The future of house calls

Although house calls remain a part of family medicine residency training, the proportion of family physicians who perform them in practice has been declining for years. One notable exception is Steven Landers, MD, MPH, medical director of the Cleveland Clinic Home Health Agency. In previous commentaries published in the Annals of Family Medicine and JAMA, Dr. Landers has called home care "a key to the future of family medicine" and "the other medical home," distinct from office-centric Patient-Centered Medical Home initiatives supported by the American Academy of Family Physicians and other primary care groups.

American Medical News recently reported that the 2010 health reform law gave house calls a boost by mandating "Independence at Home," a Medicare demonstration project that will offer financial incentives to primary care teams performing house calls in selected high-cost areas of the U.S. starting in 2012. A similar program sponsored by the HealthCare Partners Medical Group in California, Nevada, and Florida led to a 20 percent drop in hospital use over its two years of existence, saving $2 million per year for every 1,000 members.

In addition to reductions in hospitalizations and costs, house calls produce other benefits for clinicians and patients, including improved continuity of care and new patient referrals, as family physician Samantha Pozner, MD argued in a 2003 article published in Family Practice Management.

As house calls appear poised to make a comeback, the April 15th issue of AFP delivers a timely, updated review of their effectiveness, essential elements (including a sample house call checklist), and practice management details such as current billing codes for house calls and domiciliary care.

Evaluation of a child with "failure to thrive"

"Failure to thrive is a term used to describe inadequate growth or the inability to maintain growth, usually in early childhood," begins an updated review of this topic in the April 1st issue of AFP. Accurate identification of failure to thrive should rely on a combination of anthropometric criteria, using the 2006 child growth standards established by the World Health Organization. According to Drs. Sarah Cole and Jason Lanham, 5 to 10 percent of children in primary care settings in the U.S. have failure to thrive, with the vast majority presenting before 18 months of age.

The diagnostic evaluation of failure to thrive includes "a detailed account of a child's eating habits, caloric intake, and parent-child interactions," as well as observations of breast or bottle feeding technique. Unless the child presents with one or more red flag signs or symptoms suggesting a non-behavioral cause of failure to thrive, routine laboratory testing is not recommended. Treatment usually consists of nutritional counseling and supplementation to achieve catch-up growth, with frequent follow-up visits to monitor progress.

As a previously published AFP Curbside Consultation has illustrated, however, diagnosing a psychosocial cause of failure to thrive is often challenging. The difference between neglect and parental ignorance of appropriate feeding habits may not be clear, especially when parents delay seeking medical attention for a child with apparently obvious signs of malnutrition and growth delay. When you recognize a child with failure to thrive in your practice, under what conditions would you consider referring him or her to a child protective services agency for investigation of parental neglect?

Prostate-specific antigen screening is not effective

According to the Cochrane for Clinicians summary in the the April 1st issue of AFP, a review of five randomized, controlled trials with more than 340,000 participants found no statistically significant effect of prostate-specific antigen (PSA) screening on mortality from prostate cancer. An independent meta-analysis published last year in BMJ also concluded that routine screening had no measurable health benefits and could not be recommended. On the other side of the ledger, Drs. Nathan Hitzeman and Michael Molina point out that

Established harms of PSA testing include excessive worry over false-positive results and morbidity from interventions, including infection, bleeding, pain, long-term sexual dysfunction, and urinary incontinence. A recent analysis showed that PSA testing does not attain the likelihood ratios necessary to qualify as a screening test, regardless of the cutoff value used. The inventor of the PSA test said the test's popularity has caused “a hugely expensive public health disaster.”

Despite the preponderance of evidence that this test is not effective, and frequently results in harm to patients, data from the National Health Interview Survey published earlier this week in the Journal of Clinical Oncology demonstrate that PSA screening is becoming more common in the U.S., not less. 45 percent of men age 70 to 74 years, and 25 percent of men age 85 years or older, report being screened.

The U.S. Preventive Services Task Force and the AAFP recommend against screening for prostate cancer in men age 75 years or older, due to their limited life expectancies and the high likelihood of death from a cause other than prostate cancer. Nonetheless, clinical practice remains far out of step with the evidence. What approach do you take to discussing prostate cancer screening with your patients?

Selected new AFP content now open to all

Unlike most medical journals, AFP has always had a fairly liberal online access policy, with no restrictions or charges on accessing content 12 months after the date of publication. (Content published within the past 12 months is freely available to members of the American Academy of Family Physicians and to other health professionals with subscriptions.) While our primary concern is to serve the journal's 170,000 regular readers, we also recognize that having immediate access to some new content would be valuable to others in the primary care community and our patients. Therefore, starting with the March 15th issue, the following sections of the journal will now be freely accessible online, regardless of publication date:

Graham Center Policy One-Pagers
U.S. Preventive Services Task Force statements
Pro/Con Editorials (only members and paid subscribers can post comments)
AAFP News Now
Close-Ups: A Patient's Perspective
Patient Handouts

These sections of the journal were selected because they are intended for our patients or the wider medical community, and most are freely available on other sites.

We hope that AFP's new "selected open access" policy will benefit family physicians and their patients by allowing the journal to reach a wider online audience, while continuing to reserve continuing medical education-associated content to members and paid subscribers.

New health maintenance and preventive care resources

The March 15th issue of AFP features a two-part article summarizing important health maintenance issues in school-aged children. Part One focuses on surveillance, screening, and immunizations; and Part Two addresses counseling recommendations. An accompanying editorial by David Ortiz, MD outlines strategies to improve the delivery of preventive services to children, ranging from immunization reminder or recall systems to parent-response developmental tools that can be filled out prior to office visits. Dr. Ortiz concludes by encouraging family physicians to work collaboratively with allied health professionals and office staff to achieve prevention goals:

Although achieving widespread adoption of system-wide changes is a daunting task, family physicians can begin by taking small steps to improve the preventive and well-child care services they provide to their patients. By using chart review or abstraction and identifying key measures to improve (e.g., immunization rates, anticipatory guidance on select topics), family physicians and their staff can assess how well they currently deliver these services, then set improvement goals. Family physicians and their staff can also work together to use well-studied quality improvement techniques, such as the PDSA (plan, do, study, act) cycle, to identify and develop practice-specific ways to improve well-child services.

Since preventive care guidelines for children and adults are updated frequently, we are pleased to provide two new AFP By Topic Collections on Health Maintenance and Counseling and Immunizations. In addition to cutting-edge clinical content, be sure to check out valuable Improving Practice articles from Family Practice Management on subjects such as the recent Medicare preventive services expansion, working with behavioral health specialists, and coding sports physicals.

Evaluating chest pain in the office setting

While much medical literature has been devoted to the evaluation of chest pain in emergency room and acute care settings, relatively few tools have been published for evaluating chest pain in primary care offices. AFP's Deputy Editor for Evidence-Based Medicine, Mark Ebell, MD, MS, addresses this need in the March 1st issue of the journal with a Point-of-Care Guide that includes a five-item clinical decision rule to identify patients with chest pain caused by coronary artery disease. Dr. Ebell then provides a suggested algorithm for integrating decision rule results with ECG findings. Moderate- and high-risk patients should be evaluated further for coronary artery disease, while low-risk patients should generally be evaluated for noncardiac causes of chest pain.

You can find additional information about diagnosis, treatment, and prevention of coronary artery disease in the AFP By Topic collection, and more Point-of-Care Guides on a variety of clinical topics in the Department collection.

Lead screening recommendations: not "one size fits all"

In a Letter to the Editor in the March 1st issue of AFP, Dr. Matt Viel challenges a previous review article's "one size fits all" recommendation to test all Medicaid-enrolled or eligible children for elevated lead levels at one and two years of age. (This recommendation is based on a 2007 practice guideline from the Centers for Disease Control and Prevention.) Pointing out that his county has a known lead poisoning prevalence of less than 0.1 percent, making it unlikely that screening will yield appreciable health benefits, Dr. Veil reports that "our practice loses revenue because Medicaid often denies most or all of our claim for the well-child visit if we do not order lead screening tests."

In her response, Dr. Crista Warniment endorses a more targeted approach to lead screening:

The CDC has released revised guidelines urging local and state health officials to update screening recommendations for lead poisoning in Medicaid-enrolled or -eligible children based on state and local data rather than on insurance status alone. Recent data suggest that the incidence of elevated blood lead levels is decreasing among the Medicaid population in certain areas, approaching the lower risk seen in children not enrolled in or eligible for Medicaid. For example, Minnesota and Wisconsin are among the first states to report less of a disparity in elevated blood lead levels between children who are Medicaid-enrolled or -eligible and those who are not.

It is also worth mentioning that the U.S. Preventive Services Task Force and the AAFP consider the evidence to be "insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children one to five years of age who are at increased risk," and recommend against screening children at average risk. AFP's Putting Prevention Into Practice case study provides further information.

Financial considerations, evidence limitations, and conflicting recommendations make it tempting to simply take a "one size fits all" approach to lead screening, even if this approach is not necessarily in the best interest of our patients. What strategy does your practice use to manage lead screening and similar clinical issues?