Monday, September 18, 2017

Prompting physicians and patients increases colorectal cancer screening

- Jennifer Middleton, MD, MPH

Despite multiple available options for colorectal cancer screening, a significant portion of adults aged 50-74 in the United States do not get screened as frequently as recommended by the United States Preventive Services Task Force (USPSTF). A pair of studies this past week describe moderately successful outreach strategies to patients and physicians, respectively, to boost rates.

The first study randomized nearly 6000 US adults aged 50-64 who were not up to date on their colon cancer screening into 3 groups: a colonoscopy outreach group, a fecal immunochemical test (FIT) outreach group, and a usual care group. Participants in the colonoscopy outreach group received mailings encouraging them to call to schedule a colonoscopy; if they didn't within 2 weeks, research staff called them. Participants in the FIT outreach group received mailings with a FIT kit and accompanying instructions. 38.4% of the colonoscopy outreach group and 28.0% of the FIT outreach group completed screening compared to only 10.7% of the usual care group. In the discussion section, the authors note some disappointment that "screening process completion for both outreach groups remained below 40%, highlighting the potential for further improvement."

The second study randomized nearly 1500 general practitioners in France into 3 groups: physicians in the first group received a personalized letter listing all of their patients who were not up to date on colorectal cancer screening, physicians in the second group received a letter describing their region's overall screening rate, and physicians in the third group received no communication at all. The researchers found a small increase in colorectal cancer screening rates in the physician group that received personalized letters (24.8% versus 21.7% for the regional screening information group versus 20.6% for the usual care group) that was statistically significant compared to the other 2 groups. In the discussion section, these authors note that this increase was "modest" and that they, similar to the study described above, also expected a higher screening rate than their results found.

Dr. Lin has written previously on the blog about the various methods available to screen for colorectal cancer in the US and the USPSTF's lack of guidance regarding which method to choose. The USPSTF states that, in addition to colonoscopy and FIT, fecal DNA testing and CT colonography are also options, and the task force encourages physicians to choose the test "that would most likely result in completion." You can read more about these methods in this 2015 AFP article and in the AFP By Topic on Colorectal Cancer.

I'd like to see a study that combines outreach efforts to physicians and patients; it would be interesting to see if the effect is additive in terms of increasing rates. In the meantime, perhaps your own office might create or review a registry of patients not up to date on their colorectal cancer screening, while also providing physicians with a list of these patients. Perhaps you might implement a standard script to discuss colorectal cancer screening with patients at appointments. Or, perhaps you might hire or train an existing staff member to serve as a care coordinator to manage these lists and reach out to patients.

With so many methods to choose from, which one will your office try next to improve colorectal cancer screening rates?

Monday, September 11, 2017

Blood pressure goals in patients with CKD: how low should we go?

- Kenny Lin, MD, MPH

In 2013, the Eighth Joint National Committee (JNC 8) recommended that adults with hypertension and chronic kidney disease (CKD) be treated to a blood pressure (BP) goal of lower than 140/90, after finding no evidence that treating to lower BP goals showed the progression of CKD. At the same time, the American College of Physicians published a guideline on screening, monitoring, and treatment of Stage 1 to 3 CKD that suggested pharmacologic therapy with an ACE inhibitor or angiotensin II receptor blocker, but noted "no difference in end-stage renal disease or mortality between strict blood pressure control (128 to 133/75 to 81 mm Hg) and standard control (134 to 141/81 to 87 mm Hg)."

Less than two years later, however, findings from the Systolic Blood Pressure Intervention Trial (SPRINT) suggested that some older adults at high risk of cardiovascular disease, including those with CKD, may experience additional benefits if treated to a systolic BP goal of 120. After reviewing SPRINT and other recent studies, the American Academy of Family Physicians and the American College of Physicians decided in a new guideline for adults aged 60 years or older to stick with a systolic BP goal of 140 for adults at high cardiovascular risk.

Two systematic reviews and meta-analyses published recently in JAMA Internal Medicine ensure that debate about BP goals for adults with CKD will continue. The first study, by Dr. Wan-Chuan Tsai and colleagues, identified 9 randomized trials (n=8127) that compared intensive BP control (less than 130/80 mm Hg) with standard BP control (less than 140/90 mm Hg) in nondiabetic patients with chronic kidney disease. They found no significant differences between the groups in annual rate of change in glomerular filtration rate (GFR), doubling of serum creatinine level, a composite renal outcome, or all-cause mortality over a median follow-up of 3.3 years.

The second study, by Dr. Rakesh Malhotra and colleagues, extracted data from 18 randomized trials that included 15,924 participants with CKD to determine if more intensive (mean systolic BP 132 mm Hg) compared with less intensive (mean systolic BP 140 mm Hg) control reduced mortality risk in persons with CKD stages 3 to 5. The authors found that more intensive BP control was associated with a statistically significant 14% lower relative risk of all-cause mortality.

An accompanying editorial by Dr. Csaba Kovesdy did a good job of putting these findings into perspective. Dr. Kovesdy pointed out that the benefits of a systolic BP goal of 120 for persons with CKD remain uncertain, and that the meta-analysis could have low external validity because trials had much lower absolute mortality rates than those in observational cohorts of adults with CKD. Finally, he observed that any incremental mortality benefit from intensive BP control is small in comparison to that already achieved by standard BP control:

We must remember that the highest risks of hypertension occur in those with extremely elevated BP levels, and the benefits accrued with treating systolic BP to levels below about 140 mm Hg are much smaller. ... More intensive vs less intensive BP lowering resulted in a [number needed to treat] to prevent 1 death of 167 based on the absolute risk reduction estimated in the meta-analysis by Malhotra et al and an NNT to prevent 1 composite renal failure event of 250 based on the results of another meta-analysis. These diminishing absolute benefits have to be weighed against the increased likelihood of adverse effects and the higher costs associated with more intensive BP lowering.

Bottom line: if family physicians choose to devote more resources to patients with CKD or other cardiovascular risk factors who might benefit from lower-than-usual BP goals, they should not lose focus on improving care for the 46% of U.S. adults with hypertension whose BPs are not adequately controlled by any standard.

Tuesday, September 5, 2017

Using clinical risk scores wisely

- Jennifer Middleton, MD, MPH

Physicians have several clinical calculator apps to choose from, but guidance about choosing the right score and interpreting its results isn't always as readily available. Busy family physicians looking to enhance their use of clinical risk scores will find several discussed among the articles in the current issue of AFP; understanding the nuances of each may help physicians choose the best ones to "favorite" in their calculator app of choice.

A practice guideline on "Newly Detected Atrial Fibrillation" and an editorial on the "Differences Between the AAFP Atrial Fibrillation Guideline and the AHA/ACC/HRS Guideline" both include a discussion on risk scores to predict stroke and bleeding risk in these patients. Using the CHA2DS2-VASc score increases the number of persons recommended to receive anticoagulation compared to the CHADS2 score, but the authors of both articles argue that these risk scores' ability to predict stroke risk is identical. Interestingly, neither of the clinical calculator apps that I have on my smartphone include the CHA2DS2-VASc score. The practice guideline does describe the HAS-BLED score's ability to predict bleeding risk as "slightly better" than other bleeding risk scores for patients on anticoagulation.

"Pleuritic Chest Pain: Sorting Through the Differential Diagnosis" discusses the importance of ruling out pulmonary embolism (PE), the most common life-threatening cause of pleuritic chest pain. The authors advocate for using a validated risk score in patients presenting with pleuritic chest pain to guide decisions about testing for PE; one of the reference articles describes several available validated risk scores but lists the Wells rule as "widely validated and commonly used;" regardless of the score used, a negative D-dimer test in a patient with a low pre-test probability score usually negates the need for further testing.

Similarly, "Exercise Stress Testing: Indications and Common Questions" discusses the use of the Diamond and Forrester score to calculate the pre-test probability of coronary artery disease (CAD) in patients with chest pain. Exercise stress testing provides the highest diagnostic utility in patients with an intermediate pre-test probability for CAD; low risk patients with negative cardiac enzymes typically require no further testing, and high risk patients should receive prompt intervention.

The AFP By Topic on Point-of-Care Guides provides not only numerous risk scores to use with patients but also an evidence-based summary of how to use them each in practice. You can bookmark this department collection and also save your most-used clinical calculator websites under your AAFP "Favorites" tab for easy future reference.

Tuesday, August 29, 2017

Taking stock of a new guideline for hypertension in children

- Kenny Lin, MD, MPH

Last week, the American Academy of Pediatrics (AAP) published a new practice guideline on screening, evaluation and management of high blood pressure in children and adolescents, updating a 2004 guideline from the National Heart, Lung, and Blood Institute. The new guideline includes 30 evidence-informed "key action statements" and 27 other recommendations based on consensus opinion. The AAP recommends that blood pressure be measured annually in every child starting at 3 years of age, and at every health care encounter in children with obesity, renal disease, diabetes, aortic arch obstruction or coarctation, or who are taking medications known to increase blood pressure. Notably, the guideline's blood pressure tables lower previous thresholds for abnormal blood pressure in children by several mmHg because they are based on normal weight children only.

The American Academy of Family Physicians (AAFP) currently supports the U.S. Preventive Services Task Force's (USPSTF) 2013 statement that "current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood." According to the USPSTF, the accuracy and reliability of blood pressure screening protocols in children has not been well studied; a sizable percentage of persons with high blood pressure in childhood will have normal blood pressure as adults; and there is inadequate evidence that lifestyle modification or pharmacotherapy results in sustained blood pressure decreases in children or prevents cardiovascular events. Also, abnormal blood pressure thresholds in the AAP guideline are based on a normal population distribution (with 3 different readings >95th percentile defined as hypertensive) rather than on patient-oriented evidence of improved outcomes, as in the JNC-8 guidelines for hypertension management in adults.

How can family physicians know if a new guideline is trustworthy and applicable to their patients? In a 2009 AFP article, Dr. David Slawson and I proposed several attributes of good practice guidelines:
  • Comprehensive, systematic evidence search with end date noted
  • Evidence linked directly to recommendations via strength of recommendation grading system
  • Recommendations based on patient-oriented rather than disease-oriented outcomes
  • Transparent guideline development process
  • Potential conflicts of interest identified and addressed
  • Prospectively validated (i.e., guideline use has been shown to improve patient-oriented outcomes)
  • Recommendations offer flexibility in various clinical situations
Subsequently, the Institute of Medicine (IOM; now the National Academy of Medicine) published a report, "Clinical Practice Guidelines We Can Trust," that recommended many similar criteria. The IOM report informed the American Academy of Family Physicians' current processes for developing and endorsing clinical practice guidelines from other organizations. The AAP guideline will undergo a structured quality assessment by AAFP staff and members of the Commission on the Health of the Public and Science, who will recommend to the Board of Directors if the guideline should be fully endorsed, receive an Affirmation of Value, or not endorsed. So stay tuned for more news and analysis of this guideline in future issues of AFP.

Monday, August 21, 2017

STEADI-ing our older patients against falls

- Jennifer Middleton, MD, MPH

Falls can feel like an inevitable part of aging, but with just a little effort and teamwork we can help keep our older patients safe. The current issue of AFP reviews several evidence-based resources at our disposal in a feature article and an accompanying editorial, including the Centers for Disease Control's (CDC) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program.

The authors of the feature article, Preventing Falls in Older Persons, review the prevalence and risk factors for falls in the United States along with relevant Choosing Wisely recommendations. They provide an algorithm from the STEADI toolkit to identify patients at risk for falls using a patient checklist and the Timed Up and Go (TUG) test. Incorporating these 2 screening instruments into the Welcome to Medicare Visit fulfills the requirement to review functional ability and level of safety. Recommending physical therapy, reviewing medications, and ensuring home safety, visual correction, and appropriate footwear have been found to benefit patients at moderate to high risk of falling. Prescribing vitamin D is also recommended for some older adults, though Dr. Lin has written previously on the blog about the limited benefit of vitamin D supplementation for community-dwelling elders.

The accompanying editorial discussing the STEADI initiative reviews the costs for caring for older adults after a fall ($31 billion a year from Medicare alone) along with the development and components of the STEADI initiative: screen, assess, and intervene. A 2016 Community Blog guest post by Dr. Stephen Hargarten of the CDC reviewed each of these STEADI components. Plans to integrate STEADI screens and interventions in electronic health records (EHR) should assist physicians with incorporating falls assessment into our everyday workflow; while waiting for these build updates to arrive, creating a macro or template of the STEADI checklist within your own EHR might be useful.

Besides the printed materials available at the CDC's STEADI website, a quick search of your smartphone's app store will turn up an app or two for administering the TUG test; although I could not find any that were rigorously evaluated, the test is simple enough that a quick practice run using the app should demonstrate its utility. Family Practice Management has a topic collection on Medicare Annual Wellness Visits with tools for incorporating fall prevention into your practice, and there's an AFP By Topic on Geriatric Care that includes articles on gait and balance disorders as well as writing exercise prescriptions. Your office team might want to measure its progress with implementing these changes with a plan-do-study-act (PDSA) cycle, and the Institute for Healthcare Improvement has a video reviewing PDSA cycles along with a worksheet for charting the outcomes of your chosen intervention. You can obtain continuing medical education (CME) credit by completing the CDC's STEADI online course and/or by completing a Knowledge Self-Assessment (KSA) for the American Board of Family Medicine on Care of Vulnerable Elders.

Which of these resources have you and your office team found useful for helping reduce your elderly patients' fall risk? Which new resource are you eager to investigate?

Tuesday, August 15, 2017

Procedures and prevention: the challenges of Choosing Wisely

- Kenny Lin, MD, MPH

A 55 year-old woman with chronic low back pain and symptomatic knee osteoarthritis asks your opinion about lumbar fusion surgery and some arthritis walking shoes she saw advertised on television. She is prescribed long-acting oxycodone and physical therapy for back pain, and her orthopedist recently began a series of hyaluronic acid injections for her knees. She is up-to-date on cervical and breast cancer screening, but also desires screening for ovarian cancer.

Next, you see this patient's husband, a 60 year-old man with stable coronary artery disease. He was recently hospitalized for an episode of chest pain, and although tests did not show a myocardial infarction, a cardiac catheterization found an 80% stenosis in the left anterior descending artery. He already takes a baby aspirin daily, but his cardiologist has advised adding clopidogrel and having a coronary stent placed. Last year, he quit smoking after going through a pack of cigarettes a day for 40 years, and he is interested in screening for lung cancer. Also, since his brother was diagnosed with colorectal cancer at age 50, he has undergone screening colonoscopies at ages 40, 45, 50, and 55. These have all been normal, and he wonders if it is necessary for him to continue having them every 5 years.

Although both of these patients are fictitious, they represent common clinical scenarios in family medicine that contain enormous potential for overdiagnosis and overtreatment. In the August 15 issue of American Family Physician, Drs. Roland Grad and Mark Ebell present this year's edition of the "Top POEMs Consistent with the Principles of the Choosing Wisely Campaign," which includes the following suggested clinical actions:
As with last year's Top POEMs list, questioning unnecessary procedures or non-beneficial treatments is an effective way to protect patients from harm. But it's important to take a critical approach to preventive care as well to avoid overscreening. For example, as Dr. Jennifer Middleton noted in a previous blog post, one high-profile screening test for ovarian cancer still has big gaps in the evidence regarding its effect on mortality. Drs. Grad and Ebell advise against screening for ovarian cancer and carefully weighing the risks and benefits of lung and colorectal cancer screening:
It is challenging, and sometimes uncomfortable, to question long-accepted practices that feel like "old friends," AFP assistant medical editor Allen Shaughnessy wrote in a 2016 editorial. He suggested that clinicians keep in mind that the purpose of these evidence-based recommendations, and all of those from the Choosing Wisely campaign, is to improve care and reduce harm:

Every aspect of patient care—every word we say, every test or exam we perform, every treatment or procedure we employ—carries with it the possibility of harm as well as the opportunity for benefit. Although eliminating overuse is often perceived as a way of cutting medical costs, it is really about decreasing wasteful, unnecessary testing and treatment that offer only the potential of harm without the corresponding possibility of benefit. Sometimes, we need to leave our old friends behind.