Monday, December 17, 2018

The top ten AFP Community Blog posts of 2018

- Kenny Lin, MD, MPH

This year's list includes (#1 and #2) two of the top five most-viewed posts since this blog began in 2010. (In case you are wondering, the best-read post of all, on acetaminophen for nasal congestion from the common cold, has been viewed nearly 10,000 times.)

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1. PSA screening: USPSTF recommendations changed, but the evidence did not (October 22) - 3061 views

The first question family physicians ought to ask is: what new evidence compelled the Task Force to move from recommending against PSA screening in all men to determining that there was a small net benefit for screening in some men?

2. Acute Flaccid Myelitis: what family physicians should know (October 29) - 3018 views

Although still quite rare, occurrences of acute flaccid myelitis (AFM), a polio-like condition that results in sudden limb weakness, have been increasing in the United States. Family physicians can aid the CDC's investigation by recognizing AFM's presentation and reporting suspected cases to their local health departments.

3. Guest Post: Practicing what I preach about generic drugs (May 30) - 1152 views

I am a cancer survivor. I am alive today because of the love and support of my family, friends, and co-workers. I am alive because of the incredible doctors and medical staff at Walter Reed. I am also alive because of generic drugs. Generic drugs saved my life.

4. For hypertension and diabetes, lower treatment targets not necessarily better (March 21) - 891 views

Primary care clinicians often chose to intensify glycemic control in an older adult with a HbA1c level of 7.5% and multiple life-limiting comorbidities. As family physicians look for opportunities to improve care for patients with hypertension and diabetes, we should not miss opportunities to avoid harm.

5. Continue to Choose Wisely: updates to the AAFP Choosing Wisely recommendations (September 10) - 806 views

Developed by the AAFP's Commission on Health of the Public and Science, each of these evidence-based recommendations focuses on a practice that is either harmful or has very little supporting evidence of benefit.

6. For mild hypertension in low-risk adults, harms of drug therapy outweigh benefits (November 6) - 712 views

After a median follow-up duration of 5.8 years, there were no differences in all-cause mortality, stroke, myocardial infarction, acute coronary syndrome, or heart failure. However, the treated group had an increased risk of hypotension (number needed to harm = 41 at 10 years), syncope (NNH = 35), electrolyte abnormalities (NNH = 111), and acute kidney injury (NNH = 91).

7. Summer travel tips for you and your patients (June 18) - 667 views

Readers of American Family Physician should know about all of the resources available in our archives for prevention and management of medical conditions in travelers, the best of which are included in our Travel Medicine collection.

8. Supporting our patients' health outside of the office (May 7) - 661 views

Our patients' incomes, neighborhoods, and educational levels impact their health at least as much, if not more, than the interventions we discuss with them within our practice settings.

9. Increasing pneumococcal vaccination rates (April 9) - 649 views

In persons with COPD, the number needed to treat (NNT) for pneumococcal vaccination is 21 to avoid an episode of community-acquired pneumonia and 8 to avoid an acute COPD exacerbation.

10. Top research studies of 2017 for primary care practice (April 30) - 589 views

This year's top 20 studies included potentially practice-changing research on cardiovascular disease and hypertension; infections; diabetes and thyroid disease; musculoskeletal conditions; screening; and practice guidelines.

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On behalf of all of us at AFP, happy holidays and many blessings for the New Year.

Monday, December 10, 2018

Creating a welcoming office for LGBTQ patients

- Jennifer Middleton, MD, MPH

The current issue of AFP highlights "Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know" along with an accompanying editorial describing "The Responsibilities of Family Physicians to Our Transgender Patients." Both articles discuss the importance of tangibly demonstrating openness to transgender and gender-diverse persons by displaying "transgender-affirming materials," training staff regarding inclusive language and behavior, and adopting intake forms to offer more than just binary descriptors of "male" or "female." Several additional resources are available to family physicians to ensure that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals feel comfortable accessing healthcare in our offices.

The American Medical Association's Population Care website includes a page on creating an LGBT-friendly practice. The AMA emphasizes providing visual clues that your office is LGBTQ-friendly such as brochures, posters, and a nondiscrimination statement. There's a link to a podcast with more suggestions and information about listing your practice in the Gay and Lesbian Medical Association (GLMA) Provider Directory.

The United States Department of Health and Human Services' Adolescent Health website includes a section on Ensuring Inclusivity of of LGBTQ Youth. Their resources focus on inclusivity regarding contraception access and teen pregnancy prevention efforts. One handout stresses that "sexual identity is separate from sexual behavior" and cites data that LGBTQ teens are at higher risk of pregnancy than their heterosexual, cisgender peers.

Your office might also consider participating in a "Safe Zone" training session, described in more detail at the Safe Zone Project's website. LGBTQ individuals may seek out signs such as a "Safe Zone" emblem as a visual clue that they are in an accepting and affirming healthcare site.

We cannot deliver the best care to our communities if some members of our communities feel unsafe entering our offices. Educating ourselves - and our residents - is essential. The AAFP has a curriculum guide for family medicine residencies on Lesbian, Gay, Bisexual, and Transgender Health, citing data that the majority of family medicine residents rate their training on LGBTQ health as "fair or poor."  The AFP By Topic on Care of Special Populations also includes a subheading on Gay, Lesbian, Bisexual, and Transgendered Persons if you'd like to read more as well.

Tuesday, December 4, 2018

Improving care transitions for formerly incarcerated patients

- Kenny Lin, MD, MPH

A young man with schizophrenia, opioid use disorder (OUD) and chronic hepatitis C infection recently completed a 5-year prison sentence and was discharged back into the community. While he was incarcerated, he received antipsychotic medications and periodic laboratory monitoring of his liver disease; medication-assisted treatment for OUD was unavailable. At the time of his release, he was given a 30-day supply of pills and told to follow up with a primary care physician. The next few weeks will be a critical time for this patient's health, according to an article on care of incarcerated patients in the November 15th issue of American Family Physician:

Most inmates are discharged from correctional facilities without a supply of medications or referrals to primary care, mental health services, or substance abuse treatment. Lack of care coordination directly affects the health of former inmates. In the two weeks following release, former inmates are 129 times more likely to die of a drug overdose and 12 times more likely to die of any cause than members of the general public.

Former inmates face two significant obstacles to accessing primary care: affording care, and the reluctance of some clinicians to accept formerly incarcerated patients. Before 2014, an estimated 80 percent of incarcerated persons lacked health insurance or the financial resources to pay for basic health care. Even after the expansion of Medicaid to single and childless adults earning up to 138% of the federal poverty level in 36 states and the District of Columbia, many patients continue to slip through the cracks. A 2016 article in Kaiser Health News recounted the case of Ernest, a man with severe mental illness who served prison time in Indiana for killing his 2 year-old daughter during a psychotic delusion. Even though Indiana had expanded Medicaid by the time of Ernest's release and set up a system to enroll all eligible prisoners, records show that he was forced to enroll in the program on his own, wasting valuable time and delaying his transition of care:

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled. “Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Having health insurance does not necessarily mean that a patient will be able to access care, as illustrated in a recent Canadian study published in the Annals of Family Medicine. Researchers posing as prospective patients telephoned all family physicians listed as accepting new patients in British Columbia. The only difference between the patient roles was that one set mentioned that he or she had been released from prison a few months before. Among the 250 family physicians who answered the phone and were still providing primary care, control patients were twice as likely to be offered an appointment compared to persons recently released from prison (absolute risk difference = 41.8%).

In 2017, the American Academy of Family Physicians published a position paper on Incarceration and Health that suggested "family physicians can promote the health of individuals during the transition from correctional facilities to the community by supporting reentry processes that begin prior to release; collaborations between prison and community health services; integrated models of care; and linkages to housing, employment, and mental health support." To that, I would add that we should not discriminate against patients with a history of incarceration.

Monday, November 26, 2018

The 2018 ACC/AHA cholesterol guidelines: updates for family physicians

- Jennifer Middleton, MD, MPH

The American College of Cardiology (ACC) and American Heart Association (AHA), along with several other specialty organizations, have released a new "Guideline on the Management of Blood Cholesterol." Of note, this multi-specialty collaboration did not include primary care organizations like the American Academy of Family Physicians (AAFP) or the American College of Physicians (ACP); family physicians will find many similarities between this guideline and the 2013 ACC/AHA cholesterol guidelines, but a few changes may further complicate risk assessment and treatment discussions.

There is no change regarding the ACC/AHA's emphasis on lifestyle change as the basis for ASCVD prevention. There are also no changes to the treatment of two patient populations: individuals with clinical atherosclerotic cardiovascular disease (ASCVD) and individuals with serum low density lipoprotein cholesterol (LDL-C) levels greater than 190 mg/dL. For both groups, risk calculation with the ASCVD risk score is unnecessary; prescribe high-intensity (or maximally tolerated) statin therapy.

Recommendations regarding the use of statin medication for the primary prevention of ASCVD in persons with diabetes mellitus (DM) have been slightly revised. Moderate-intensity statin therapy is still recommended, as a starting point, for all patients with DM between the ages of 40-75 years. Previously, an ASCVD risk score greater than or equal to 7.5% was an indication for high-intensity statin therapy in this population; the 2018 guideline expands this recommendation to also include patients with one or more "diabetes-specific risk enhancers" (long duration of DM, albuminuria, eGFR < 60 mL/min, retinopathy, neuropathy, ankle-brachial index < 0.9) regardless of ASCVD risk score.

Perhaps the most complex changes center around those individuals aged 40-75 years who do not have DM and do not have clinical ASCVD. The 2013 guideline stratified these individuals into 2 risk categories, but the 2018 guideline now has 4:

  • Low risk: ASCVD risk score < 5%
  • Borderline risk: ASCVD score 5-7.4%
  • Intermediate risk: ASCVD score 7.5-19.9%
  • High risk: ASCVD score > 20%

Per this new guideline, low risk persons should focus on a healthy lifestyle. Borderline risk persons with one or more "risk enhancers" (see list below*) may consider moderate-intensity statin therapy after risks/benefits discussion with their physician. Intermediate risk persons should initiate moderate-intensity statin therapy if one or more risk enhancers* are present. High risk persons should initiate high-intensity statin therapy.

The 2018 ACC/AHA guideline also emphasizes following patients' LDL-C levels to both confirm adherence to therapy and to maximize benefit. They recommend that moderate-intensity statin therapy should lower LDL-C by 30-49%, and high-intensity statin therapy should lower LDL-C by at least 50%. The sources cited by the guideline to support these recommendations are expert opinion, however, and not randomized controlled trials (RCTs). It remains to be seen if primary care organizations such as the AAFP and ACP will endorse all or some of this guideline, especially this change regarding lipid monitoring.

The 2016 United States Preventive Services Task Force (USPSTF) recommendations regarding statins are similar regarding the benefit of primary prevention of those persons at highest risk (ASCVD risk score > 20%). The task force was less convinced regarding statins' primary prevention benefits among those at lower risk, giving a "B" grade for adults aged 40-75 years with an ASCVD risk score > or equal to 10% and at least one risk factor and a "C" grade for similarly aged adults with an ASCVD risk score between 7.5-9.9% and at least one risk factor. Statin therapy for primary prevention in persons > 75 years of age received an "I" grade, which is reasonably consistent with the 2018 ACC/AHA guideline's statement that "[f]or patients > 75 years of age, RCT evidence for statin therapy is not strong." The USPSTF also pointed out that most of the trials evaluating statins' efficacy in primary prevention enrolled participants based on the presence of risk factors, not based on the results of risk assessment tools.

The 2018 ACC/AHA cholesterol guideline contains much more content including a discussion regarding the use of statins in patients younger than 40 and also recommendations about appropriate candidates for coronary artery calcium scoring. The entire guideline has been published online ahead of print here. This "top 10 points" summary of the guideline may also be of interest. There's an AFP By Topic on Hyperlipidemia if you'd like to read more, which includes this Medicine by the Numbers article on "Statins in Persons at Low Risk of Cardiovascular Disease."

ACC/AHA's ASCVD "risk enhancers" include: family history of premature ASCVD, persistently elevated LDL-C > 160 mg/dL, chronic kidney disease, metabolic syndrome, women with history of pre-eclampsia or premature menopause, history of inflammatory diseases (for example, rheumatoid arthritis, psoriasis, HIV), ethnicity, persistently elevated triglycerides > 175 mg/dL. 

Tuesday, November 20, 2018

Safe outpatient management of low-risk patients with acute pulmonary embolism

- Kenny Lin, MD, MPH

I've practiced family medicine long enough to remember when treatment of any patient with acute deep venous thrombosis (DVT) required hospitalization for several days administering intravenous unfractionated heparin and oral warfarin while waiting for the patient's international normalized ratio (INR) to reach a therapeutic level. Thanks to the development of low molecular-weight heparins and direct-acting oral anticoagulants (DOAC), outpatient treatment of uncomplicated DVT is now the norm. But patients with newly diagnosed pulmonary embolism (PE) are still typically hospitalized, since they often have hemodynamic instability or other potentially life-threatening conditions.

According to a 2017 article in American Family Physician, the American College of Chest Physicians suggests considering outpatient treatment of acute PE "if the risk of nonadherence is low and the patient is clinically stable; has no contraindications to anticoagulation, such as recent bleeding, severe renal or liver disease, or platelet count of less than 70; and feels capable of managing the disease at home." A recent Point-of-Care Guide reviewed clinical decision tools that predict mortality in patients with newly diagnosed PE. The simplified Pulmonary Embolism Severity Index (sPESI) stratifies patients into low and high risk categories. Low risk patients have a 30-day mortality rate of 1%, while high risk patients have a 9% mortality rate.

A prospective cohort study published in CHEST earlier this year enrolled 200 consecutive adults with newly diagnosed PE and a low risk of mortality using the related Pulmonary Embolism Severity Index (PESI). Participants were observed in the emergency department (ED) for 12 to 24 hours, then treated with anticoagulant medications in the outpatient setting (173 patients were treated with DOACs). After 90 days, no patients had died or suffered a recurrent venous thromboembolism (VTE). One patient had a major bleed after a traumatic thigh injury that required a blood transfusion and surgery.

A pragmatic controlled trial in Annals of Internal Medicine evaluated the effect of implementing an electronic clinical decision support system (CDSS) that included the PESI tool and an educational intervention on decision making for patients with acute PE in the 21 community EDs of Kaiser Permanente Northern California. 10 EDs received access to the CDSS and in-person education and feedback from an onsite emergency physician-researcher ("study champion"); the other 11 EDs served as control sites. The primary outcome was discharge to home from the ED or an ED-based outpatient observation unit. At the intervention sites, home discharge increased from 17.4% to 28%, while there were no changes in discharge practices at control sites. The intervention was not associated with increases in 30-day major adverse events (recurrent VTE, major hemorrhage, or all-cause mortality).

One day, one of my trainees will be able to write, "I've practiced family medicine long enough to remember when even low-risk patients with acute PE required hospitalization ..."

Monday, November 12, 2018

Putting the "family" in family physicians' care of children with type 2 diabetes

- Jennifer Middleton, MD, MPH

The current issue of AFP includes a review on Type 2 Diabetes Mellitus in Children, reviewing current guidelines for screening, diagnosis, and treatment. Children with type 2 diabetes mellitus (DM2) have optimal success with their treatment regimens when their families are engaged in their care. This engagement is crucial to success with both lifestyle and pharmacologic treatments.

Improving nutrition and exercise can lower A1Cs and improve clinical outcomes in children with DM2. Physicians can guide these changes by providing dietician referrals, exercise prescriptions, and screen time limits. Just as children and adolescents with DM2 tend to be obese, their families also tend to have similarly elevated body mass indices along with "high fat intake, minimal physical activity, and a high incidence of binge eating." Encouraging the entire family to work together to improve their nutrition and exercise improves the pediatric diabetic patient's chance of success with these changes. 

Sometimes, though, engaging children and families in the office alone is insufficient. Interdisciplinary interventions, such as multi-systemic therapy led by a trained family therapist, lowers A1Cs, reduces hospitalizations, and reduces costs in children with type 1 diabetes mellitus; though these interventions have not been systematically studied in children with DM2, it seems reasonable to assume that they would be similarly effective. Interestingly, parents often under-estimate their children's health-related quality of life; it may be that these interdisciplinary interventions help younger diabetic patients better understand the severity of their disease and, consequently, increase their adherence.

Unfortunately, children initially prescribed only lifestyle change after a DM2 diagnosis rarely succeed at sustained blood sugar improvement; lifestyle measures alone only effect meaningful change in hemoglobin A1C values in 10% of pediatric DM2 patients. As such, the American Academy of Pediatrics recommends that all children be started on metformin, in addition to lifestyle counseling, at the time of diagnosis. Pairing medication taking with daily family routines significantly increases medication adherence, as does multi-systemic therapy as outlined above. Encouraging parents to adopt a more permissive parenting style may be another technique to increase adherence to both lifestyle and medication recommendations; "[y]outh with T2DM who perceive more autonomy (less parental control) in day-to-day and diabetes tasks are more likely to adhere to medication regimens." 

Working collaboratively with families and other disciplines are strengths of our specialty and can greatly benefit our younger patients with DM2. You can read more about DM2 in the AFP By Topic on Diabetes: Type 2, which includes both further reading for physicians and patient resources.