Checking the resurgence of pertussis

- Kenny Lin, MD

According to several news stories, more than twice as many cases of pertussis (whooping cough) have already been reported in the U.S. this year than in all of 2011. Although some of the disease resurgence may be due to increasing rates of vaccine refusal, experts are concerned that another culprit may be waning immunity from the acellular pertussis vaccine that has been used in the U.S. since the 1980s. Although a recent Cochrane review concluded that acellular pertussis vaccines (preferred due to their lower incidence of side effects) were as effective as whole-cell vaccines, the review relied mostly on indirect comparisons and limited follow-up intervals. In contrast, an Australian study published in the August 2nd issue of JAMA found that acellular vaccines were clearly inferior to whole-cell vaccines in preventing pertussis 10 to 12 years after vaccination.

In order to prevent new pertussis infections, especially in infants who are too young to be immunized, all adolescents and adults should receive Tdap immunizations instead of the traditional Td booster. To encourage patients to receive age-appropriate immunizations, parents should be counseled about vaccine safety, and standing orders and patient reminders instituted to prompt physicians and support staff when immunizations are recommended. Additional information on immunizations for pertussis and other vaccine-preventable diseases is available in the AFP By Topic collection.

Treating common ailments of Olympic athletes

- Kenny Lin, MD

As I write, competitors at Summer Olympic Games in London are pushing their bodies to their physical and mental limits, leading to plenty of work for family physicians and other sports medicine clinicians. Elite endurance cyclists and long-distance runners encounter a host of common problems, ranging from overuse injuries to heat-related illnesses. Runners and gymnasts also are at increased risk for lower extremity stress fractures. Tennis players traditionally suffer from lateral epicondylitis, while basketball and soccer players are vulnerable to ankle sprains and anterior cruciate ligament injuries when they step on to the court or field of play. Beach volleyball star Kerri Walsh recently underwent multiple surgeries for acute shoulder injuries suffered during championship-level competitions. Swimmer Jessica Hardy, competing in several events at the current Games, also qualified for the 2008 Summer Games in Beijing but withdrew and served a one-year ban from the sport after testing positive for a banned sports supplement.

With such an extensive variety of ailments that might surface during the Summer Games, U.S. team physicians and medical personnel can at least breathe a sigh of relief that the athletes' medical records are, for the first time, being stored digitally. As Alice Park recently wrote in Time magazine:

While fans can follow their favorite Olympian via Twitter and texts, and get real-time updates on their activities, until this Games, medical records were handled in a conspicuously old-school way — shipped, in dozens of palettes, to the Games. For Beijing, the files literally took a slow boat to China, says Dr. Bill Moreau, managing director of sports medicine at the USOC. “Heaven forbid that an athlete would actually need something from their record while it’s being shipped, or on the ocean, or stuck in a harbor,” he says. With the electronic records, anyone caring for an Olympic athlete, from a trainer to a physical therapist to a physician treating an emergency injury, can get a quick look at the athlete’s medical history at a glance, and update it with the latest developments.

That's medical progress that all of us watching from home can cheer about!

Making wiser choices about medical tests and treatments

- Kenny Lin, MD

The July 15th issue of AFP features an special online editorial by AFP editor Jay Siwek, MD that compiles family medicine-relevant items from the multi-specialty Choosing Wisely campaign that aims to reduce the provision of "unnecessary" care, defined as medical tests and treatments that offer no health benefits and may result in harm to patients. Based on trusted sources of evidence-based medicine such as the U.S. Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus, these "don't do" recommendations have the potential to save both lives and money, if they can be effectively put into practice. To inform patients about the campaign, Consumer Reports has created fact sheets about many of the included items.

Reactions to the Choosing Wisely campaign in the blogosphere have been varied. Calling it "the health reform we need," cardiologist John Mandrola writes, "I hope it sticks like super glue." On the other side, emergency physician William Sullivan argues that the campaign "has good intentions, but isn't a good idea," noting that "there isn’t a Suing Wisely campaign for attorneys and there isn’t a Legislating Wisely campaign for Congress." Similarly, family physician Mike Sevilla contends that while Choosing Wisely may "score political points" for sponsoring physician organizations, it is unlikely to change their members' behavior, which is also driven by patient demands and fears of lawsuits over interventions not taken. Where do you stand on this spectrum? Is the Choosing Wisely campaign good or bad for family medicine, or perhaps some of both?

Which test should be used for TB screening?

- Kenny Lin, MD

The tuberculin skin test has a long and venerable history as the screening test of choice for latent tuberculosis infection in the United States. A 2009 AFP article called it "the most acceptable method" of tuberculosis screening. However, the tuberculin skin test has limitations: it requires 2 patient visits, and may be difficult to interpret in persons from other countries that have received bacille Calmette-Guerin (BGC) vaccinations. In contrast, interferon-gamma release assays (IGRAs) performed on blood samples require only a single patient visit, do not cross-react with BCG, and according to a recent systematic review, have comparable specificity to TSTs. The Centers for Disease Control and Prevention now recommends that IGRAs be the preferred test for patients with prior BCG vaccinations and those who are unlikely to return for a TST reading (e.g. homeless persons). But why not go one step further and abandon the tuberculin skin test entirely?

In an editorial in this week's JAMA, Drs. Phillip LoBue and Kenneth Castro examine the case for replacing traditional skin with blood tests for tuberculosis. They note that although the evidence is limited, positive IGRAs are able to predict which patients will eventually develop active tuberculosis in the absence of treatment at a rate similar to TSTs, albeit poorly (5 to 10 percent). It is also uncertain if having a single positive cutoff value for IGRAs will produce additional false-positive results, compared to the 3 values for a positive TST based on a person's health status and tuberculosis risk. Finally, an IGRA costs 3 times as much as TST, even factoring in costs associated with a follow-up visit.

What test or tests does your practice currently use to screen patients for latent tuberculosis infections? Do you think the convenience and ease of interpretation of the blood test is worth the additional cost? Please let us know your thoughts.

Electronic health records may improve preventive care

- Kenny Lin, MD

In an editorial in the May 15th issue of AFP, I summarized the mixed evidence that using electronic health records with clinical decision support systems (CDSSs) improves processes and outcomes of preventive care. Most of the literature supporting a positive effect of EHRs with CDSSs is either anecdotal, observational, or limited to specific settings (namely, practices of employed physicians in large, integrated health systems). I concluded that it remained uncertain if these results could be duplicated in randomized trials in typical private practices.

Uncertain, that is, until this week, following a study by Alex Krist and colleagues, "Interactive Preventive Health Record to Enhance Delivery of Recommended Care: A Randomized Trial," in the Annals of Family Medicine. The authors randomized 4500 patients from 8 primary care practices in Virginia to usual care versus an invitation to use MyPreventiveCare, an interactive personal health record (IPHR) that generates a list of screening and counseling recommendations based on guidelines from the U.S. Preventive Services Task Force, as well as links to more detailed explanations of these preventive services and relevant decision aids. When patients used the IPHR, their physicians also received a summary of the recommendations in their EHRs.

Although only about 1 in 6 invited patients had actually used the personal health record 16 months later, it was enough to show a statistically significant difference between the proportion of patients in that group who were up-to-date on all recommended services, compared to the control group. After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users. The authors concluded: "Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefits." A how-to guide on the use of personal health records to promote preventive services is available on the Agency for Healthcare Research and Quality website.

Rhythm or rate control for atrial fibrillation?

- Kenny Lin, MD

For many years, the standard thinking regarding treatment of patients with atrial fibrillation was that drug therapy to restore sinus rhythm (rhythm control) was superior to drug therapy to slow the ventricular response rate (rate control). That all changed in 2002, when a clinical trial found no difference in survival between patients randomized to rhythm or rate control, and a higher incidence of adverse effects in the rhythm control group.

This trial and other evidence led the American Academy of Family Physicians to issue a guideline that recommended rate control with chronic anticoagulation as the preferred strategy for most patients with atrial fibrillation. A recent AFP review article echoed this guidance, assigning an "A" strength of evidence rating to the following statement:  "Rate control is the recommended treatment strategy in most patients with atrial fibrillation. Rhythm control is an option for patients in whom rate control is not achievable or who remain symptomatic despite rate control."

On occasion, however, evidence-based interventions achieve different results in primary care than in clinical trials. A study published earlier this month in the Archives of Internal Medicine used administrative databases in Quebec, Canada to compare mortality between older patients with atrial fibrillation who were initially prescribed rhythm or rate control therapy after their diagnoses. After experiencing similar mortality through 4 years of follow-up, patients in the rhythm control group had a significantly lower risk of death, with 23% lower relative mortality than patients in the rate control group at 8 years. These surprising results beg the question: was this new study somehow flawed? If not, as the subtitle of an accompanying editorial asked, can observational data trump randomized trial results?

Although it is unlikely that treatment guidelines will change any time soon, this study should remind clinicians that management of patients with newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.

Family physicians and Communities of Solution

Every so often, AFP reviews a public health topic, such as outdoor air pollutants, disaster preparedness and response, or reducing the effects of climate change. And occasionally we receive feedback from readers who suggest that these topics are not appropriate for a family medicine journal, since family physicians are practicing clinicians who provide direct care to individual patients, not public health professionals responsible for large populations. However, this view of the limited role of family physicians is by no means unanimous.

In response to concerns about the shrinking scope of family medicine, Dr. Joseph Scherger wrote on the Society of Teachers of Family Medicine blog that "family medicine today is more complex and expansive in some ways than ever before." Family physicians must learn advanced motivational counseling and information management skills to practice excellent preventive and chronic care. Also, the patient-centered medical home requires family physicians to take population-based approaches to managing chronic illnesses.

In March, the Institute of Medicine published a report on opportunities for integrating primary care and public health. Notably, the report did not advocate for large numbers of family physicians to obtain formal public health degrees. Just as an editorial in the Annals of Internal Medicine argued that the subspecialty of geriatric medicine would be best served by incorporating its unique resources and skills into primary care training, a group of family medicine leaders convened by the American Board of Family Medicine recently declared:

The modern primary care physician, who values “community participation, political involvement, and collective advocacy," can, in effect, be a true public health professional, forming partnerships with community-based organizations that facilitate healthy change. This paradigm shift includes the transition from treating individuals in isolation to treating people in the context of their lives in their communities, indeed, culminating in community-centered care.

In a publication in the Annals of Family Medicine, this group re-examined and updated the 1967 Folsom Report, which provided a blueprint for connecting the personal physician with community resources in "Communities of Solution." What do you think of this ambitious vision of the family physician as a public health professional? Is this a desirable goal, and if so, what would it take to achieve it?