Tuesday, December 16, 2014

What should doctors do at well-child visits?

- Kenny Lin, MD, MPH

As a family physician who provides care to children, and as a father of four ranging in age from 6 months to 8 years, I have a professional and personal interest in the content of well-child visits beyond childhood immunizations. Not only can health maintenance and counseling vary from practice to practice, previous reviews have found large gaps in the evidence to support preventive services recommended by government health agencies and medical groups. Also, clinicians who compare the Bright Futures / American Academy of Pediatrics "Recommendations for Preventive Pediatric Health Care" to the clinical recommendations for children published by the American Academy of Family Physicians (AAFP) will find that groups sometimes disagree about which services should be offered at well-child visits.

To provide perspective on how the AAFP evaluates evidence regarding the net benefit of individual preventive services in children, I recently wrote an editorial in American Family Physician that reviewed the guideline process and discussed why there is insufficient evidence to recommend screening children for autism spectrum disorders, high blood pressure, and cholesterol levels. (Note to readers: although I am a member of the Commission on the Health of the Public and Science and verified that this editorial reflects current AAFP recommendations, it should not be considered an official statement of the AAFP.) Here is the bottom line:

Time is a precious clinical resource. Clinicians who spend time delivering unproven or ineffective interventions at health maintenance visits risk “crowding out” effective services. For example, a national survey of family and internal medicine physicians regarding adult well-male examination practices found that physicians spent an average of five minutes discussing prostate-specific antigen screening, but one minute or less each on nutrition and smoking cessation counseling. Similarly, family physicians have limited time at well-child visits and therefore should prioritize preventive services that have strong evidence of net benefit.

Monday, December 8, 2014

Desmopressin works for adults with nocturia, too

- Jennifer Middleton, MD, MPH

Desmopressin has been a staple in the treatment of pediatric nocturia for years, and the December 1 issue of AFP reviews a recent systematic review describing desmopressin's effectiveness for adults as well.

The systematic review examined 10 randomized controlled trials (RCTs) of varied quality with approximately 2200 patients in total. The average age of participants ranged from 55-74 years, and men and women were both represented. All of the RCTs compared desmopression to placebo (1 compared desmopression plus furosemide to placebo).

Here is the decrease in the mean number of voids for each dose:

25 mcg = 0.38 [95% CI 0.09, 0.48] fewer voids/night
50 mcg = 0.44 [95% CI 0.16, 0.72] fewer voids/night
100 mcg = 0.72 [95% CI 0.48, 0.96] fewer voids/night

And, here is the increase in time until first waking to void:
"low dose" (less than 100 mcg) = 42.18 more minutes [95% CI 19.94, 64.42]
"high dose" (100 mg or higher) = 68.30 more minutes  [95% CI 39.42, 97.17]

Desmopressin does reduce nocturia, and it is a reasonable option to offer adult patients. The included RCTs did not, however, assess participant satisfaction. Did participants feel more rested the next morning? Was their quality of sleep better? How about their quality of life? Is an extra 42-68 minutes of sleep before waking up to go to the bathroom meaningful to patients? Without participant satisfaction studies, physicians are left to interpret for themselves the clinical significance of this data.

After all, statistical significance doesn't always equal clinical significance. To the authors' credit, they broach these same questions in their discussion section. Studies looking specifically at participant satisfaction could aid patient-physician decision making. Using desmopression may involve some patient-centered decision making; physicians may choose to share the above data with patients, perhaps also with the number needed to harm (NNH) of 20 for the side effect of hyponatremia, and let patients decide if it is worthwhile to give desmopressin a try.

Evidence-based medicine is the intersection of evidence, clinician expertise, and patient preference. Desmopressin decreases nocturia, but will patients be happy with the difference?  The answer will likely vary from patient to patient and from clinician to clinician. There's an AFP article on "Sleep Problems in the Elderly" if you'd like to read more broadly about this topic.

How does your office care for adults with nocturia?

Monday, December 1, 2014

Right-sizing care of patients with serious illnesses

- Kenny Lin, MD, MPH

Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Value Task Force of the American College of Physicians (ACP) recently published a synthesis of best practices on patient-centered communication about serious illness care goals. Although these conversations can sometimes be uncomfortable for clinicians or patients, the authors offered several reasons that they should occur early and often:

An understanding of patients’ care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress.

What clinical situations should trigger discussions about end-of-life preferences? The authors recommended making time for a conversation in the setting of worsening symptoms or frequent hospitalizations in patients with COPD, congestive heart failure, and end-stage renal disease; in all patients with non-small cell lung cancer, pancreatic cancer, and glioblastoma; in patients older than 70 years with acute myelogenous leukemia; in patients receiving third-line chemotherapy; and in hospitalized patients older than 80 years. The ePrognosis website offers useful tools for clinicians to estimate prognoses in older persons with serious illnesses.

According to the ACP, key elements to address in these conversations include understanding of prognosis; decision making and information preferences; prognostic disclosure; patient goals; patient fears; acceptable function; trade-offs; and family involvement. Additional guidance for discussing end-of-life care and eliciting patient preferences has been published in American Family Physician and Family Practice Management. Previous AFP Community Blog posts have also discussed misconceptions about palliative careprogressive disability in older adults, and gaps in end-of-life planning.

Monday, November 24, 2014

USPSTF: strategies to stop smoking initiation of moderate benefit

- Jennifer Middleton, MD, MPH

We have an impressive array of medical technology to diagnose and treat tobacco-related illness, but we should not let that technology keep us from the vital task of stopping people from smoking before they start. Last week on the AFP Community Blog, Dr. Lin wrote about shared decision making regarding low-dose CT screening for lung cancer in current and former smokers. He quoted Dr. Gates from his November 1st AFP article:

"[C]onvincing persons to quit smoking (or to not start) is far more effective in preventing lung cancer deaths than low-dose CT screening."

Cigarette smoking is linked to hundreds of thousands of deaths in the United States every year, with thousands more afflicted with COPD, cardiovascular disease, or one of the many cancers that smoking can cause. One of the great triumphs of public health in the U.S. has been the dramatic reduction in smoking over the last several decades; in 1965, 42% of US adults smoked tobacco, compared with 19% in 2011 (latest year for which data is available).

19%, however, still leaves still plenty of room for improvement. The benefits to the individuals who never start smoking, as well as the resources saved from not treating the many serious sequelae that can arise from smoking, are innumerable. Most individuals who smoke begin before age 18, making our offices an ideal place to provide counseling to children and teens to keep them from picking up the habit. The USPSTF recently weighed in on the usefulness of office strategies to prevent tobacco initiation among children and adolescents, and the November 15 AFP issue reviews this new "B" recommendation:

"The USPSTF found adequate evidence that behavioral counseling interventions, such as face-to-face or phone interaction with a health care professional, print materials, and computer applications, can reduce the risk of smoking initiation in school-aged children and adolescents."

The first step for clinicians is to assess the adolescent's risk of initiating smoking, the most powerful being parental tobacco use. Other important risk factors include peer smoking, low parental involvement, and exposure to tobacco ads. Medical offices don't have to go to great lengths to provide a meaningful intervention for these at-risk teens; although some of the interventions the USPSTF studied were quite intensive, even pre-printed anti-tobacco messages decreased tobacco initiation in one study. 

We can all have a role to play in stopping the initiation of tobacco use in children and adolescents. You can get more ideas, along with patient education materials, at the AFP By Topic for Tobacco Abuse and Dependence. If every family physician's office in the U.S. adopted one or more of these interventions, how many cases of COPD, cardiovascular disease, and cancer might we prevent?

How does your office discourage smoking among the kids and teens that you care for?

Tuesday, November 18, 2014

Shared decision-making for lung cancer screening: will it work?

- Kenny Lin, MD, MPH

Last week, the Centers for Medicare & Medicaid Services (CMS) officially proposed coverage for annual low-dose computed tomography (LDCT) screening for lung cancer in current or former smokers age 55 to 74 years with at least a 30 pack-year history. In doing so, CMS followed the lead of the U.S. Preventive Services Task Force, which had previously given a "B" grade recommendation for screening in a similar population through age 80 years.

In the November 1st American Family Physician cover article, Dr. Thomas Gates reviewed concepts and controversies in cancer screening. Dr. Gates observed that in the 1960s and 1970s, physicians were misled by lead-time and length-time bias into believing that screening smokers for lung cancer with chest radiography saved lives, when in fact, it did not. He also noted that although LDCT screening has reduced lung cancer and all-cause mortality in a randomized controlled trial, adverse effects include a high false-positive rate, uncertain harms from radiation exposure, and overdiagnosis (leading to potentially unnecessary treatment). For these reasons, the American Academy of Family Physicians decided not to endorse the USPSTF recommendation. In an editorial published earlier this year, AFP Contributing Editor Dean Seehusen, MD, MPH elaborated on arguments against routine LDCT screening.

Notably, CMS has proposed to pay for not only the LDCT itself, but also for a "counseling and shared decision making visit" with a physician to review benefits and harms of lung cancer screening and emphasize smoking cessation (in current smokers) and continued smoking abstinence (in ex-smokers). This element is critical, as Dr. Gates observed in his article:

Perhaps the most important issue with low-dose CT screening is that it is a costly, high-tech response to what is essentially a behavioral and lifestyle problem. Smoking is responsible for 85% of lung cancers; convincing persons to quit smoking (or to not start) is far more effective in preventing lung cancer deaths than low-dose CT screening.

Shared decision-making is increasingly recommended by screening guidelines, but I worry that these difficult discussions may not actually take place, even if family physicians are paid to initiate them with patients eligible for LDCT screening. Will clinicians merely go through the motions and just order the test, as happened with prostate-specific antigen testing for prostate cancer and screening mammography for women in their 40s? What do you think?

Monday, November 10, 2014

Bronchodilators don't help bronchiolitis

- Jennifer Middleton, MD, MPH

Autumn brings the start of another Respiratory Syncytial Virus (RSV) season in the U.S., a virus that can cause bronchiolitis in younger children. The wheezing - and sometimes decreased oxygen saturation - of bronchiolitis can be scary for parents and physicians alike; since bronchodilators like albuterol help many older kids and adults with wheezing, it seems intuitive that they would help bronchiolitis as well. The November 1 issue of AFP discusses a Cochrane update, however, demonstrating that bronchodilators don't improve outcomes in most kids aged less than 2 years with bronchiolitis.

The Cochrane reviewers found that, in children less than 24 months old with bronchiolitis who were wheezing for the first time, bronchodilators didn't improve oxygen saturation, didn't keep children in the Emergency Department from getting admitted to the hospital, and didn't reduce the length of stay in children already admitted to the hospital. Unfortunately, bronchodilators also caused harm; children who received them were more likely to have tachycardia and decreased oxygen saturation.

It can be frustrating to see child suffering with bronchiolitis and not be able to offer treatment with a medication, but a recent AFP article on RSV infection reinforces that no studied pharmaceutical interventions have demonstrated a meaningful impact on patient-oriented outcomes. Hydration and supplemental oxygen remain the treatments of choice for the more than 90,000 children admitted with bronchiolitis in the U.S. every year; fewer children are being admitted in recent years than in the past, but the children who are being admitted are more likely to have high-risk conditions and require mechanical ventilation.

  1. Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.
  2. Don't routinely use bronchodilators in children with bronchiolitis.
  3. Don't use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.

Will this Cochrane review change how you treat young children with bronchiolitis?