First, do no harm: preventing elective inductions before 39 weeks

A recent article published in the Journal of the American Board of Family Medicine reported that fewer than 1 in 5 board-certified family physicians provide routine prenatal care, and just over 13 percent perform deliveries. Therefore, more family physicians are referring patients for maternity care and have less influence over troubling national trends, such as declining rates of vaginal births after previous Cesarean delivery (VBAC) and increasing rates of "late" premature delivery (between 34 and 38 6/7ths weeks gestation) due for the most part to elective inductions.

In an editorial in the December 15th issue of AFP, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:

The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.

If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.

Screening mammography decisions are close calls

A physician reader of AFP submitted the following post.

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I read with interest the December 1st Cochrane for Clinicians article by Dr. Joanne Wilkinson, "Effect of Mammography on Breast Cancer Mortality." On the first page of the article in big print is the "Evidence-Based Answer," which gives a SORT "A" recommendation in favor of mammography because of an approximate 15% reduction in mortality from breast cancer attributed to mammography screening. In small print inside are the conclusions from the Cochrane abstract, which note a 30% rate of overdiagnosis and overtreatment. The Cochrane authors write:

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. It is not clear whether screening does more good than harm.

Having read this - I wonder how many women would continue to opt for regular mammography screening if told that only 1 out of every 2,000 will benefit, whereas 10 out of 2,000 will be overtreated (some presumably with mastectomy), and 200 out of 2,000 (10%) will be temporarily overdiagnosed (and subject to important psychological distress for many months) because of a false-positive mammography reading. Given these statistics, observers outside of the medical community might wonder why "primary care physicians should continue to recommend mammography every two years in women 50 to 74 years of age," as the last paragraph of Dr. Wilkinson's commentary states.

As in much that the primary care clinician does, there are pros and cons to any intervention. For patients to give truly informed consent, it is essential for us to convey to them the numerical chance for life-prolonging benefit (1 in 2,000 for women who undergo yearly mammography for a decade) versus the 1 in 10 risk of a falsely positive mammogram report, and the 1 in 200 risk of overtreatment during that 10-year period. For some women who subscribe to the "n of 1" theory, screening mammography may be worth the risk, effort and cost because of the chance that it may save their lives. Others may decide that the odds of experiencing benefit are not in their favor. Shouldn't the choice to undergo mammography be up to the patient?

Ken Grauer, MD
Gainesville, Florida
http://ecg-interpretation.blogspot.com/

AFP By Topic is your 24-7 virtual Scientific Assembly

Since we first introduced AFP By Topic in June 2010, this online and mobile-friendly collection of the journal's best current content selected by AFP's medical editors has grown to include 52 topics that family physicians and other primary care clinicians commonly diagnose and treat in their patients. Recently, we compared the list of AFP By Topic collections to the most popular sessions at the 2011 American Academy of Family Physicians' Scientific Assembly in Orlando, Fla. Of the clinical subjects of 13 non-plenary sessions with an attendance of at least 500 physicians, 10 regularly rank among our most widely viewed topic collections, encompassing a diverse spectrum of acute (e.g., abdominal pain, pulmonary embolism) and chronic (e.g., diabetes, kidney disease, hyperlipidemia) health conditions.

Also at the Scientific Assembly, David T. Walsworth, MD, gave a presentation titled “Medical Applications: Finding the Right App for That." In his presentation, Dr. Walsworth discussed the utility of mobile devices and tablets, including the many uses for related apps in a family physician’s day-to-day practice. Some of the criteria he uses in appraising a medical app include asking the following questions: Does the app do something that I will use frequently? Do I trust the source? and Does the value justify the cost? Ranking highly on all of these criteria, the free AFP By Topic Mobile App not only made his personal Top Ten list, but came in at number 2!

Whether you access AFP By Topic collections on the Web or your mobile device, content links are updated continually to ensure that they remain as current and as useful as possible. The collections include pertinent AFP articles and departments, summaries of practice guidelines from major medical organizations, articles from Family Practice Management, and the AAFP's METRIC practice improvement modules. In short, we aim for AFP By Topic to be your 24-7 virtual Scientific Assembly. Please let us know how we're doing.

Managing symptoms in end-of-life care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of AFP, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care. A collection of previous Cochrane for Clinicians articles is also available online.

Universal cholesterol screening in children: what is the evidence?

New guidelines released today by the American Academy of Pediatrics and the National Heart, Lung, and Blood Institute recommend replacing risk-based approaches to cholesterol testing with universal screening for all children at ages 9 and 17. To inform the debate that is sure to follow, we note that AFP has previously published commentaries that review the potential benefits and harms of different screening strategies. Below is our blog post on this topic from September 1, 2010.

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The September 1 issue of American Family Physician inaugurates a new editorial feature that presents two opposing views on a controversial clinical topic and asks readers to post comments online. In this issue, Dr. Robert Gauer argues that because atherosclerosis begins in childhood, using cholesterol-lowering drugs in children with hyperlipidemia is essential to prevent coronary events and cardiovascular mortality in later life. On the other hand, Dr. Michael LeFevre contends that since only 40 to 55 percent of children with elevated cholesterol levels will have persistent hyperlipidemia as adults, and the potential benefits and harms of decades of drug therapy are unknown, physicians should demand a high "evidence bar" for instituting screening and treatment.

Since hyperlipidemia causes no symptoms, these views reflect in large part the dueling guidelines of the American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) on lipid screening in children. While the AAP recommends that screening for hyperlipidemia begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors, the USPSTF found insufficient evidence to recommend for or against screening in any group of children. [Editorial note: the AAP now recommends universal, rather than targeted, screening.]

This leaves family physicians and other clinicians who care for children with an important clinical dilemma. Should they act now based on disease-oriented evidence and extrapolation from studies of primary prevention of cardiovascular disease in adults, or should they instead wait for patient-oriented evidence from long-term followup studies of children with elevated lipid levels? Which approach do you take in your practice, and why? You are welcome to post comments here or on AFP's Facebook page; AAFP members can also post comments on the AFP web page. We look forward to the discussion!

Graham Center: Integrate mental health into primary care

Based in part on a positive recommendation from the U.S. Preventive Services Task Force, the Centers for Medicare and Medicaid Services recently announced that it will cover annual depression screenings for Medicare patients in primary care settings "that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up." However, as the below Figure illustrates, translating the USPSTF guideline into practice has been challenging for many primary care physicians.

A Policy One-Pager from researchers at the Robert Graham Center, published in the November 1st issue of AFP, details the obstacles that clinicians face in identifying and treating depression and other mental health problems. As Dr. Robert Phillips and colleagues observe, "Current health care policy makes it difficult for most primary care practices to integrate mental health staff because of insufficient reimbursement, mental health insurance carve-outs, and difficulty of supporting colocated mental health professionals, to name a few."

On a related note, an editorial in the November 1st issue discusses strategies for improving adult immunization rates, which have historically lagged far behind rates of immunizations in children. According to Dr. Alicia Appel, immunization registries and electronic clinical decision-support systems can complement low-tech interventions such as patient reminders and standing orders. What has been your experience with incorporating depression screening and immunizations into routine care for adult patients?

ACIP recommends routine use of HPV vaccine in boys

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices voted earlier this morning to recommend that boys be routinely vaccinated against human papillomavirus (HPV). With this new recommendation, the cervical cancer-preventing vaccine that the AAFP's ACIP liaison Johnathan Temte, MD, PhD has called a "cornerstone of female health" is now poised to be incorporated into the ACIP's childhood vaccination schedule for boys as well. Previously, the advisory group had taken a "permissive" stance toward HPV vaccine in boys, noting that it could be administered to prevent genital warts but not recommending it routinely.

Important AFP online content on HPV infection includes a recent clinical overview of its manifestations, testing, and prevention; and short drug reviews of the quadrivalent and bivalent vaccines. The latter review notes that the bivalent vaccine "does not protect against the two strains of HPV responsible for genital warts and is of no value in males."

What do you think of the new ACIP recommendation, especially in light of recent political controversies over HPV vaccine mandates? Have you been following the ACIP's previous recommendation to routinely administer HPV vaccine to girls, and if so, do you now plan to do so with boys? We would love to hear your thoughts.