Tuesday, August 14, 2018

Overdiagnosis in lung cancer screening: don't tell, don't ask?

- Kenny Lin, MD, MPH

Although the U.S. Preventive Services Task Force recommended in 2013 that current and recent smokers 55 to 80 years of age with at least a 30 pack-year history receive annual low-dose CT screening for lung cancer, family physicians have been slow to implement this recommendation in their practices. Concerns about this screening test include the quality of the supporting evidence (which the American Academy of Family Physicians judged to be insufficient) and potential harms, including overdiagnosis and overtreatment of tumors that, left undetected, would never have caused symptoms during a patient's lifetime. An analysis of the National Lung Cancer Screening Trial (NLST) suggested that one in five lung cancers were overdiagnosed. In recognition of the balance of benefits and harms of lung cancer screening, the Centers for Medicare & Medicaid Services requires that eligible patients first have a "counseling and shared decision making visit" with a clinician that utilizes a patient decision aid prior to undergoing a scan.

A previous study of screening for other cancer types found that clinicians mentioned overdiagnosis as a potential harm less than 10 percent of the time. Are lung cancer screening discussions any different? In a study published this week in JAMA Internal Medicine, researchers evaluated shared decision making (SDM) using the validated Observing Patient Involvement in Decision Making (OPTION) scale in a sample of transcribed physician-patient conversations. Relative to the mean total visit length (just over 13 minutes), physicians spent a mean of 59 seconds discussing lung cancer screening. None of the conversations mentioned decision aids, and the mean total OPTION score was 6 out of 100 (where 0 indicates no evidence of SDM and 100 indicates SDM at the highest skill level), reflecting that physicians rarely informed patients about harms of low-dose CT scans or asked patients how they valued these harms.

This lack of attention to harms of lung cancer screening is concerning because the magnitude of overdiagnosis may be considerably higher than previous estimates. Researchers recently analyzed data from the Danish Lung Cancer Screening Trial, in which participants underwent 5 annual low-dose CT screenings (compared to 3 in the NLST) and concluded that two-thirds of lung cancers were likely overdiagnosed. In an accompanying commentary that compared the methods used to estimate overdiagnosis, AFP Deputy Editor Mark Ebell, MD, MS and I stressed the importance of communicating with patients about this "often underappreciated harm of screening":

Patients can make informed choices about low-dose CT only if practitioners fully disclose all the potential harms of screening, including the risk of overdiagnosis. It will be important to researchers to continue to refine estimates of lung cancer overdiagnosis, allowing physicians to provide more accurate information to our patients.

To best serve patients, primary care physicians and pulmonologists must do better than 59-second conversations about lung cancer screening that only mention potential benefits. We need to take the time to tell patients about harms such as overdiagnosis, and ask them how they value these harms relative to the benefits, before ordering the scan.

Monday, August 6, 2018

Overcoming rhinitis adherence challenges

- Jennifer Middleton, MD, MPH

The current issue of AFP includes an overview of "Chronic Nonallergic Rhinitis" (the newer term for "vasomotor rhinitis"). The article includes tips to distinguish allergic from nonallergic rhinitis along with treatment regimens. Many of the medications that are useful for allergic rhinitis are also useful for nonallergic rhinitis, including intranasal corticosteroids, intranasal antihistamines, oral decongestants - with the addition of intranasal ipratropium for nonallergic symptoms. Unfortunately, patient adherence to these intranasal medications tends to be low.

For many patients, rhinitis symptoms are inconsistent and episodic, waxing and waning with seasonal changes and exposure to triggers. While not taking intranasal medications when symptoms and triggers are absent may be reasonable, taking them only when symptoms are severe (and not more moderate) can result in decreased efficacy, increased physician visits, and increased healthcare costs. Many intranasal medications for rhinitis also have unpleasant tastes and smells that can affect adherence. Cost is another factor; some of these medications are not available in generic versions and can be expensive. Interestingly, personality type and gender may also correlate with intranasal medication adherence; in one study, men with higher "neuroticism" scores were less adherent to allergy medications, while men with higher "agreeableness" or "conscientiousness" scores were more adherent. Among women in this same study, however, personality traits did not correlate with adherence.

Knowing when patients are not using their intranasal medications is important to accurately assess treatment efficacy as well as the risk of worsening co-morbid conditions like asthma. The Allergic Rhinitis Treatment Satisfaction and Preference (ARTSP) scale provides information about a patient's preferences regarding intranasal treatment, which can guide physician and patient decision-making regarding specific medications. Prescribing an intranasal medication with characteristics that patients prefer (odor, taste, comfort, delivery device, cost) may increase adherence. Other solutions for increasing adherence include problem-solving solutions to identified barriers with patients and using text messaging to send patients daily reminders to use their intranasal medications.

You can read more about rhinitis treatment by using this AFP keyword search. There's also an AFP By Topic on Allergy and Anaphylaxis, which includes this reference on "Diagnosing Rhinitis: Allergic vs. Nonallergic" and an Allergic Rhinitis Treatment Guideline from 2015.

Tuesday, July 31, 2018

Help your patients achieve food security with SEARCH

- Kenny Lin, MD, MPH

As screening for social determinants of health in clinical settings "moves from the margins to the mainstream," research has focused on how to efficiently identify and address social needs in practice. An article in the May/June issue of FPM by Drs. David O'Gurek and Carla Henke provided a suite of practical approaches, including tools, workflow, and coding and payment considerations. Dr. Sebastian Tong and colleagues reported the experiences of primary care clinicians screening for social needs in 12 northern Virginia practices in the Journal of the American Board of Family Medicine. Knowledge of a social need changed care delivery in 23% of patients and improved communication in 53%, but clinicians often felt ill-equipped to help patients with identified needs or connect them to appropriate services.

Help is on the way. The American Academy of Family Physicians (AAFP) recently launched an interactive online tool, the Neighborhood Navigator, to make it easier for family physicians to connect patients with community organizations and social services. This tool complements other resources in the AAFP's EveryONE Project to support patients' health outside of the office that Dr. Jennifer Middleton discussed in a previous Community Blog post.

In the August 1 issue of American Family Physician, Dr. Shivajirao Prakash Patil and colleagues review the problem of food insecurity, defined as "limited availability of nutritionally adequate and safe food or the inability to acquire these foods in socially acceptable ways," which affected an estimated 12% of American households in 2016. According to the authors, food insecurity (FI) has a cyclical relationship with chronic disease, constraining dietary options in ways that increase the risk for development and progression of diseases in children and adults. They recommend that family medicine practices follow the SEARCH mnemonic and utilize food security resources and food assistance programs in appropriate patients:

S (Screen) - "An affirmative response to either of the following statements can identify FI with 97% sensitivity and 83% specificity: (1) Within the past 12 months we worried whether our food would run out before we got money to buy more, and (2) Within the past 12 months the food we bought just didn't last, and we didn't have money to get more."

E (Educate) - "Educate patients at risk of FI about appropriate coping strategies. Although some individuals with limited resources manage without major disruptions to food intake, many eat less or eat less healthy foods to get by."

A (Adjust) - "Adjust the patient's medication if it should be taken with food. Prescribe medications that minimize the likelihood of hypoglycemia for patients with FI who have diabetes."

R (Recognize) - "Recognize that FI is typically recurrent but is usually not chronic."

C (Connect) - "Connect patients with assistance programs and encourage patients with FI to use food banks."

H (Help) - "Help other health care professionals recognize that poor health and FI often exacerbate one another."

Family physicians can also choose to advocate to improve the quality and quantity of food resource programs available in their communities and across the nation.

Monday, July 23, 2018

Top Infectious Disease POEMS of 2017

- Jennifer Middleton, MD, MPH

The current issue of AFP includes the "Top POEMS of 2017 Consistent with the Choosing Wisely Guidelines," an annual round-up of practice-changing studies for family physicians from the last year. 14 POEMs are described in detail (along with 7 more in eTable A). 3 of these practice changers deal with common outpatient infections: oral corticosteroids don't help acute wheezing in adults without asthma, tympanostomy tubes don't improve hearing outcomes in children with recurrent acute otitis media (AOM) or chronic otitis media with effusion (OME), and adding trimethoprim/sulfamethoxale (TMP/SMX) to cephalexin doesn't improve outcomes for adolescents and adults with uncomplicated cellulitis.

The authors of the first study discuss the desirability of avoiding antibiotics for viral lower respiratory tract infections (LRTI), and having an alternative to offer patients may help decrease unnecessary antibiotic prescriptions. Unfortunately, 5 days of prednisolone did not improve the duration or severity of cough or wheezing compared to placebo in this multi-center, randomized controlled trial (RCT) of 401 adults without asthma in the United Kingdom. For now, conservative measures such as rest, fluids, honey (in children over 1 year of age), and antitussives (only in patients older than 6 years) will have to suffice for patients with LRTI as reviewed in this 2010 AFP article on "Diagnosis and Treatment of Acute Bronchitis."

A meta-analysis of 18 RCTs found no difference in hearing after tympanostomy tube placement in children with either recurrent AOM or chronic OME after 12-24 months with age-matched controls. Nearly 7% of US children have had tympanostomy tubes placed, making it the most common ambulatory surgery performed on children in the US at a mean cost of $769 per surgery. That's a lot of parental concern, patient discomfort, and expense for a procedure that's not improving outcomes. This AFP Clinical Evidence Handbook article reminds us that, without antibiotics, AOM symptoms resolve in 80% of children within 3 days. Searching AFP by the keyword "otitis" yields several other useful review articles.

An RCT of 496 patients aged 12 years and older across 5 US emergency departments found no difference in clinical cure rates between patients with uncomplicated cellulitis treated only with cephalexin and patients treated with both cephalexin and TMP/SMX. Dr. Lin discussed this study last year on the blog, reminding us that reducing unnecessary antibiotic prescriptions is an important step to reducing antibiotic resistance. (Patients with a skin abscess requiring incision and drainage, however, may benefit from either oral clindamycin or TMP/SMX.)

Changing established practice habits can be challenging; tools such as office QI projects and pre-visit planning may help, along with using motivational interviewing when patients request inappropriate treatments and using electronic health system reminders. This 2016 AFP editorial reviews "How to Prescribe Fewer Unnecessary Antibiotics: Talking Points that Work With Patients and Their Families." I've added that editorial and the Top POEMS of 2017 article to my AFP Favorites page for quick future reference.

Tuesday, July 17, 2018

Best practices for preventing gun violence in the clinic and the community

- Kenny Lin, MD, MPH

Family physicians have long recognized that gun violence is a national public health epidemic. In 2015, a coalition of nine medical, public health, and legal organizations, including the American Academy of Family Physicians and the American Bar Association, endorsed several specific recommendations for preventing firearm-related injury and death. These measures included universal criminal background checks for all firearm purchases; educating patients about gun safety and intervening in those at risk of self-harm or harm to others; improving access to mental health care; regulating civilian use of firearms with large capacity magazines; and supporting more research on evidence-based policies to prevent gun violence. A 2014 editorial in AFP also reviewed the role of primary care clinicians in counseling about gun safety based on the best available evidence.

After the February massacre of 17 people at Marjory Stoneman Douglas High School in Parkland, Florida by a 19 year-old former student wielding a legally purchased semiautomatic AR-15-style rifle, the medical editors of AFP felt that we needed to do more to empower clinicians. Surely, when the Founding Fathers endorsed the necessity of a "well-regulated Militia" in the Second Amendment to the U.S. Constitution, they did not envision mentally disturbed teenagers toting weapons with enough firepower to overwhelm entire regiments of Minutemen.

In a special editorial recently published online ahead of print, Dr. Sexton and the AFP medical editors argue that family medicine's emphasis on care of the whole person creates a duty to "confront the epidemic of violence by persons using guns." We review the evidence of the effects of firearm regulations, mental health counseling, and active shooter training on gun safety and violence. Unfortunately, evidence for many interventions remains limited:

A 2018 RAND review of U.S. studies on gun policy published since 2003 concluded that child-access prevention laws (e.g., safe gun storage) reduce self-inflicted and unintentional firearm deaths and nonfatal injuries among youth, and may reduce unintentional firearm injuries among adults. The review also found moderate evidence that laws requiring background checks and prohibiting firearm purchases by individuals with mental illness reduce violent crime and deaths. In contrast, state stand-your-ground laws are associated with increased homicide rates. There was insufficient evidence to determine whether any laws prevent mass shootings. 

Notably, almost two-thirds of the 36,000 firearm-related deaths in the U.S. each year are suicides, leading to our recommendation that "strategies to mitigate firearm suicides should include depression screening and nonjudgmentally asking anyone with depression whether they have a gun in the home." Useful clinical tools include the FIGHTS screening tool for adolescent firearm carrying, the SAD PERSONS suicide risk assessment scale, and the Violence Screening and Assessment of Needs tool for assessing risk of violence in military veterans.

Finally, we encourage family physicians to address the epidemic by making their voices heard in community meetings, online forums, and local publications and communicating with elected state and federal officials to advocate for funding research to study ways to reduce gun violence: "Whether it is speaking up in clinical settings, within our community, or with our elected officials, our voices can make a meaningful difference for our patients, our communities, and our nation."

Monday, July 9, 2018

Minimizing adverse effects from antibiotics: short duration + narrow spectrum

- Jennifer Middleton, MD, MPH

Adverse effects are not uncommon with antibiotics, and two recent POEMs (Patient Oriented Evidence that Matters) in AFP review strategies to minimize them. The first POEM found that shorter courses of antibiotics are equivalent to longer courses for several common outpatient infections. The 2nd POEM found that, for outpatient respiratory tract infections in children, narrow-spectrum antibiotics have a lower risk of adverse effects compared to broad-spectrum antibiotics with equivalent treatment efficacy.

The first POEM is a systematic overview of 9 systematic reviews comparing antibiotic treatment durations for urinary tract infection (UTI), acute pyelonephritis, sinusitis, and community-acquired pneumonia (CAP) in adults, and strep pharyngitis, CAP, UTI, and acute otitis media (AOM) in children. They found that:

AOM (children): 7 or less days =  more than 7 days
CAP (children): 3 days = 5 days
CAP (adults): 7 or less days = more than 7 days
Strep pharyngitis (children): 5-7 days = 10 days
Sinusitis (adults): 3-7 days = 6-10 days
UTI (children): 2-4 days =  7-14 days
UTI (non-pregnant, premenopausal women): 3 days = 5 or more days
UTI (older women): 3-6 days = 7-14 days
The authors found a reduced risk of adverse events for patients treated with shorter durations for AOM, sinusitis, and younger women with UTI; they found no difference among patients with pharyngitis, pyelonephritis, or older women with UTI. Adverse event data was not available for patients treated for CAP or children with UTI.

The 2nd POEM included both a large retrospective cohort arm (over 30,000 children) that reviewed outcomes of children with sinusitis, AOM, or strep pharyngitis diagnoses and a prospective cohort arm (almost 2500 children) examining the same conditions. The findings of the retrospective arm and the prospective arm concurred: broad-spectrum antibiotics (amoxicillin/clavulantate, cephalosporins, macrolides) offered no treatment benefit over narrow-spectrum antibiotics (penicillin, amoxicillin) but did increase the rate of reported adverse effects. The retrospective cohort only reported adverse event rates as documented in the medical record, but the prospective cohort included data gathering of adverse events from parents. The prospective cohort had a much higher rate (10.3 times higher) of adverse effects reported by parents, suggesting that many patients and/or their parents are not reporting these events to physicians.

It's possible that some of the patients who received antibiotics in these studies did not need them at all, thus explaining the lack of benefit in longer antibiotic treatment durations; for example, most cases of acute bacterial sinusitis will resolve without antibiotics (consider offering an intranasal corticosteroid instead), and deferring antibiotics for AOM in children over the age of 2 years with non-severe symptoms is a Choosing Wisely recommendation. Determining which patient needs an antibiotic is not always clear, either; Centor scoring can assist with pharyngitis, but, as Dr. Lin reviewed last week on the blog, procalcitonin levels may not distinguish CAP from lower respiratory tract infections that don't improve with antibiotics (such as bronchitis).

Limiting antibiotic overuse benefits patients and communitiesAFP's Choosing Wisely tool facilitates quick review of these recommendations, and there are also AFP By Topics on Pneumonia, Respiratory Tract Infections, and Urinary Tract Infections/Dysuria that include resources on diagnosis and treatment.