Tuesday, September 16, 2014

The demise of the small practice has been greatly exaggerated

- Kenny Lin, MD, MPH

When I was in high school, a national hardware retailer opened a new franchise down the street from the mom-and-pop hardware store that had served my neighborhood for many years. Since the new store had the advantage of larger volumes and lower costs, it seemed to be only a matter of time before it drove its smaller competitor out of business, the way that big bookstore chains and fast-food restaurants had already vanquished theirs.

But a funny thing happened on the way to the inevitable. By the time I left for college, the new hardware store had folded, and the mom-and-pop operation had moved into their former building. How did this small business manage to retain its customers and win new ones without prior loyalties? The answer was quality of service. I remember visiting both stores when a classmate and I were working on a physics project. At the mom-and-pop store, the owner himself happily held forth for several minutes on the advantages and disadvantages of various types of epoxy adhesive. At the national hardware chain, the staff consisted mostly of kids my age who didn't know much more about glue than I did.

A few years ago, an editorial authored by White House officials in the Annals of Internal Medicine blithely predicted that small primary care practices would eventually be absorbed by "vertically integrated organizations" as a result of health reforms. The editorial prompted the American Academy of Family Physicians to send the White House a letter defending the ability of solo and small group practices to provide high-quality primary care. Despite the migration of recent family medicine residency graduates into employed positions, researchers from the Robert Graham Center estimated in the August 15th issue of American Family Physician that up to 45% of active primary care physicians in 2010 practiced at sites with five or fewer physicians.

The limited resources of small practices seem to put them at a disadvantage relative to integrated health systems and newly formed Accountable Care Organizations. Small practices have less capital to invest in acquiring and implementing technology such as patient portals, and fewer resources (dollars and personnel) to devote to quality improvement activities, such as reducing preventable hospital admission rates. Nonetheless, like the small hardware store of my youth, some small practices are not only surviving, but thriving in the new health care environment. Dr. Alex Krist and colleagues recently reported in the Annals of Family Medicine that eight small primary care practices in northern Virginia used proactive implementation strategies to achieve patient use rates of an interactive preventive health record similar to those of large integrated systems such as Kaiser Permanente and Group Health Cooperative. An analysis of Medicare data published in Health Affairs found that among primary care practices with 19 or fewer physicians, a smaller practice size was associated with a lower rate of potentially preventable hospital admissions.

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement. For example, Dr. Jennifer Brull reported how her practice and four others in north-central Kansas succeeded in improving hypertension control rates in an article and video in the September/October issue of Family Practice Management.

These examples illustrate that the demise of the small primary care practice has been greatly exaggerated. Whether small practices can continue to flourish in the post-Affordable Care Act era remains an open question, but I do know this: the small hardware store in my home town is still thriving, more than twenty years later.

Monday, September 8, 2014

An evidence-based alternative to antibiotics for acute sinusitis

- Jennifer Middleton, MD, MPH

It's that time of year when the kids go back to school and bring home colds, or viral upper respiratory tract infections (URIs), to their families. These viral infections can progress to acute bacterial sinusitis (ABS), and in my office we are starting to see the usual fall uptick in "sinus" complaints. The September 1st edition of AFP reviews a Cochrane meta-analysis of intranasal corticosteroids' effect on ABS symptoms.

AFP provides the key details from this 2013 Cochrane review, which examined 4 studies and included about 2000 children and adults in total. The studies included patients who were both prescribed and not prescribed antibiotics. The Cochrane reviewers deemed 1 of these studies to be of low quality and excluded it from the meta-analysis. From the remaining 3 studies, the number needed to treat (NNT) with an intranasal corticosteroid (fluticasone, mometasone, or budesonide) to resolve or improve symptoms was 15.

Most patients with ABS will recover without an antibiotic, and the Choosing Wisely campaign exhorts us to avoid prescribing antibiotics unless symptoms are severe and/or persistent. The Choosing Wisely materials provide several alternate treatment recommendations, but patients may still be getting antibiotic prescriptions because it's more satisfying for us to write one than advise patients about rest, fluids, and salt water gargles. Pressures to keep patients satisfied may also influence our prescribing; you may recall hearing about a study from 2012 that correlated higher patient satisfaction scores with increased prescription costs (along with increased emergency department visits and mortality).

An AFP Curbside Consultation from 2005 provides guidance for responding to patients who insist on receiving an antibiotic for sinusitis despite clinician advice against it. The article recommends centering discussions on the risk of future harm to patients and their loved ones related to antibiotic resistance. Providing brochures and posters throughout the office that educate on appropriate antibiotic use can also be helpful. There's an AFP By Topic on Upper Respiratory Tract Infections if you'd like to read more.

The duty of tackling antibiotic resistance belongs to all of us; perhaps having an evidence-based alternative to antibiotics in the form of intranasal corticosteroids will decrease inappropriate antibiotic use along with the office practices described above.

How do you treat ABS? Will this Cochrane review change your practice?

Wednesday, September 3, 2014

Why is anyone still prescribing bed rest in pregnancy?

- Kenny Lin, MD, MPH

Maternity care providers have traditionally prescribed "bed rest," or activity restriction, for a host of pregnancy complications (including preterm contractions, short cervix, multiple gestation, and preeclampsia) despite evidence that it does not improve maternal or neonatal outcomes. On the other hand, prolonged activity restriction in pregnancy increases risk for muscle atrophy, bone loss, thromboembolic events, and gestational diabetes. Although it did not include this practice in its Choosing Wisely "Five Things Physicians and Patients Should Question" list, the Society of Maternal and Fetal Medicine (SMFM) recently published a strongly worded position paper recommending against activity restriction in pregnancy for any reason.

This isn't the first time reviewers have examined the evidence for activity restriction and found it lacking; a 2013 summary of several Cochrane reviews of therapeutic bed rest in pregnancy also found such poor data to support the practice that the authors concluded its use should be considered unethical outside of the context of a randomized controlled trial.

The message isn't getting through to physicians or patients, though. A 2009 survey of SMFM members found that 71 percent would recommend bed rest to patients with arrested preterm labor, and 87 percent would advise bed rest for patients with preterm premature rupture of membranes at 26 weeks gestation, even though most of them did not believe it would make make any difference in the outcome (the most common answers were "minimal benefit" and "minimal risk"). Unfortunately, the risk may be more than minimal. Not only does activity restriction expose pregnant women to harm, a secondary analysis of a randomized trial of preterm birth prevention found that nulliparous women with short cervices whose activity was restricted were actually more likely to deliver before 37 weeks' gestation than those who were not.

Similarly, a search of the terms "bed rest" on popular pregnancy websites Babyzone and Pregnancy.org yielded the following statements that fly in the face of evidence: "Changing the force of gravity usually helps minimize preterm labor." "It [bed rest] helps keep blood pressure stable and low." "In most cases, bed rest is used to help the body have the best chance to normalize." A handout on WebMD provided a more balanced assessment:

Bed rest has been a way of treating pregnancy complications for more than a hundred years. But there's a problem. While bed rest is a common treatment, there's no proof that it helps. It doesn't seem to protect your health or your baby's. In fact, bed rest has risks itself. Doctors still prescribe it, but more because of tradition than good evidence that it works.


The handout went on to advise patients to question their physicians closely or get a second opinion if bed rest is recommended. That's sensible advice. Physicians who are reluctant to abandon this useless and potentially harmful maternity practice should consult the SMFM paper or the American Family Physician By Topic collections on Prenatal Care and Labor, Delivery, and Postpartum Issues, where no articles recommend activity restriction for pregnancy complications.

Monday, August 25, 2014

Who is defining Family Medicine?

- Jennifer Middleton, MD, MPH

Perhaps you've already heard - a cardiologist raised the profile of family physicians last week.

National Public Radio's Fresh Air program interviewed Dr. Sandeep Jauhar, a cardiologist working in New York City, August 19 and he had this to say about family physicians:

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not coordinated....no one is really talking and trying to coordinate this care, so it makes it very difficult for the physician who is trying to manage the whole patient...
This particular piece of the interview reminded me of a powerful editorial written a few years ago in the Annals of Family Medicine by Dr. Kurt Stange. Published in 2009, Dr. Stange tells the story of a patient with unresolved low back pain in whom he diagnosed with a large abdominal aortic aneurysm, esophageal cancer, and incidental renal cancer. 
A narrowly focused approach is fine when an obvious problem is linked to a clear solution. When multiple problems are woven into the fabric of life, however, the generalist approach is critical.
In a recent guest post for the Community Blog, Dr. Loftus takes this idea of the generalist's role a step further:
Family physicians should then focus on mastering the knowledge and expertise that we have acquired during our medical education and embrace our role as experts at managing multiple complex chronic diseases, especially with psychosocial co-morbidities. We should be supervising and leading teams of community health workers, health coaches, care coordinators, nurses, pharmacists, physician assistants, and nurse practitioners who are managing the simpler medical issues, as is often the case in many other countries around the world. 
The struggles of our health care system are bringing our specialty to a critical juncture. Who will we be as family physicians 5, 10, 15 years from now? Will we continue to passively accept employment and reimbursement models that push us to see as many patients in as little time as possible? Will we continue to spend time counseling patients on topics that a well-trained medical assistant, nurse, or pharmacist could probably do more effectively? 

Dr. Stange ends the editorial mentioned above with a call for action to rebuild our health care system with primary care at its core. He provides a long list of concrete steps we can each take; here is just an excerpt:
We can cultivate the courage to take on the narrow self-interest that fuels our system dysfunctions. We can be willing to sacrifice in the short term for a larger good in the long term. We can develop relationships with individuals and groups and societies that are different from us, and thus develop a broader sense of community.As individuals, groups, systems, and society, we can strive to be humble, connected, and open....Think and act in ways that bring meaning to apparently low-level tasks that develop relationships, and iterate between the parts and the whole to foster a larger good.

Maybe just keeping abreast of how others are championing Family Medicine is another worthy first step. Trying to keep up with everything that is happening in the larger world of healthcare policy and legislation might feel burdensome to already overworked family docs, but AAFP News Now provides concise updates in your AFP journals. Supporting and being involved with AAFP, our specialty's advocacy organization, is an easy way to support those efforts.

Sometimes changing the world can feel too big for one person. But maybe if each of us worked within our sphere of influence on just one of Dr. Stange's action steps, our health care system could get back to serving patients instead of payors and companies. Maybe then we wouldn't need cardiologists to raise our specialty's profile.

Monday, August 18, 2014

ACC/AHA cholesterol guideline: summary and perspectives

- Kenny Lin, MD, MPH

As previewed in a previous blog post, the August 15th issue of AFP features a concise summary of the American College of Cardiology / American Heart Association updated cholesterol treatment guideline. Key points include an expansion of the role of statins in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); elimination of specific low-density lipoprotein cholesterol (LDL-C) target levels; and a new tool for assessing of 10-year and lifetime risk for ASCVD. An accompanying POEM notes that full implementation of the new guideline would increase the number of U.S. adults eligible to take statins by nearly 13 million, with the percentage of adults 60 to 75 years of age for whom statins are recommended rising from 47.8% to 77.3%.

Two editorials in the same issue further explore the implications of the new guideline. Writing for the members of the guideline panel, Dr. Patrick McBride and colleagues emphasize that the recommendations are largely based on high-quality evidence from randomized controlled trials that measured patient-oriented outcomes. They argue that "these changes should simplify the approach to clinical practice by reducing titration of medication, the addition of other medications, and the frequency of follow-up laboratory testing." In a second editorial, Dr. Rodney Hayward concurs with the panel's decision to abandon LDL-C targets, but disagrees with setting a universal 10-year ASCVD risk threshold of 7.5% for treatment with a statin:

My biggest criticism of the new guideline is that it does not acknowledge a specific gray zone—a range in which the potential benefits and harms of a statin make the “right decision” predominantly a matter of individual patient circumstances and preferences. It may be reasonable to set 7.5% as a starting point for discussion (e.g., for every 33 patients treated for 10 years, roughly one heart attack will be prevented [i.e., number needed to treat = 33]). But these risks and benefits are estimates with a nontrivial margin of error. The guideline does note that shared decision making should be used, but it provides no clear direction on when statins should be recommended rather than just discussed.

A similar debate is taking place in the United Kingdom, where its National Institute for Health and Care Excellence (NICE) recently recommended offering a statin to all persons with a 10-year cardiovascular event risk of 10% or more. An editorial in BMJ observed that doctors need better shared decision making tools to help patients understand the tradeoffs involved in taking medications that have potentially large population health benefits but are unlikely to prevent a bad outcome in an individual patient:

Doctors are unlikely to start giving patients clear numerical information simply because they are told to do so. They might do so if NICE can recommend information tools with the same force as when it recommends drugs, and if it becomes as easy to give contextual numerical advice as it is to print a prescription. ... We will need better data, from bigger trials, and better risk communication than for conventional medical treatment. ... Without such innovation in the use of medical data, we can say only that statins are—broadly speaking—likely to do more good than harm. That is not good enough.

Have you already integrated the ACC/AHA cholesterol guideline into your practice? If so, how do you decide whether to "recommend" versus "discuss" statins with patients? If not, what reservations or workflow issues have prevented you from transitioning to the new guideline?

Monday, August 11, 2014

More evidence against initiation of perioperative beta blockers in non-cardiac surgeries

- Jennifer Middleton, MD, MPH

Patients undergoing intermediate- or high-risk non-cardiac surgeries often get a perioperative beta blocker, and the American College of Cardiology Fellows (ACCF) and the American Heart Association (AHA)'s 2007 guideline advises as such. The ACCF/AHA's 2009 update, though, recommends perioperative beta blockers only in patients with a history of coronary artery disease (CAD) and/or at least 2 CAD risk factors. A 2014 meta-analysis additionally found that perioperative beta blockade in patients not chronically on beta blockers increased mortality -- even if they had CAD or at least 2 CAD risk factors.

JFP reviewed this 2014 meta-analysis recently in an online article. This article discussed serious methodological problems regarding a group of Dutch studies that heavily informed the ACCF/AHA 2007 guideline and 2009 update. These studies failed to consistently obtain written informed consent for subjects, recruited inappropriate patients, and could not produce their raw data when requested by a review panel. These flawed studies are the backbone for the ACCF/AHA's current recommendation to add a perioperative beta blocker to patients with at least 2 CAD risk factors and/or a history of CAD*.

Perioperative beta blockers were certainly controversial even prior to these studies' public disgrace; a 2012 AFP article on Perioperative Cardiac Risk Reduction cited several of the studies included in the 2014 meta-analysis and advised caution in using perioperative beta blockers in patients without known cardiac disease.

The 2014 meta-analysis examined post-operative outcomes for patients who were not taking a beta blocker prior to surgery (including patients with CAD and/or risk factors) and who were undergoing non-cardiac surgeries. The researchers included 9 high quality randomized controlled trials (RCTs) and excluded the suspect data from the Dutch trials. They found that beta blockers did decrease perioperative non-fatal myocardial infarctions (RR = 0.73 [0.61-0.88]), but they also increased the risk of stroke (RR = 1.73 [1.00-2.79]), hypotension (RR = 1.51[1.37-1.67]), and 30-day all cause mortality (RR = 1.27 [1.01-1.60]). For patients not previously on a beta blocker prior to intermediate- or high-risk surgery, adding one causes more harm than good (NNH for 30-day all cause mortality = 160).

When newer studies conflict with previously published guidelines, physicians have an important decision to make. Assuming the new study is methodologically sound, should we abandon the earlier guideline because of the updated evidence? Or, should we wait until the original recommending body assesses the new evidence?

The answer probably involves multiple variables: the amount of trust in the earlier guidelines, the degree to which our colleagues are changing their practice, and, perhaps, even our level of comfort in assessing the study's quality. Maybe it feels like the stakes are too high to change our practice based on one study, especially if larger recommending bodies have yet to weigh in.

Our specialty is fortunate to have high quality journals whose editorial experts sift through new studies and assist us with interpreting and applying them. AFP recently reviewed the ACCF/AHA guidelines for management of congestive heart failure, for example, and handily summarized the high points of this 300 page document into a brief article geared toward busy family docs. Although we should use our evidence-based medicine skills to reach our own independent conclusions about newly published studies, we can also rely on AFP and others to help confirm our assessments.

How comfortable are you changing your practice when new studies conflict with prior recommendations?

* Admittedly, most patients with CAD should be on a beta blocker chronically, but I suspect I'm not the only family doc with a couple of patients who either can't tolerate them or refuse to take one. Several of the studies included in this 2014 meta-analysis included this group of patients in their RCTs.