Monday, October 17, 2016

Putting Choosing Wisely into practice: how are we doing?

- Jennifer Middleton, MD, MPH

Changing long-standing habits can be challenging, but several well-established axioms in medicine have fallen in the last couple of years. How are we doing with changing our practice to eliminate these unhelpful and/or possibly harmful interventions?

AFP recently published the "Top POEMs of 2015 Consistent with the Principles of the Choosing Wisely Campaign" which includes the following evidence-based findings:

Last fall, Dr. Lin commented on the early uptake of 7 of the Choosing Wisely recommendations; the study found decreased use of imaging in line with 2 recommendations, but, unfortunately, use of the other 5 "Things Providers and Patients Should Question" either did not change or increased.

More recent studies have examined physician behavior regarding several of the Choosing Wisely initiatives. The number of inappropriate DEXA scans ordered in women under age 65 in a large ambulatory care network in the DC area did not change with the Choosing Wisely recommendation to not "use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors." A broader study created a composite score of adherence to 11 Choosing Wisely recommendations and examined national patterns; the researchers found preoperative cardiac testing for low-risk procedures to be the most prevalent low-value service performed (46.5%), followed by prescribing antipsychotics to dementia patients (31.0%), prescribing opioids for migraines (23.6%), and early imaging of acute low back pain (22.5%). The study found wide geographic variation in adherence and also found that:
[T]otal Medicare spending per capita was associated with low-value care utilization, in addition to a higher ratio of specialist to primary care physicians, a higher proportion of minority beneficiaries and a higher proportion of residents with poor or fair health.
Primary care physicians have higher awareness of Choosing Wisely than do other specialties, but we have room for improvement in implementation. A national survey of 2000 primary care physicians' attitudes about Choosing Wisely found that "[t]he most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists." Awareness of Choosing Wisely is an important first step, but we still have work to do regarding how we put it into practice.

The Choosing Wisely campaign's mission to reduce unnecessary medical care aligns well with the Right Care Alliance's mission "to restore trust, balance, professional ethics and principles of justice and equality to healthcare in the United States." This week is Right Care Action Week, where "thousands will be participating in radical actions that reimagine health care as listening, hearing, sharing, partnering, caring... and sanity." Ensuring that the care we deliver is "effective, affordable, and needed," the Right Care Alliance provides many opportunities to get involved, both in small and big ways. You can start by signing up to learn more about them here.

Monday, October 10, 2016

How can family physicians avoid making diagnostic errors?

- Kenny Lin, MD, MPH

Due to our broad scope of practice, family physicians are likely the most vulnerable of all physicians (with the possible exception of emergency medicine physicians) to diagnostic errors. Patients of all ages and different co-morbidities come in with undifferentiated complaints that could be attributed to multiple organ systems. In an editorial in the September 15th issue of AFP, Drs. John Ely and Mark Graber reviewed underlying reasons for incorrect diagnoses:

Most diagnostic errors are caused by the physician's cognitive biases and failed heuristics (mental shortcuts), such as anchoring bias (overly relying on the initial information received or initial diagnosis considered), context errors, or premature closure of the diagnostic process. More than 40 of these biases have been described, but most lead to a single pathway in which the physician fails to generate an adequate differential diagnosis or to even consider the correct diagnosis as a possibility. The single most common reason for a diagnostic error is simply, “I just didn't think of it."

In a previous Curbside Consultation, Dr. Caroline Wellbery explored some of these cognitive biases in greater detail. For example, availability bias "refers to the ease with which a particular answer comes to mind," and can lead physicians toward making diagnoses based on other recent patients with similar presenting symptoms. Premature closure may occur when a framing/anchoring bias causes a physician to view the patient through a familiar lens and dismiss evidence that is not consistent with that frame. Similarly, confirmation bias may lead physicians to overemphasize test findings that support their preliminary diagnoses. Dr. Allan Detsky brought some of these dry concepts to life in a recent narrative in JAMA where he compared difficult diagnoses to the plastic snakes that he used to scare away ducks from the dock at his family's vacation home:

When faced with a difficult and ongoing diagnostic dilemma, refocus on the key assumptions that have driven the strategy to search for the "snakes." Start by dividing the findings into those that are based on facts and those that are based on inferences derived from those facts. Design an experiment to see if those inferences are indeed true, like holding the snakes under the water to see what they will look like on the bottom of the lake.

In their AFP editorial, Drs. Ely and Graber suggested three approaches to reduce diagnostic errors in primary care: 1) Involve the patient as a partner in the diagnostic process; 2) Get second opinions from colleagues or consultants who have not been previously involved in the patient's care; 3) Use a diagnostic checklist to make sure that all appropriate differential diagnoses have been considered. On a health system level, the National Academies of Medicine published a report on "Improving Diagnosis in Health Care" last year, and the Society to Improve Diagnosis in Medicine is leading a coalition of professional organizations, including the American Academy of Family Physicians, to devise and implement strategies to prevent diagnostic errors across all specialties and healthcare settings.

Monday, October 3, 2016

Including women’s partners in preconception care

- Jennifer Middleton, MD, MPH

The September 15 issue of AFP reviews the new AAFP position paper recommending the discussion of preconception care at every visit for women of reproductive age. Along with asking female patients about their reproductive plans, the authors encourage us to work with them to optimize their health in case of unplanned pregnancy. Appropriately, the paper includes an often forgotten individual in determining maternal and infant well-being: the father and/or pregnant woman’s partner. The health of these potential fathers, along with the lifestyle habits of both male and same-sex female partners, are also important determinants of pregnancy outcomes

It can be challenging to remember to include preconception care during already busy visits, but the biggest challenge may be just getting these partners to our offices in the first place. Men visit physicians far less often than women, even when visits for OB care are excluded. Low income and uninsured men are even less likely to see physicians, and men of all income and insurance statuses do not routinely receive much counseling about mental health, sexual health, or violence and safety when they do come into the office. Including mental health assessment and counseling is especially important given that fathers can also experience perinatal depression, which can have consequences for both their partners and their children. Even more than their older counterparts, male adolescents may find accessing care for their sexual health especially stressful and intimidating. Discomfort regarding care-seeking affects same-sex female partners as well. Lesbian women access health care far less frequently than heterosexual women despite having comparatively higher rates of chronic disease, tobacco use, and heavy drinking. Ensuring access to welcoming care is an important first step in providing preconception care for the partners of women of child-bearing age, be they male or female.

Making our offices safe places for everyone is, then, a critical first step. Once they are there, incorporating preconception care into our everyday practice will likely require a team approach. Pre-visit planning may be one way of systematizing this care. There’s a Family Practice Management Topic Collection on Care Team & Staffing if you’re interested in other possible approaches. You can also read more about common psychosocial issues in men here, and there's an AFP By Topic on the Care of Special Populations that includes a subsection on Gay, Lesbian, Bisexual, and Transgendered Persons.

How is your office addressing preconception care?

Thursday, September 22, 2016

Guest Post: Falls Prevention Awareness Day

- Stephen Hargarten, MD, MPH

Today is the 9th annual observation of Falls Prevention Awareness Day in the United States. Falls are the leading cause of both fatal and nonfatal injuries among older adults age 65 and over. The Centers for Disease Control and Prevention (CDC)’s latest Morbidity and Mortality Weekly Report (MMWR) article, Falls and Fall Injuries Among Adults Aged 65 Years and Over — ­­­United States, 2014 outlines the epidemiology of older adult falls, and how clinicians can use CDC’s evidence-based STEADI (Stopping Elderly Accidents, Deaths, & Injuries) initiative to help prevent them. STEADI provides tools for clinicians to use with older adult patients to screen for fall risk using three simple steps:

· Ask: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling?

· Review/Reassess/Discontinue any medications or combinations that can increase the risk of falling.

· Recommend at least 800 mg IU of vitamin D to improve bone, muscle, and nerve health in older adults.

Every hour of every day, in communities across the United States, a patient who either just fell or is a fall risk, is being evaluated by a family physician or emergency care clinician. It is critically important that clinicians in urgent and primary care settings ask, review, and recommend fall prevention strategies for older adults.

The new CDC article highlights that in 2014, over 27,000 older adults died because of falls, and 2.8 million people were treated in emergency departments (EDs) for falls-related injuries. In the same year, CDC discovered that one in four older adults reported falling, totaling almost 29 million falls, and seven million fall injuries.

Falls not only cause injuries and affect the independence of older adults—they also have an impact on the economy. The annual medical costs associated with older adult falls are estimated to be $31 billion per year. The article estimates that the older adult population will increase 55% by 2030. The incidence of falls among this growing population will continue to increase unless effective interventions like STEADI are implemented nationwide.

Older adult falls are preventable. For patients in the ED or inpatient setting, care givers need to constantly evaluate and reevaluate for fall risk. Hospital bed side rails always should be in place to avoid an unintended fall from the bed.

Clinicians can play a critical role by following STEADI’s comprehensive approach of: 1) Asking older adult patients about falls, 2) assessing gait and balance, 3) reviewing medications, 4) prescribing interventions such as strength and balance exercises, 4) and recommending least 800 mg IU of vitamin D every day to prevent falls among older adults. Because many patients do not discuss the problem with their doctor, clinicians must be vigilant about asking patients about their falls, screening for fall risk, and implementing STEADI into practice.

As we acknowledge Falls Prevention Awareness Day, I encourage you all to take a stand against falls by integrating into your daily practice: Ask, Review, and Recommend for older adults. It’s good medicine!


Dr. Hargarten is Chair of the CDC's National Center for Injury Prevention and Control, Board of Scientific Counselors, and Professor and Chair of the Department of Emergency Medicine and Associate Dean for the Global Health Program at the Medical College of Wisconsin.

Monday, September 19, 2016

Should family doctors treat opioid addiction?

- Jennifer Middleton, MD, MPH

The physicians in the office where I practice recently received the opportunity to train for a Drug Abuse Treatment Act (DATA) waiver for buprenorphine prescribing. A lively discussion among us ensued, with a few of us willing to be trained but the rest uncomfortable with the idea. As I've discussed this issue with others, it seems that many family physicians have strong feelings about not prescribing buprenorphine. The common argument seems to be that these often complex patients should be left to addiction specialists to treat.

Barriers cited in the medical literature to physician prescribing of buprenorphine include a lack of resources, time, and institutional support but also "mistrust of people with addiction...and [a] difficult patient population." 40% of physicians in a 2013 survey believed that buprenorphine diversion contributes to accidental overdoses and is thus dangerous to prescribe.

In the September 1 issue of AFP, though, physicians from the Robert Graham Center argue that family physicians need to be more involved in treating opioid addiction with buprenorphine. They cite a 2014 Cochrane systematic review that demonstrated buprenorphine's efficacy in treating patients with opioid addiction, and they call for policy changes to encourage more family physicians to prescribe buprenorphine. A study in the Annals of Family Medicine found that most physicians with DATA waivers were concentrated in urban areas, leaving 30 million in the U.S. without access to buprenorphine treatment; this same study also found that only 3% of family physicians had DATA waivers as of 2012.

I wrote about current recommendations for opioid use and monitoring a few months ago, and certainly family physicians have an obligation to be responsible regarding opioid prescribing. We have an obligation as a specialty, however, to consider our response to opioid addiction as well. Just under 4000 physicians in the U.S. are board certified by the American Board of Addiction Medicine, which is far insufficient to meet the needs of the estimated 2 million individuals in the U.S. currently struggling with opioid addiction.

The medical literature to date provides little guidance regarding measures to increase buprenorphine prescribing. Providing training in treating addiction during residency increased psychiatry residents' use of buprenorphine in their practices after residency; training Family Medicine residents might be similarly effective. Institutional support and adequate local mental health resources are also likely key. The AAFP recently updated their position paper on chronic pain management and opioid misuse (including a section on buprenorphine use) which includes this call to action:
[T]he AAFP challenges itself and its members at the physician, practice, community, education, and advocacy levels to address the needs of a population struggling with chronic pain and/or opioid dependence.
You can read here about how to obtain a DATA waiver. This 2006 AFP article provides information about initiating and managing buprenorphine treatment, and there's also an AFP By Topic on Substance Abuse.

Are you currently prescribing buprenorphine, or are you considering obtaining a DATA waiver to do so?

Monday, September 12, 2016

New developments in the Zika epidemic

- John E. Delzell, Jr, MD, MSPH

In her AFP Community Blog post on February 29th, Dr. Jennifer Middleton provided a great overview of the health risks associated with the Zika virus and the recommendations from the Centers for Disease Control and Prevention (CDC). To a family doctor in South Florida, the risk of Zika seems very acute, so I have been thinking about it a lot this summer. Over the past month, 40 new patients have contracted Zika from local mosquitoes. The affected area includes the popular tourist destination, Miami Beach, and an area just north of downtown Miami. The CDC has taken the historic step of recommending against travel to these two areas. The recommendation states:

· Pregnant women should not travel to these areas.
· Pregnant women and their partners living in or traveling to these areas should follow steps to prevent mosquito bites.
· Women and men who live in or traveled to these areas and who have a pregnant sex partner should use condoms to prevent infection every time they have sex or not have sex during the pregnancy.
· Effective contraception to prevent pregnancy in women and their partners who want to delay or prevent pregnancy is a key prevention strategy for Zika.
· All pregnant women in the United States should be assessed for possible Zika virus exposure and signs or symptoms of Zika during each prenatal care visit.
· Pregnant women who live in or frequently travel to these areas should be tested in the first and second trimester of pregnancy.
· Women with Zika should wait at least 8 weeks after symptoms began before trying to get pregnant, and men with Zika should wait at least 6 months after symptoms began.

Aedes aegypti mosquitoes can transmit several emerging viral infections, including chikungunya, dengue, and Zika. The Aedes aegypti female mosquito can lay up to 1,000 eggs, and they love to live indoors. Since 2014, the chikungunya virus has begun to have local transmission from infected mosquitoes in Florida and Puerto Rico. Dengue fever had a resurgence in 2013 in Florida, and so far in 2016 there have been 40 travel related cases and one case of local transmission.

Why are we seeing and hearing about these new tropical diseases now? There are several reasons that South Florida (the three-county area of Miami-Dade, Broward, and Palm Beach counties plus the Everglades and the Keys) is at high risk. The climate is tropical with daily rain and average high temperatures in the 80s most of the year, making for an ideal breeding ground for mosquitoes. People come from all over the world to enjoy the beaches in Miami and Fort Lauderdale. Finally, South Florida includes large, diverse immigrant populations from affected countries such as Haiti, the Dominican Republic, Venezuela, Brazil, and Cuba.

So how are public health officials responding to the Zika virus? In downtown Miami, there has been an aggressive ground and aerial spraying campaign to control the mosquito population. This has caused some controversy in the Miami Beach area with protests and a delay in aerial spraying. In the Florida Keys, there is an unpopular proposal to release genetically modified mosquitoes that will produce sterile offspring and (hopefully) decrease the overall mosquito population. On August 5, the U.S. Food and Drug Administration approved these modifications as posing little to no risk of harm to humans, but the project has yet to begin.

Right now preventing Zika infection consists mostly of mosquito control and avoidance, but efforts to develop a vaccine have accelerated and may only be a year or two away, as reported in a fascinating story in the New Yorker. In the meantime, it is important for family physicians to stay up to date on the latest information about the Zika virus. The Featured Content section of the AFP homepage includes other useful resources on this evolving epidemic from the American Academy of Family Physicians, the CDC, and the World Health Organization.


Dr. Delzell (@Ed_in_Med) is Assistant Editor at AFP and Vice President and Designated Institutional Officer of Broward Health Medical Center in Fort Lauderdale, Florida.