Aspirin for primary CVD prevention: the continuing debate

In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that primary care clinicians discuss preventive aspirin use with adults at increased risk of cardiovascular events. Four years later, the National Commission on Prevention Priorities (NCPP) ranked counseling for aspirin use the number one priority on its list of the most effective clinical preventive services. According to the NCPP, if the percentage of eligible patients using aspirin (then estimated to be about 50 percent) increased to 90 percent, 45,000 additional lives could be extended each year.

At that time, the benefits of aspirin use in men and women were assumed to be the same. However, an updated USPSTF recommendation statement published in the June 15th issue of AFP indicates that aspirin use actually prevents heart attacks in men, but ischemic strokes in women. In addition, physicians and patients must weigh the benefits of reduced cardiovascular risk with the risk of gastrointestinal bleeding events, and use shared decision making when these risks are closely balanced.

To further complicate matters, a 2009 meta-analysis published in the journal The Lancet questioned the value of aspirin for primary prevention, concluding that for patients who without a history of cardiovascular disease, "aspirin is of uncertain net value." In response, family physicians and USPSTF members Ned Calonge and Michael LeFevre wrote an editorial that concluded, "There is not a simple message for aspirin prophylaxis as a primary preventive strategy, and we need to consider gender, age, and the associated balance of potential risks and benefits to provide the best advice and preventive care for our patients."

We pick up the continuing debate with two thought-provoking editorials in the June 15th issue. Alison L. Bailey and colleagues caution that routine aspirin use is not justified for primary prevention in adults at low risk of CVD. On the other hand, W. Fred Miser asserts that the main issue regarding aspirin for primary prevention continues to be underuse in appropriate-risk patients. Finally, a Putting Prevention Into Practice case study applies information from the USPSTF recommendation to a sample patient scenario.

FP Blog Roundup: Remembering Barbara Starfield

The recent passing of legendary primary care researcher Barbara Starfield, MD, MPH was the subject of many Family Medicine blog posts this week. At Medicine and Social Justice, Josh Freeman, MD called Dr. Starfield "the pre-eminent scholar on health workforce policy." At Family Medicine Rocks, Mike Sevilla, MD posted a video of her receiving the Family Medicine Education Consortium's Lifetime Achievement Award and commented on the surprising silence from family medicine organizations about Dr. Starfield, who, though a pediatrician by training, "gave this specialty [of family medicine] a voice." Finally, at The Singing Pen of Doctor Jen, Jennifer Middleton, MD, MPH pondered, "With all of the national chatter about [unsustainable] heath care costs, why hasn't the media broadcasted the message of primary care's cost-saving and health-prolonging benefits?"

Through her research, Dr. Starfield did more than perhaps any other individual to establish the essential role of family medicine in improving population health outcomes in the U.S. and abroad. In a 2009 interview for AAFP News Now, she observed:

The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality. [This] is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. Primary care everywhere in the world is most of the care, for most of the people, most of the time. We have done a reasonably good job at making subspecialty care available, but a lot of subspecialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily. If we followed what the evidence shows, we could do a whole lot better with a much better infrastructure of what we call primary health care.

Earlier that year, in a provocative editorial published in Family Practice Managment, Dr. Starfield had argued that the timeless principles of family medicine - first-contact care; comprehensive care; person-focused care over time; and care coordination - should be driving practice reforms such as the Patient-Centered Medical Home, rather than the other way around. To honor Dr. Starfield's career, Health Affairs is offering free access until June 28th to four landmark articles that she previously wrote in their journal.

Evaluation and management of heat-related illness

Last July, a record-breaking heat wave affected most of the Northern Hemisphere and led to many cases of heat-related illness in the U.S. and abroad. As the summer of 2011 approaches, Drs. Jonathan Becker and Lynsey Stewart from the University of Louisville, Kentucky present an updated review of the evaluation and management of heat cramps, heat exhaustion, and heat stroke in the June 1st issue of AFP. In addition to using the suggested evaluation algorithm, family physicians should also be aware of the many conditions and substances that may increase the risk of heat-related illness. As the authors note, heat stroke is a true medical emergency that requires immediate assessment and lowering of core body temperature, preferably through cold water immersion.

Addressing family medicine's "Top 5" list

Last week, the journal Archives of Internal Medicine published "The 'Top 5' Lists in Primary Care," a physician-authored consensus statement that recommended five activities each for the specialties of family medicine, internal medicine, and pediatrics to pursue to reduce waste and improve quality. Here is the top 5 list for family physicians, together with related online resources from AFP By Topic collections:

1) Don't do imaging for low back pain within the first 6 weeks unless "red flags" are present.

AFP By Topic: Muculoskeletal Care - Neck and Back

2) Don't routinely prescribe antibiotics for acute sinusitis.

AFP By Topic: Upper Respiratory Tract Infections - Treatment

3) Don't order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients.

AFP By Topic: Coronary Artery Disease - Screening and Diagnosis

4) Don't perform Pap tests on women younger than 21 years or in women status post hysterectomy for benign disease.

AFP By Topic: Cancer - Cervical Cancer

5) Don't use DEXA screening for osteoporosis in women under age 65 years or in men under 70 years with no risk factors.

AFP By Topic: Osteoporosis - Screening and Diagnosis

As a reminder, AFP By Topic is also available as a free mobile app in the Apple Store and the Android Market.

Autism spectrum disorders: increasing prevalence or diagnosis shift?

A physician reader of AFP submitted the following post.

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The recent editorial “The Changing Prevalence of the Autism Spectrum Disorders” in the March 1st issue discusses many of the challenges surrounding autism and the apparent increase in prevalence of this diagnosis. Having spent 30 years as the medical director of a private residential facility for children with developmental disabilities, I have some additional observations to add.

Many years ago, the most common diagnosis at our school was “mental retardation.” Subsequently, this diagnosis fell out of favor and was replaced by “static encephalopathy.” I seldom see these admitting diagnoses any more from referring neurologists and developmental pediatricians. Instead, some children are labeled as having “global developmental delay,” but virtually all children are also diagnosed as being on the autism spectrum. I am convinced that a great deal of what we are seeing in this population is a shift in diagnosis rather than a real change in prevalence.

In the past, children with known genetic disorders such as Down syndrome, Fragile X syndrome, or tuberous sclerosis were excluded from the diagnosis of autism. Now, autism is usually the second or third diagnosis. In my mind, this is like diagnosing a patient with a broken leg as having a gait disturbance. Although it may be technically true, it adds little to the diagnosis. Children with developmental disabilities typically have difficulties with social interaction, communication and behavior. Although some of these behaviors may be similar to those of children with autism, I believe that the supplemental diagnosis is not helpful.

A wide variety of services, including medical assistance, early intervention, and wraparound services, are available to children with autism which are not available to the same children if the diagnosis is mental retardation. I have often encountered parents who insist on the diagnosis of autism for their child even if I believe that the child does not fit in the autistic spectrum, because they want their children to have access to the benefits and services that accompany this diagnosis.

Many children who were previously diagnosed as having minimal brain dysfunction or being emotionally disturbed (or even just considered “odd”) are now rightfully recognized as belonging in the high functioning end of the autistic spectrum. Once again, I believe much of the increase in prevalence we are seeing is diagnosis shift.

Richard G. Fried, MD

The Camphill Special School

Glenmoore, PA

CME that makes a difference in patients' lives

Surveys of American Family Physician's readers and website visitors have consistently reported that the journal contains useful, evidence-based information that is applicable to daily practice. But as valuable as AFP is for providing continuing medical education to clinicians, does it actually save patients' lives? That's the question that primary care researchers from Sweden asked about a specific CME intervention in this month's issue of Annals of Family Medicine. Dr. Anna Kiessling and colleagues conducted a randomized trial comparing long-term outcomes in patients with coronary heart disease who received care from generalist physicians who attended repeated case-based trainings in the management of hyperlipidemia, or received usual care. Ten years later, the results were clear: the overall mortality rate in the intervention group (22%) was half of the mortality rate in the control group (44%).

The editors of AFP would like to believe that our online collections of selected content on topics such as hyperlipidemia, hypertension, and coronary artery disease have similar lifesaving benefits for your patients, but the truth is, we don't know. So how can we find out? As recently reported in AAFP News Now, journal CME quizzes for content published after the July 1st issue must be submitted online only, in order to meet new AMA requirements regarding CME credit. Although this will be a change for many readers, it presents an opportunity to think about how we might redesign CME content to better meet physicians' needs and improve measurable outcomes for their patients. If you have any thoughts or suggestions, please post them in a comment or send an e-mail to afpedit@aafp.org.

Can inappropriate MRI use be stopped?

A physician reader of AFP submitted the following post.

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I enjoyed reading and cannot agree more with the editorial in the April 15, 2011 issue on the appropriate use of magnetic resonance imaging for evaluating common musculoskeletal conditions. In many ways, the overuse of MRI is like the overuse of antibiotics for viral syndromes. Everyone knows we shouldn’t do it, but nobody seems to be able to stop.

Almost every specialist I refer to orders an MRI, often requiring them before they will even schedule a consult. Patients come in demanding an MRI after watching a professional sports event in which the sideline reporter let folks know what the MRI showed on the star who was injured during the game.

I’ve had many patients come in letting me know that their personal trainer, therapist, or next door neighbor as well as their neurologist, chiropractor or other health care professional had advised them to come in and request an MRI.

The radiologists where I practice review all MRI requests for appropriateness based on the clinical history and reported physical findings. This review process has significantly cut down on the number of MRIs that are being done at our facility, although the number of complaints has risen. In contrast, there are no financial disincentives to performing inappropriate MRIs in fee-for-service health systems.

William T. Sheahan, MD
Orlando VA Medical Center
Orlando, Florida