- 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.
Senin, 25 Februari 2013
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.
Selasa, 05 Februari 2013
Are calcium supplements bad for the heart?
- Kenny Lin, MD
Until recently, the idea that calcium-containing supplements, which more than half of older adults in the U.S. consume regularly, could be harmful would have seemed absurd. Primary care clinicians have long recommended calcium supplements to reduce the risk of osteoporotic fractures in adults who are unable to meet the Institute of Medicine's Dietary Reference Intakes through diet alone. However, a large prospective study published this week in JAMA Internal Medicine demonstrated a statistically significant association between supplemental calcium (as opposed to dietary calcium) intake and a 20 percent higher relative risk of death from cardiovascular disease in men.
This troubling finding adds to the evidence base that suggests harmful cardiovascular effects of calcium-containing supplements. A timely pair of editorials in the February 1st issue of AFP debates the population-level risk of widespread calcium supplementation. Arguing that this potential risk should be a serious concern, Drs. Ian Reid and Mark Bolland review the results of their previous randomized trial and meta-analysis that found 20 to 30 percent increases in the incidence of acute myocardial infarction in adults taking calcium supplements. In their view, these adverse effects are not worth the potential benefits to bone health:
In both of our meta-analyses, calcium supplementation was more likely to cause vascular events than to prevent fractures. Therefore, the bolus administration of this micronutrient should be abandoned in most circumstances, and patients should be encouraged to obtain their calcium intake from an appropriately balanced diet. For those at high risk of fracture, effective interventions with a fully documented safety profile superior to that of calcium are available. We should return to seeing calcium as an important component of a balanced diet and not as a low-cost panacea to postmenopausal bone loss.
In the second editorial, Dr. Rajib Bhattacharya points out that the Women's Health Initiative and other randomized trials did not indicate that calcium supplements increased cardiovascular risk. He argues that secondary analyses of trials designed with other primary outcomes in mind may have predisposed these analyses to unforeseen bias, and that there is "no compelling evidence" that calcium supplements at usual doses pose dangers to heart health.
Notably, a draft recommendation statement released by the U.S. Preventive Services Task Force last June stated that there was insufficient evidence that vitamin D and calcium supplementation prevent fractures or cancer in otherwise healthy older adults. Although the only adverse effects of supplements mentioned in the Task Force's evidence review were renal and urinary tract stones, none of the reviewed studies were specifically designed to assess cardiovascular harms. Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence might make you change your practice?
Until recently, the idea that calcium-containing supplements, which more than half of older adults in the U.S. consume regularly, could be harmful would have seemed absurd. Primary care clinicians have long recommended calcium supplements to reduce the risk of osteoporotic fractures in adults who are unable to meet the Institute of Medicine's Dietary Reference Intakes through diet alone. However, a large prospective study published this week in JAMA Internal Medicine demonstrated a statistically significant association between supplemental calcium (as opposed to dietary calcium) intake and a 20 percent higher relative risk of death from cardiovascular disease in men.
This troubling finding adds to the evidence base that suggests harmful cardiovascular effects of calcium-containing supplements. A timely pair of editorials in the February 1st issue of AFP debates the population-level risk of widespread calcium supplementation. Arguing that this potential risk should be a serious concern, Drs. Ian Reid and Mark Bolland review the results of their previous randomized trial and meta-analysis that found 20 to 30 percent increases in the incidence of acute myocardial infarction in adults taking calcium supplements. In their view, these adverse effects are not worth the potential benefits to bone health:
In both of our meta-analyses, calcium supplementation was more likely to cause vascular events than to prevent fractures. Therefore, the bolus administration of this micronutrient should be abandoned in most circumstances, and patients should be encouraged to obtain their calcium intake from an appropriately balanced diet. For those at high risk of fracture, effective interventions with a fully documented safety profile superior to that of calcium are available. We should return to seeing calcium as an important component of a balanced diet and not as a low-cost panacea to postmenopausal bone loss.
In the second editorial, Dr. Rajib Bhattacharya points out that the Women's Health Initiative and other randomized trials did not indicate that calcium supplements increased cardiovascular risk. He argues that secondary analyses of trials designed with other primary outcomes in mind may have predisposed these analyses to unforeseen bias, and that there is "no compelling evidence" that calcium supplements at usual doses pose dangers to heart health.
Notably, a draft recommendation statement released by the U.S. Preventive Services Task Force last June stated that there was insufficient evidence that vitamin D and calcium supplementation prevent fractures or cancer in otherwise healthy older adults. Although the only adverse effects of supplements mentioned in the Task Force's evidence review were renal and urinary tract stones, none of the reviewed studies were specifically designed to assess cardiovascular harms. Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence might make you change your practice?
Jumat, 25 Januari 2013
Providing culturally competent health care
- Kenny Lin, MD
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. As a previous article in American Family Physician observed, patients' beliefs regarding health and disease causation may pose obstacles to communication even when physicians and patients speak the same language. Using medical interpreters is another skill that takes practice to achieve proficiency, but has clear benefits, according to the author of a Curbside Consultation: "The skills of a medical interpreter or translator include cultural sensitivity and awareness of and respect for all parties, as well as mastery of medical and colloquial terminology, which make possible conditions of mutual trust and accurate communication that lead to effective provision of medical health services."
In the review article "Caring for Latino Patients" in the January 1st issue of AFP, Dr. Gregory Juckett notes that this population faces a number of special medical concerns:
Approximately 43 percent of Mexican Americans older than 20 years are obese, compared with 33 percent of the non-Latino white population. Diabetes and hypertension are closely linked with obesity; 11.8 percent of Latinos older than 20 years have type 2 diabetes (13.3 percent of Mexican Americans), making it the foremost health issue in this population. A higher-calorie diet, a more sedentary lifestyle, and genetic factors contribute to this problem. Because of less access to health care, Latinos with diabetes are often diagnosed later and have a greater risk of complications.
To navigate and resolve cultural differences that may impede understanding and effective treatment, Dr. Juckett advises that clinicians use the LEARN technique for cross-cultural interviewing:
1. Listen sympathetically to the patient's perception of the problem,
2. Explain his or her perception of the problem to the patient,
3. Acknowledge and discuss any differences and similarities between the two views,
4. Recommend a treatment plan, and
5. Negotiate agreement.
For practices that see sizable numbers of Latino patients, the article also includes a helpful list of strategies for creating a culturally sensitive office environment.
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. As a previous article in American Family Physician observed, patients' beliefs regarding health and disease causation may pose obstacles to communication even when physicians and patients speak the same language. Using medical interpreters is another skill that takes practice to achieve proficiency, but has clear benefits, according to the author of a Curbside Consultation: "The skills of a medical interpreter or translator include cultural sensitivity and awareness of and respect for all parties, as well as mastery of medical and colloquial terminology, which make possible conditions of mutual trust and accurate communication that lead to effective provision of medical health services."
In the review article "Caring for Latino Patients" in the January 1st issue of AFP, Dr. Gregory Juckett notes that this population faces a number of special medical concerns:
Approximately 43 percent of Mexican Americans older than 20 years are obese, compared with 33 percent of the non-Latino white population. Diabetes and hypertension are closely linked with obesity; 11.8 percent of Latinos older than 20 years have type 2 diabetes (13.3 percent of Mexican Americans), making it the foremost health issue in this population. A higher-calorie diet, a more sedentary lifestyle, and genetic factors contribute to this problem. Because of less access to health care, Latinos with diabetes are often diagnosed later and have a greater risk of complications.
To navigate and resolve cultural differences that may impede understanding and effective treatment, Dr. Juckett advises that clinicians use the LEARN technique for cross-cultural interviewing:
1. Listen sympathetically to the patient's perception of the problem,
2. Explain his or her perception of the problem to the patient,
3. Acknowledge and discuss any differences and similarities between the two views,
4. Recommend a treatment plan, and
5. Negotiate agreement.
For practices that see sizable numbers of Latino patients, the article also includes a helpful list of strategies for creating a culturally sensitive office environment.
Selasa, 15 Januari 2013
Is there a looming family physician shortage, or not?
- Kenny Lin, MD
Researchers at the American Academy of Family Physicians' Robert Graham Center (which produces the Policy One-Pagers series for AFP) recently predicted in the Annals of Family Medicine that a combination of population growth, aging, and insurance expansion from the Affordable Care Act will create the need for an additional 52,000 primary care physicians by the year 2025 - an increase of nearly 25 percent over the current workforce. Since the vast majority of internal medicine residents plan to pursue subspecialty rather than generalist careers, family medicine will be called on to supply the bulk of this looming gap in physician supply and demand. Recent efforts to increase the supply of family physicians include emphasizing community-based clinical training in medical school and temporarily increasing Medicaid and Medicare primary care fees.
Another strategy for bolstering the family medicine pipeline, contained in the Affordable Care Act, is mandating redistribution of unused residency positions to primary care programs. Unfortunately, an analysis published this month in Health Affairs concluded that a similar Medicare graduate medical education reform in 2005 not only failed to significantly boost primary care, but actually resulted in training twice as many new subspecialists. Dr. Candace Chen and colleagues conclude:
Our findings suggest that redistribution [of unused residency positions] largely supported hospitals in growing their specialty training. Some hospitals even converted primary care positions to specialty positions after receiving newly redistributed positions. ... This shifting collectively perpetuates the nation's physician workforce maldistribution, and our analysis demonstrates that Medicare continues to support these hospitals and even increases its support for them, regardless of the specialty mix of residents trained.
Not everyone agrees that meeting the future health needs of the U.S. population will require a massive influx of family physicians, however. Other researchers have argued that the widespread adoption of team-based care, "advanced access" scheduling, and replacing some in-person with electronic visits could provide enough new patient capacity to prevent a family physician shortage. Still, much uncertainty surrounds this and other projections. What steps is your practice taking, if any, to meet the anticipated needs of so many new patients? Hiring more physicians? Re-designing how you provide care? Please feel free to share your stories.
Researchers at the American Academy of Family Physicians' Robert Graham Center (which produces the Policy One-Pagers series for AFP) recently predicted in the Annals of Family Medicine that a combination of population growth, aging, and insurance expansion from the Affordable Care Act will create the need for an additional 52,000 primary care physicians by the year 2025 - an increase of nearly 25 percent over the current workforce. Since the vast majority of internal medicine residents plan to pursue subspecialty rather than generalist careers, family medicine will be called on to supply the bulk of this looming gap in physician supply and demand. Recent efforts to increase the supply of family physicians include emphasizing community-based clinical training in medical school and temporarily increasing Medicaid and Medicare primary care fees.
Another strategy for bolstering the family medicine pipeline, contained in the Affordable Care Act, is mandating redistribution of unused residency positions to primary care programs. Unfortunately, an analysis published this month in Health Affairs concluded that a similar Medicare graduate medical education reform in 2005 not only failed to significantly boost primary care, but actually resulted in training twice as many new subspecialists. Dr. Candace Chen and colleagues conclude:
Our findings suggest that redistribution [of unused residency positions] largely supported hospitals in growing their specialty training. Some hospitals even converted primary care positions to specialty positions after receiving newly redistributed positions. ... This shifting collectively perpetuates the nation's physician workforce maldistribution, and our analysis demonstrates that Medicare continues to support these hospitals and even increases its support for them, regardless of the specialty mix of residents trained.
Not everyone agrees that meeting the future health needs of the U.S. population will require a massive influx of family physicians, however. Other researchers have argued that the widespread adoption of team-based care, "advanced access" scheduling, and replacing some in-person with electronic visits could provide enough new patient capacity to prevent a family physician shortage. Still, much uncertainty surrounds this and other projections. What steps is your practice taking, if any, to meet the anticipated needs of so many new patients? Hiring more physicians? Re-designing how you provide care? Please feel free to share your stories.
Rabu, 02 Januari 2013
Questioning the need for annual pelvic examinations
- Kenny Lin, MD
New Year, time for women to schedule their annual pelvic examinations? Not so fast. An editorial that accompanies AFP's Jan. 1 cover article on health maintenance in women challenges this longstanding tradition. This is not the first time that this topic has appeared in the journal; a Curbside Consultation published in 2003 raised similar concerns:
My patients seem comfortable when I tell them they don’t need annual Pap smears. Yet, in teaching settings and among colleagues, I often hear the question, “If we’re not doing Paps, shouldn’t we be doing something?” Sexually transmitted infection screening, contraceptive counseling, safe-sex advice, and clinical breast examination are opportunities that are missed if patients don’t come to the office for annual Pap tests.
In their editorial, Drs. Giang Nguyen and Peter Cronholm observe that the reasons that clinicians commonly provide for continuing to perform these "routine" examinations are inconsistent with evidence-based recommendations. Cervical cancer screening should be performed no more often than every 3 years; ovarian cancer screening is ineffective and likely harmful; contraceptive prescriptions need not be preceded by a pelvic examination; and urine samples are highly accurate at detecting asymptomatic sexually transmitted diseases. The authors conclude:
Taking into account the time required for the patient to undress, the time to obtain the necessary equipment, and the time to perform the procedure, a screening pelvic examination can conservatively add an extra 10 minutes to an office encounter. In addition, because many physicians also require a nurse or medical assistant in the room during this examination, there is an opportunity cost associated with the other work that could have been done by the support staff during this time (e.g., stocking supply cabinets, performing immunizations, making phone calls to patients). Given the lack of evidence to support annual pelvic examinations, it would be better for patients if we spend that time addressing screening, counseling, and other preventive services for which strong evidence exists.
Although evidence supporting an unequivocal benefit of routine examinations (pelvic examination or no) remains elusive, many effective clinical preventive services for women can be provided at health maintenance-oriented visits or in the context of care for other health concerns. The review and patient education handout by Dr. Margaret Riley and colleagues, along with additional content in the AFP By Topic collection on Health Maintenance and Counseling, provide excellent summaries of these services.
New Year, time for women to schedule their annual pelvic examinations? Not so fast. An editorial that accompanies AFP's Jan. 1 cover article on health maintenance in women challenges this longstanding tradition. This is not the first time that this topic has appeared in the journal; a Curbside Consultation published in 2003 raised similar concerns:
My patients seem comfortable when I tell them they don’t need annual Pap smears. Yet, in teaching settings and among colleagues, I often hear the question, “If we’re not doing Paps, shouldn’t we be doing something?” Sexually transmitted infection screening, contraceptive counseling, safe-sex advice, and clinical breast examination are opportunities that are missed if patients don’t come to the office for annual Pap tests.
In their editorial, Drs. Giang Nguyen and Peter Cronholm observe that the reasons that clinicians commonly provide for continuing to perform these "routine" examinations are inconsistent with evidence-based recommendations. Cervical cancer screening should be performed no more often than every 3 years; ovarian cancer screening is ineffective and likely harmful; contraceptive prescriptions need not be preceded by a pelvic examination; and urine samples are highly accurate at detecting asymptomatic sexually transmitted diseases. The authors conclude:
Taking into account the time required for the patient to undress, the time to obtain the necessary equipment, and the time to perform the procedure, a screening pelvic examination can conservatively add an extra 10 minutes to an office encounter. In addition, because many physicians also require a nurse or medical assistant in the room during this examination, there is an opportunity cost associated with the other work that could have been done by the support staff during this time (e.g., stocking supply cabinets, performing immunizations, making phone calls to patients). Given the lack of evidence to support annual pelvic examinations, it would be better for patients if we spend that time addressing screening, counseling, and other preventive services for which strong evidence exists.
Although evidence supporting an unequivocal benefit of routine examinations (pelvic examination or no) remains elusive, many effective clinical preventive services for women can be provided at health maintenance-oriented visits or in the context of care for other health concerns. The review and patient education handout by Dr. Margaret Riley and colleagues, along with additional content in the AFP By Topic collection on Health Maintenance and Counseling, provide excellent summaries of these services.
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