Monday, June 22, 2015

Gloves for minor skin procedures: sterile or not?

- Jennifer Middleton, MD, MPH

When I ask my medical assistant to gather supplies for a simple skin lesion excision, I often hear this question in return: "Sterile gloves or not?" The decision of which type of gloves to wear has potential implications for both individual patients and overall healthcare costs. A POEM in the June 15 AFP asserts that, for most uncomplicated minor skin surgeries, sterile gloves are no better at preventing infection than clean, non-sterile gloves.

The authors randomized 493 patients who were receiving minor skin excisions in a primary care office to either a sterile glove or regular glove group. They had very broad inclusion criteria but did exclude patients taking antibiotics or immunosuppressives, and they did not include patients undergoing sebaceous cyst removal. They found no difference in post-procedure infection rates (-0.6%, 95th CI [-4.0%, 2.9%]) and noted that the use of non-sterile gloves saved an average of AUD $1 (USD $0.78) per procedure. These findings are consistent with a 2011 AFP article on shave and punch biopsies that lists non-sterile gloves on its "materials" table.

78 cents less for a pair of gloves may not seem like much, but The Institute of Medicine estimates that 30% of health care spending in the US is on waste. We could potentially save $53 billion a year by decreasing the costs of episodes of care. If every family doctor used non-sterile gloves for these procedures, how much might we save?

We have a finite healthcare resource pool, and every dollar spent unnecessarily is a lost opportunity. The small decisions we make every day in our offices - whether to order a CT scan, prescribe an antibiotic, or use sterile gloves for a simple excision - add up. Being a good financial steward doesn't have to equal substandard care. The Choosing Wisely campaign's primary aim is to prevent patient harm, yet avoiding unnecessary care also allows those healthcare dollars to be allocated elsewhere. True, bigger gains in healthcare cost savings require system initiatives, but we should not feel that we, as individual physicians, are powerless to make a difference. Even a simple decision about which pair of gloves to don can help.

You can read more about the Choosing Wisely campaign here, and the AFP website also has a handy Choosing Wisely search tool if you'd like to learn more about a particular initiative.

Tuesday, June 16, 2015

Antibiotics for acute appendicitis?

- Kenny Lin, MD, MPH

Until recently, the most well-studied clinical questions about acute appendicitis have been how to efficiently diagnose it using the history and physical examination and laboratory and imaging tests. Once appendicitis was identified, the next step was to perform an appendectomy, using a laparoscopic or open surgical approach. However, a recent review discussed evidence that some cases of acute appendicitis resolve spontaneously rather than leading to perforation. A 2011 Cochrane review of five randomized, controlled trials found that three-quarters of patients with acute appendicitis who were initially treated with antibiotics rather than surgery recovered completely within two weeks and did not experience a recurrence within one year. Due to the small sizes and other limitations of these trials, the American College of Surgeons has continued to recommend surgery as the "standard" treatment for acute appendicitis.

A study published in this week's JAMA may change a few minds about the utility of antibiotics for this condition. Dr. Paulina Salminen and colleagues randomized 530 Finnish adults aged 18 to 60 years with CT-confirmed uncomplicated acute appendicitis to a 10-day course of intravenous followed by oral antibiotics versus open appendectomy. 73 percent of patients in the antibiotic group did not need an appendectomy within 1 year; the rest, who underwent delayed appendectomies for signs of progressive or recurrent infections, did not develop intra-abdominal abscesses or other major complications as a result of waiting. Although the antibiotic "failure rate" of 27 percent exceeded the authors' pre-specified non-inferiority margin of 24 percent (compared to a 0.4 percent failure rate for initial surgery), the results confirm the viability of a medical approach to acute appendicitis.

A few issues would need to be addressed before antibiotics for acute appendicitis could be routinely implemented in American clinical practice. Unlike in Europe, most appendectomies in the U.S. are laparoscopic, which may make surgery more appealing to some patients. Children and adults older than age 60, who were not included in the JAMA study, may be at higher risk for complications from delayed surgery. Since acute appendicitis is common, we don't know if treatment with broad-spectrum antibiotics could worsen the problems of antibiotic resistance and Clostridium difficile infection. Finally, the lack of consensus on the "clinically important" difference needed to choose antibiotics over surgery may favor a shared decision making approach, which could be a challenge to carry out in the acute care setting.

Monday, June 8, 2015

Lowering blood pressure with behavior change instead of medication

- Jennifer Middleton, MD, MPH

I've had several patients over the years who, when diagnosed with hypertension, ask what they can do to treat it instead of starting a medication. In the June 1 issue of AFP, an article about Nonpharmacologic Management of Hypertension discusses options we can share with patients.

I discussed the JNC 8 recommendations for pharmacologic management on the blog last December, and now a subgroup of the JNC 8 has released a lifestyle management guideline discussing the evidence behind nonpharmacologic treatments. The AFP article authors outline these treatments including nutrition and exercise recommendations. While the evidence base behind these healthy behaviors is robust, helping patients to make and sustain significant lifestyle changes can be challenging. Determining where patients are regarding change and then applying an appropriate counseling tool can improve success rates.

A 2000 AFP article outlines the Stages of Change. The process of making a sustainable lifestyle change is a gradual one for most people, beginning with a lack of awareness about change and/or an unwillingness to change (pre-contemplation), to considering change, (contemplation), preparing to change (preparation), making the change (action), and sustaining the change (maintenance). Identifying what stage a patient is at enables the physician to appropriately target his or her counseling. For example, directive techniques like discussing a quit date may discourage a patient who is pre-contemplative about quitting smoking but would be entirely appropriate for a patient who is in preparation stage, ready to develop a quit plan. Here are the recommended behavioral interventions for patients based on their stage of change from that 2000 AFP article and a 2015 JFP article:

Pre-contemplation: Motivational interviewing techniques are appropriate for all stages but especially this one. Ask the patient for permission to discuss the behavior change and, if granted, explore where the patient's interest in change currently stands, possibly using a 1-10 scale ("On a scale of 1-10, how interested are you in exercising?" "Why did you choose that number and not a lower/higher number?")

Contemplation: Patients in contemplation are stuck between the pros and cons of a behavior change. This stage can be a good time to use narrative techniques, exploring with the patients how they might imagine life being different if they do or do not make a change ("What might life be like in ten years if you do lose twenty pounds? What might it be like if you didn't?"). The 2000 AFP article provides several other prompts for discussion.

Preparation: Now (and only now) is the time to begin setting goals and making directed plans. Tools like FRAMES and the 5 As can be helpful.

Action & Maintenance: All of the above tools work well for patients in these stages. Exploring risks for pitfalls, setbacks, and/or relapses and problem-solving around these can be especially helpful.

Meeting our patients where they are, instead of telling them what to do, can result in a better experience for both patient and physician. Patients who wish to avoid medication for hypertension may be highly motivated to make these beneficial lifestyle changes, but it's up to us to help them capitalize on that opportunity.

Monday, June 1, 2015

"Change is possible": learning to leave asymptomatic bacteriuria alone

- Kenny Lin, MD, MPH

Outside of pregnancy, antibiotics for patients with asymptomatic bacteriuria - that is, a positive urine culture in a patient with no signs or symptoms of a urinary tract infection - do more harm than good. Consequently, comprehensive guidelines and a Choosing Wisely recommendation from the Infectious Diseases Society of America strongly discourage this practice. But just as it is difficult for an interventional cardiologist to not stent a narrowed coronary artery in a patient with stable angina, many physicians have a hard time not treating bacteria that grow in a urine culture, no matter what the science says. To avoid this situation, the U.S. Preventive Services Task Force recommends not screening for asymptomatic bacteriuria in men and nonpregnant women.

Unfortunately, these guidelines are frequently ignored in clinical practice. Perhaps a patient's urine smells funny, or it looks darker or cloudier than usual. Someone (who may not have actually evaluated the patient) obtains a urine culture. The culture grows bacteria, the incorrect diagnosis of "urinary tract infection" makes its way into the patient's chart, and the patient subsequently receives antibiotics that at best do not help, but possibly lead to individual adverse effects and increased antibiotic resistance. Performing urine cultures on patients with urinary catheters is especially problematic, since virtually all of them develop asymptomatic bacteriuria.

A recent study by Dr. Barbara Trautner and colleagues in JAMA Internal Medicine reported on the results of an intervention to reduce treatment of asymptomatic bacteriuria in catheterized inpatients at a Veterans Affairs hospital in Texas. The intervention, part of the aptly named "No Knee-Jerk Antibiotics Campaign," focused on reducing inappropriate urine culture ordering through case audits and feedback and distribution of a guideline-based diagnostic algorithm on a pocket card. When unnecessary screening and/or overtreatment of asymptomatic bacteriuria was judged to have occurred, researchers used a script to provide feedback to teams of internal medicine residents. During the 3-year intervention and maintenance period, the rate of treatment of asymptomatic bacteriuria fell by 75 percent.

"Changing the behavior of clinicians is fraught with challenges, but change is possible," wrote Dr. Manisha Juthani-Mehta in an accompanying editorial. "Some of the components that have been successfully shown to facilitate a change in behavior include education, feedback, participation by clinicians in the change effort, and administrative interventions." The study by Trautner and colleagues demonstrated that for this unnecessary care scenario, it is possible to motivate physicians to Choose Wisely.

Tuesday, May 26, 2015

Another strike against annual pelvic exams?

- Jennifer Middleton, MD, MPH

Despite changes in cervical cancer screening guidelines and the lack of an evidence base to support it, many physicians are still recommending and performing annual pelvic exams. The May 15 issue of AFP reviews the new recommendation from the American College of Physicians (ACP) about annual pelvic exams; similar to many others in the last few years, the ACP finds only harms associated with screening pelvic examinations that are not associated with cervical cancer screening.

The ACP performed a systematic review that included both benefits and harms of annual pelvic exams. They found that pelvic exams did not help women to live longer or better; detection rates of both ovarian and cervical cancer were unchanged. Admittedly, the authors found no studies assessing rates of asymptomatic pelvic inflammatory disease or cancers other than ovarian or cervical, but they did find:
Many false-positive findings are associated with pelvic examination, with attendant psychological and physical harms, as well as harms associated with the examination itself. Harms of pelvic examination include unnecessary laparoscopies or laparotomies, fear, anxiety, embarrassment, pain, and discomfort. 
The AFP Community Blog has tackled this subject twice before; in 2013, Dr. Lin reviewed the lack of evidence to support the reasons clinicians give for continuing this practice, and in 2014, he discussed an earlier iteration of the ACP's recommendation and connected it to the Choosing Wisely recommendation against the annual physical exam. Despite ever-increasing objections and a lack of supporting evidence, subjecting women to annual pelvic exams - sometimes still accompanied by an annual pap test - remains a common practice. The American Congress of Obstetricians and Gynecologists (ACOG) continues to recommend annual pelvic exams for women aged 21 and up, though they acknowledge the lack of evidence to support this stance. It's not hard to find appeals from OB/GYNs to continue this practice, however; they argue that the annual gynecologic visit provides the benefit of reassurance to women when everything "looks normal" and the opportunity for physicians to uncover embarrassing complaints that might, otherwise, have gone unvoiced.

Doing less in health care is hard, and changing practice habits can be difficult, especially when specialty organizations disagree. Family physicians, historically, have depended on other specialist organizations to provide us with guidance about caring for patients with various conditions. Unfortunately, the narrowed patient populations that those specialists see in practice are often quite different than the broader, undifferentiated population seen by primary care physicians. Family physicians should not hesitate to follow population-based screening recommendations oriented to primary care that deviate from other specialty organizations who care for different subsets of patients.

The United States Preventive Service Task Force (USPSTF) is currently preparing to issue an recommendation regarding annual pelvic examination, so stay tuned; in the meantime, the AFP By Topic on Health Maintenance and Counseling contains several helpful resources.

Wednesday, May 20, 2015

Do medical scribes improve physician or patient experiences?

- Kenny Lin, MD, MPH

According to a national survey, a typical family physician spends nearly half of his or her working hours outside of the examination room doing follow-up care or documentation. I think most of my colleagues would agree that entering notes into the electronic health record is one of their least favorite parts of practicing medicine. After all, we went into medicine to care for patients, not to spend endless hours scrolling through screens full of check boxes to prove to payers that we are caring for patients. At the same time, patients may be unable to connect emotionally or convey subtle physical findings when their doctors spend so much of the visit looking at a computer screen.

One solution to the problems posed by electronic documentation requirements is for physicians to delegate the task to a medical scribe. As described in a recent article in Family Practice Management, this trained assistant (medical assistant, medical student, licensed practice nurse, or registered nurse) gathers initial data; documents the physician's examination, assessment, and plan; and provides patient education and implements the care plan while the physician moves on to the next patient. One of the authors reported that his increased efficiency and net revenue more than made up for cost of training and paying for an additional medical assistant functioning as a scribe. Further, the presence of the scribe seemed to have positive effects on the patients' experience:

We've also noted significant increases in our patient satisfaction scores as we've adopted this new model of care. One thing that surprised me was the relationships my patients developed with my MAs, sometimes telling my MAs things they won't tell me. Patients consider the MAs as additional advocates to whom they can go with problems or questions. I thought more patients would object to having another person in the exam room, but that has not been the case.

Beyond this suggestive anecdote, what is the evidence that medical scribes improve practice productivity, revenue, or the physician and patient experience? A systematic review on the use of medical scribes in the Journal of the American Board of Family Medicine found only five studies, none performed in primary care practices. In emergency department, cardiology, and urology settings, scribes appeared to improve clinician satisfaction, efficiency, revenue, and patient-clinician interactions, but did not improve patient satisfaction. Still, given the ever-increasing burden of documentation in primary care, the demand for medical scribes is likely to increase in the future.