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?

Wednesday, November 5, 2014

For homeless patients, housing is preventive health care

- Kenny Lin, MD, MPH

Every year, a medical school course that I teach invites two speakers to tell students their compelling stories about how being homeless negatively affected their health. Conversely, I care for patients whose declining health led to homelessness because they were unable to work and fell too far behind on mortgage or rent payments. The American Academy of Family Physicians and other professional societies, such as the American College of Obstetricians and Gynecologists, encourage their members to provide compassionate and unbiased care to homeless persons, and a recent article in American Family Physician reviewed strategies for managing clinical conditions that commonly occur in this population.

The standard approach to chronically homeless persons with mental illness and/or substance dependence has been to improve control of these underlying medical problems before placing them in permanent housing. The trouble is that not knowing where one will eat or sleep from day to day is about the worst possible environment to improve mental health or recover from addiction. Dr. Kelly Doran and colleagues reported in the New England Journal of Medicine on a pilot program that used New York State Medicaid funds to house high-risk homeless patients:

Placing people who are homeless in supportive housing — affordable housing paired with supportive services such as on-site case management and referrals to community-based services — can lead to improved health, reduced hospital use, and decreased health care costs, especially when frequent users of health services are targeted.

New York health officials hope that much of its investment will pay for itself by reducing acute and emergency care visits, but so far has been unable to convince the Centers for Medicare and Medicaid Services (which only pays for nursing homes through Medicaid) to make a similar investment. Despite a lack of federal support, this "Housing First" approach has been successful in other states too, notably Utah, as James Surowiecki recently described in The New Yorker. Like it because it's the decent thing to do, because it saves money, or both, Housing First has garnered support across the political spectrum.

Some may view advocating for Housing First policies to improve the health of homeless persons to be outside of the scope of family medicine, but I don't. I have come to realize that some of my patients will not be able to fully address their chronic health issues until they have roofs over their heads and the stability and security that comes with having a place to call home. As Surowiecki observed, this approach can be viewed as a cost-effective form of preventive health care:

Our system has a fundamental bias toward dealing with problems only after they happen, rather than spending up front to prevent their happening in the first place. We spend much more on disaster relief than on disaster preparedness. And we spend enormous sums on treating and curing disease and chronic illness, while underinvesting in primary care and prevention. This is obviously costly in human terms. But it’s expensive in dollar terms, too. The success of Housing First points to a new way of thinking about social programs: what looks like a giveaway may actually be a really wise investment.

Monday, October 27, 2014

Bariatric surgery for diabetes: does it work?

- Jennifer Middleton, MD, MPH

I can't remember the last time I referred a patient for weight loss surgery. I precept residents, and I can't remember the last time one of them told me that they'd like to refer their patient for bariatric surgery. I hear colleagues say, not infrequently, that they will not refer patients for bariatric surgery, usually alluding to its risks. Three recently published studies, though, describe the benefits of bariatric surgery to maintain weight loss and potentially reverse co-morbid disease.

The October 15 issue of AFP includes a POEM describing a recent study that compared diabetes outcomes in patients who underwent bariatric surgery compared with those who continued with conventional medication treatment. The study was published in the New England Journal of Medicine in March 2014 and randomized 150 patients with diabetes to either intensive medical management alone or intensive medical management with bariatric surgery (Roux-en-Y bypass or sleeve gastrectomy). Participants had A1Cs > 7.0% (average = 9.3%) at the study onset, had body mass indexes (BMI) that ranged from 27-43, and were between 20 and 60 years old. The researchers studied participants for 3 years and found bariatric surgery + medication superior to medication alone; the number needed to treat (NNT) to get A1Cs less than 6.0% was 3 for Roux-en-Y and 5 for sleeve gastrectomy.

A few months after this NEJM study, Cochrane published a systematic review evaluating the evidence regarding benefits of bariatric surgery. They included all randomized controlled trials (RCTs) comparing either surgery to non-surgical obesity management or different surgical procedures to each other. They looked at several outcomes, including maintenance of weight loss, quality of life, and remission of diabetes. They found that bariatric surgery, overall, "results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used." They also found, however, that studies did not adequately report complication rates.

Another group of researchers published a slightly different systematic review in the Journal of the American Medical Association (JAMA) a month later. These researchers only included studies whose participants had a BMI of at least 35 and who had at least 2 years of follow-up data, and they did not limit included studies to RCTs. And, although the researchers noted the overall lack of long-term follow-up studies, their findings from the available evidence base to date are in line with the Cochrane reviewers'.

Bariatric surgery is certainly not a zero-risk proposition. But given these outcomes, we should at least be presenting it to appropriate patients as an option among others for obesity and diabetes treatment. The AFP By Topic on Obesity contains further references if you'd like to read more.

How do you discuss bariatric surgery with your patients?

Wednesday, October 22, 2014

The natural history of symptoms in primary care

- Kenny Lin, MD, MPH

Not long ago, I was sitting in my office catching up on some electronic charting when I began to feel chilly, achy, and weak. I went home, skipped dinner, and went straight to bed. Although I felt mostly better the next morning, my appetite didn't fully return until later in the day. My self-diagnosis: probable viral infection. But the truth was that I had no idea if my symptoms were related to any kind of disease.

Medical education trains physicians to approach patients' symptoms foremost as manifestations of an underlying cause. Only "treating the symptoms," in contrast, can often feel like a sort of failure. But as Dr. Kurt Kroenke reported in a narrative review published in the Annals of Internal Medicine, at least one-third of common physical symptoms evaluated in primary care (including pain, fatigue, dizziness, sleep disturbances, and gastrointestinal symptoms) are "medically unexplained," meaning that they are never connected to a disease-based diagnosis after an appropriate history, physical examination, and testing.

Dr. Kroenke further asserted that viewing symptoms as purely disease-oriented influences the language physicians use to describe them:

The lack of a definitive explanation for many symptoms is further underscored by the use of adjectival modifiers indicating what a symptom is not ("noncardiac" chest pain or "nonulcer" dyspepsia) or implying causal explanations that are weakly defensible ("tension" headache, "mechanical" low back pain, or "irritable" bowel syndrome).

Not only do some symptoms have no obvious causes, but others have multiple possible causes which may be unproductive to approach separately. For example, why does a patient with congestive heart failure, anemia and depression feel tired all the time? Also, symptoms usually occur in a group, rather than in isolation; for example, a classic symptom cluster in cancer patients is SPADE (sleep  / pain / anxiety / depression / energy).

Studies show that about a quarter of symptoms that present to primary care eventually become chronic. Fortunately, very few of these patients harbor a serious missed diagnosis such as an occult infection or cancer. As family physicians know, even if we are uncertain about if or when a particular symptom might improve, communication still has great therapeutic value. "Is this normal, doctor?" is the question I hear most frequently from my patients who have persistent symptoms without diagnoses. I usually respond that there is a wide range of "normal," and what's more important to me is working with him or her to make these particular symptoms more manageable.

Monday, October 13, 2014

ADHD spotlight: treatment adherence issues and effects of meds on adult height

- Jennifer Middleton, MD, MPH

The October 1 AFP included a useful review article on ADHD in children, and not long after I read it, I saw two more articles on ADHD that got me thinking even more about this subject: one on adherence to ADHD medication and one on the effect of psychostimulant medication on height.

The AFP article on "Diagnosis and Management of ADHD in Children" reviews the diagnostic criteria for ADHD, the differential diagnoses for common presenting complaints, and initial treatment options. The authors review the data for various treatments and conclude that psychostimulants are still the most effective class of medications for those children in whom meds are indicated.

A recent article published earlier this year in Patient Preference and Adherence reviewed how adolescent patient beliefs affected treatment adherence to ADHD medications. The author reviewed several studies, both qualitative and mixed-methods, that investigated adolescent attitudes toward their ADHD medications. Multiple studies found that the strongest predictors of non-adherence were either adverse medication effects, lack of perceived benefit, and/or "changes to the patient's sense of self." Teens with ADHD rated the perceived efficacy of medications higher than behavioral interventions, yet adolescents themselves are more likely to stop their medications on their own than to involve a parent in that decision.

Another recent article, this one from Pediatrics, seeks to lay to rest concerns about psychostimulant medications' effect on final adult height. The researchers obtained medication and growth histories from around 1000 children born between 1976-1982 in a town in Minnesota; for every 1 child identified with ADHD, they matched 2 control children without ADHD. The researchers obtained growth records on these children along with their final adult height, and they found no difference in growth patterns or final adult height between children with ADHD and children without ADHD; they also found no difference between children with ADHD on medication compared to children with ADHD who were not on medication. This study followed only one geographically-limited cohort, though, and the authors acknowledge the impossibility of knowing whether these children's physicians adjusted their medications due to changes in their growth curves. Despite these limitations, this study's years of longitudinal data are still compelling.

I spend significant time reviewing growth charts with parents of children or teens with ADHD on stimulant medication, but I don't ask questions about medication adherence the way I do, for example, with my patients with other chronic conditions. These two articles suggest that my priorities need reversing.

According to the AFP article, "children with ADHD [on a stimulant] are less likely to be held back a grade." Being held back a grade is definitely Patient-Oriented-Evidence-that-Matters! Since adolescents typically make the decision to stop their medication, centering discussions related to medication issues on them, instead of their parents, during office visits makes sense. And it is nice to be able to share with adolescents and their parents the recent Pediatrics study that was reassuring regarding possible height loss due to long-term stimulant use.

Certainly, as Dr. Lin wrote about earlier this year, medication is not always the right course for treating ADHD. But when it is, these two articles will change my practice. If you'd like to read more, there's an AFP By Topic on ADHD.

How do you counsel parents and their children and/or teens about ADHD treatment?