Monday, April 14, 2014

Should we stop dreading the lists patients bring to appointments?

- Jennifer Middleton, MD, MPH

I confess to feeling a little nervous when a patient brings a list to his or her appointment. I admit that it can be helpful at times, but I always get a flutter of irrational fear when I see a patient with one. I'm mostly afraid that the list will be a dozen pages long and/or that this particular patient encounter will be especially lengthy.

A study published in the Journal of Family Practice this month, however, has significantly decreased my anxiety. Researchers at 2 primary care offices in Israel consecutively enrolled patients who had brought a list of concerns and/or issues to their doctor's appointment; for every enrolled patient, the researchers then enrolled a patient who had not brought a list. From their Electronic Health Record (EHR), they obtained basic demographic information on each patient, along with their occupations, disease lists, medication lists, and number of visits to that office in the last year. They also asked patients who had brought a list why they brought it.

They found some differences between the patients who brought a list to their visit and those who did not. For starters, patients who brought a list tended to be older (mean age 63.0 vs 46.7 years) and retired. The patients who brought lists had more chronic medical conditions and had seen their physicians more often in the last year. Women were as likely to bring a list as men, though, and although the list-bringers received more prescriptions for benzodiazepines, the psychiatric histories between the groups was similar; list-bringers were not more likely to suffer from mental illness.

The most common reason patients gave for bringing a list was "a desire to completely satisfy the objectives of the visit." The authors cite a study which showed that lists can improve patient satisfaction without lengthening the visit time. It's not surprising that patients with more complicated medical issues are more likely to use a list. The authors state that patients who bring a list "have no discernible ill intention, and the list serves as a memory aid to help them make the most of the visit."

This study was a small one, though, and may not be generalizable to other countries. The researchers essentially used a convenience sample (whoever showed up to the office that day) and admit that they did not obtain a random sample of the office's patients. I agree with their call for further studies to either refute or confirm their findings. But, despite its limitations, this study still has me rethinking my reaction to the lists patients bring to their appointments. If you'd like to read more, check out the section titled "Improving Practice" in the AFP By Topic on Health Maintenance and Counseling.

What you think of patients who bring a list to their appointments?

Monday, April 7, 2014

Supporting women with incomplete miscarriages

- Jennifer Middleton, MD, MPH

All family physicians, even those not providing full obstetric (OB) care, can have a role in helping women and their partners through the heartbreak of an incomplete miscarriage. Last week's AFP examined a recent Cochrane review titled "Medical Treatments for Incomplete Miscarriage." While we may not all be making this diagnosis and prescribing treatment, understanding the treatment options and recognizing the prevalence of grief and depression after treatment can allow us to provide much-needed caring and support to these women and their families.

An algorithm can help physicians determine if an incomplete miscarriage has taken place; the options for women and their partners, then, fall into three categories: expectant management (waiting for the miscarriage to happen naturally), surgical evacuation, or medical treatment with misoprostol. The AFP reviewers state that most women don't want surgery but also don't want to wait up to 14 days for a natural miscarriage. Medical treatment with misoprostol can offer women and their partners closure while avoiding a surgical procedure.

The Cochrane reviewers looked at 20 studies and found that misoprostol is almost as good as surgical evacuation regarding successful completion of miscarriage. Misoprostol was safe and helped women avoid the need for surgery 95% of the time, though it did result in an average of 2 more days of bleeding compared with surgery and expectant management. Misoprostol is available in several dosing preparations, though the AFP reviewers note that the vaginal route has fewer gastrointestinal side effects compared with oral routes.

The completion of a miscarriage is rarely the end of the story for patients and their loved ones, though. Grief following a miscarriage can be as profound for women and their partners as the loss of a close friend or family member. A study published in JAMA in the late 1990s shows that women are at increased risk of depression following any type of pregnancy loss; more recent studies in the OB/GYN literature and psychiatry literature found similar results. A thoughtful review in an OB nursing journal a few years ago describes several websites that provide excellent support following miscarriage, providing some concrete ways to help these women and their partners.

Although many family physicians do provide full spectrum OB care and are in an excellent position to care for women after a miscarriage, even those family physicians who don't provide OB care have much to offer these grieving women within the context of the doctor-patient relationship. There's an AFP By Topic on prenatal care, with a section on pregnancy loss, if you'd like to read more.

How do you and your office care for women after a miscarriage?

Tuesday, April 1, 2014

Modest programs and big ideas to boost primary care

- Kenny Lin, MD, MPH

The April 1st issue of AFP includes a Graham Center Policy One-Pager that uses historical data to project the effect of the 2010 Primary Care Residency Expansion Program (PCRE). By its conclusion in 2015, the PCRE program will have funded an additional 900 residency trainees in family medicine, general internal medicine, and general pediatrics above the current cap on Medicare-supported residency positions. Based on historical trends, though, only 39 percent of internists will end up practicing primary care, compared to 51 percent of pediatricians and 92 percent of family physicians. As a result, only about two-thirds of these residents are likely to enter the primary care workforce. Of course, 600 new primary care physicians are better than none, but at an estimated $100,000 per year per resident, this well-intentioned federal program will also spend $90 million to train additional internal medicine and pediatric subspecialists that are already in plentiful supply.

In addition to modest programs like PCRE, big ideas are needed to transform U.S. health care to a patient-centered system, grounded in primary care, that delivers the best possible health outcomes for all. AFP assistant medical editor Corey Fogleman, MD and Thomas Gates, MD propose several in a recent article in the Journal of Lancaster General Hospital, including:

1) Making medical school free, and providing residency training stipends only to graduates who choose primary care programs
2) Direct primary care: "eliminating the middle-man of third-party insurance"
3) Single payer systems providing universal insurance coverage on the state level

Of these three big ideas, direct primary care appears to face the fewest political and logistical obstacles. Drs. Fogleman and Gates observe:

Advocates of this approach point out that insurance is meant for large unexpected expenses, while expenses for primary care are relatively modest and predictable. It makes little sense to pay for these through an insurance model, any more than it would make sense to buy auto insurance to protect from the cost of an oil change or new tires. Instead, patients in direct primary care contract directly with a primary care provider for access to a broad range of office-based primary care services, in return for a monthly or annual retainer fee.

Unlike “concierge medicine,” the fee is modest (usually on the order of $500-$1000 per year), and can complement high-deductible or catastrophic insurance (which would cover large and unexpected expenses like hospitalization). An element of competition safeguards consumers: practices that don’t deliver quality and accessible primary care will quickly lose patients.


A collection of articles about direct primary care and membership-based practices is available on the Family Practice Management website.

Monday, March 24, 2014

Azithromycin & levofloxacin safety concerns continue

- Jennifer Middleton, MD, MPH

Safety concerns with azithromycin and levofloxacin seem to be mounting of late, and a new study titled "Azithromycin and Levofloxacin Use and Increased Risk of Cardiac Arrhythmia and Death," just published in the Annals of Family Medicine, adds fuel to the fire.

Rao et al conducted a retrospective cohort study, comparing US veterans who had received azithromycin or levofloxacin to those who had received amoxicillin. The researchers looked at outcomes during the 10 days after starting one of these three antibiotics (first dose of antibiotic = day 1). Participants were excluded if they had been on another antibiotic in the month prior to receiving one of the three antibiotics and/or if they had any current "life-threatening" condition. The researchers then looked through participants' charts and identified which ones had been admitted for a serious cardiac arrythmia (long QT syndrome, ventricular tachycardia, ventricular fibrillation, ventricular flutter, or cardiac arrest), been evaluated in the emergency department with one of those cardiac arrythmias, and/or had died of any cause.

They found that, compared to amoxicillin, treatment with azithromycin and levofloxacin was associated with an increased risk of both death and serious cardiac arrythmia.

During days 1-5, the hazard ratio (HR) for risk of death with azithromycin was 1.48 (95% Confidence Interval 1.05-2.09) and the HR for risk of death with levofloxacin was 2.49 (95% CI 1.70-3.64). In days 6-10, the HR for death in the azithromycin group was no longer statistically significant (1.14 95% CI [0.81-1.62]) but the HR for death in the levofloxacin group still was (1.95 95% CI [1.32-2.88]). The data for cardiac arrythmias follows a similar trend and may be viewed here.

The authors do note that a similarly styled study in Denmark last year was reassuring regarding these risks in a young, healthy cohort, but caring for older men with multiple co-morbidities is a significant portion of my patient panel and, I suspect, is for a significant number of other family docs as well. These men are more likely to have pneumonia, for which I frequently use one of these drugs, and azithromycin and levofloxacin are also recommended for patients with severe COPD exacerbations.

This study's findings warrant attention, even if it is a retrospective study. Although many physicians prefer basing practice change on a prospective study, retrospective studies are better suited than prospective studies to detect rare events. With a prospective study, researchers would need to identify large groups of participants and potentially follow them for a long time before having enough cases to meet statistical rigor. That can take a lot of expense and time to accomplish and can be an understandable turn-off for a potential researcher. So, this retrospective cohort study may be as good as it gets for a while.

As for me, I'll be checking out the AFP By Topics on Pneumonia and COPD to investigate alternative antibiotics to use in my older male patients. How about you - will this retrospective cohort study change how you prescribe azithromycin and/or levofloxacin?

Monday, March 17, 2014

Truth and consequences of antibiotic overuse

- Kenny Lin, MD, MPH

The cover article of AFP's March 15th issue, "Common Questions About Clostridium Difficile Infection," reviews truths about a disease that is a direct consequence of medicine's good intentions: antibiotic use, both appropriate and inappropriate. A recent Vital Signs report from the Centers for Disease Control and Prevention (CDC) addressed the magnitude of the latter by demonstrating that broad-spectrum antibiotics are up to three times as likely to be used in some hospitals compared to others. Additional analyses concluded that 37 percent of prescriptions for intravenous vancomycin and antibiotics for urinary tract infections were not supported by diagnostic testing or documentation of symptoms.

The CDC estimated that reducing the use of broad-spectrum antibiotics by 30 percent could eliminate more than 1 in 4 Clostridium difficile infections. CDC Director Thomas Frieden, MD, MPH outlines seven steps for hospitals to improve accountability and monitoring of antibiotic prescribing in the video below.



Increasingly, Clostridium difficile infections are occurring in outpatient as well as inpatient settings. A study published in Pediatrics revealed that 71% of laboratory-confirmed Clostridium difficile infections identified by a U.S. population-based surveillance system from 2010 to 2011 were community-acquired, with the highest incidence among children 3 years of age or younger.

According to the AFP review article by Dr. Bradford Winslow and colleagues, many Clostridium difficile infections can be prevented by minimizing the frequency and duration of antibiotic prescriptions; practicing hand hygiene and adhering to contact precautions; and prescribing probiotics to patients who are taking antibiotics for infections.

Monday, March 10, 2014

Weight loss medications: how much of a solution are they?

- Jennifer Middleton, MD, MPH

I have patients requesting prescriptions for a weight loss medication nearly every week, and I suspect that many family docs could report the same. Some of these patients would likely benefit from losing 10-20% (or more) of their body weight, and some just want to lose "that last 5 pounds." Some of these patients are already doing a great job with lifestyle modifications, and some want the ease of a pill that allows them to avoid exercise and/or nutrition changes. I rarely prescribe weight loss medications, as I have doubts about their long-term efficacy, and I worry about their side effects. I will only prescribe them to a patient who is already working on lifestyle changes and would likely benefit from a significant weight loss.

The current issue of AFP includes a POEM of a systematic review published in JAMA earlier this year regarding the benefit of prescription weight loss medications. This thoughtful systematic review only included studies of at least 1 year's duration and looked at lipid, glucose, and blood pressure outcomes in addition to weight lost.

The medications included in the review were orlistat, lorcaserin, and phentermine/topiramate. Interestingly, no studies examining phentermine alone met the systematic review's 12 month duration requirement, even though, as the POEM notes, it's the most commonly prescribed weight loss medication. The AFP POEM provides the average weight lost among all studies (2.5 - 8.0 kg), which is a useful adjunct to the wide range of "successful weight loss" (where "success" = at least 5% body weight lost) percentages quoted in the original study's abstract.

All of the studies measured the effect of these medications along with nutrition and exercise changes, so I feel justified in continuing to insist upon lifestyle changes prior to initiating treatment with any of these medications. The authors also recommend discontinuing weight-loss medications if 5% body weight is not lost in 12 weeks, as participants who did not lose at least that much weight were unlikely to lose any after continued medication.

The POEM points out that this systematic review did not, however, find any evidence of POEM (Patient Oriented Evidence that Matters) level benefit for these medications besides weight loss. Lipid, glucose, and blood pressure readings are all disease-oriented evidence (DOE); we have no studies to date showing that any of these medications reduce complications from hypertension, diabetes, heart disease - or even whether they help people live longer. It seems reasonable to assume that patients who lose weight with these medications will improve their risk of those complications, but that's only an unverified inference at this point.

The study's authors state that "[t]he need for constant vigilance to sustain behavior changes in the face of biologic and environmental pressures to regain weight emphasizes the challenges faced by even the most motivated patients who have achieved weight loss." They then use this statement to validate the importance of weight loss medications as a way to combat those pressures. Frankly, I'd prefer to see us work to lessen those biologic and environmental pressures instead of adding another pill to our patients' regimens. Our commitment as 21st century family physicians must be to our communities as well as our individual patients if we are ever to turn the tide of rising obesity rates. There's an AFP By Topic on obesity if you'd like to read more.

That said, here in the here and now, these medications may have a role to play. Are you prescribing medications to help your patients lose weight? If so, how do you choose which patients to prescribe them to?