of overdiagnosis on attitudes toward mammography in several focus groups of Australian women 40 to 79 years of age. Few women had ever been informed about overdiagnosis as a potential harm of screening. Most women continued to feel that mammography was worthwhile if overdiagnosis was relatively uncommon (30 percent or less of all breast cancers detected). However, a higher estimate of overdiagnosis (50 percent) "made some women perceive a need for more careful personal decision making about screening."
Notably, a 2011 Cochrane Review estimated that 30 percent of breast cancers detected through screening are overdiagnosed:
This means that for every 2,000 women invited for screening over 10 years, one will have her life prolonged, and 10 healthy women who would not have been diagnosed if there had not been screening will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false-positive findings.
Given this information, what approach do you take to screening mammography? Do you believe that this test should be routine for women of eligible ages, a shared decision for some, or (as Drs. Harris and Kinsinger advocate), a shared decision for all? Why is it often difficult to promote shared decision making in clinical practice?
Jumat, 08 Februari 2013
Announcing the AFP mobile app edition
- Matthew Neff, Senior Editor, AFP Online
Now you can keep up with American Family Physician in a format that's as mobile as you are. AFP is pleased to announce the new mobile app edition of the journal. This app provides a digitally enhanced replica of AFP for tablets and smartphones. Other features include downloading for offline reading; quick links to full articles; bookmarking content; sharing articles with colleagues; and real-time news and content feeds from the American Academy of Family Physicians (AAFP) and the AFP Community Blog.
Now you can keep up with American Family Physician in a format that's as mobile as you are. AFP is pleased to announce the new mobile app edition of the journal. This app provides a digitally enhanced replica of AFP for tablets and smartphones. Other features include downloading for offline reading; quick links to full articles; bookmarking content; sharing articles with colleagues; and real-time news and content feeds from the American Academy of Family Physicians (AAFP) and the AFP Community Blog.
The apps are free for AAFP members, print and online paid subscribers, and individuals who currently receive the journals in their own name; all others can purchase individual issues within the app. The app is now available in the Apple App Store and will be coming soon to Google Play. Search the App Store for “AAFP” or “American Family Physician” to download the app, and then sign in using the e-mail address associated with your AAFP account to start downloading issues.
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