Monday, July 21, 2014

Nebulizers: old habits die hard

- Jennifer Middleton, MD, MPH

Last week's JFP discussed an updated Cochrane review reasserting that nebulizers cost more, cause more side effects, and offer equivalent treatment compared with a metered dose inhaler (MDI) and a spacer (aerochamber). The Cochrane reviewers conducted a systematic review of 39 trials that included both children and adults as well as office and emergency department (ED) settings. They found no difference in hospital admission rates for adults or children who received albuterol via a MDI and spacer versus a nebulizer. Hospital length of stay was no different for adults who received albuterol via an MDI/spacer versus a nebulizer. Children's ED visit time was, on average, 33 minutes less for those who received albuterol with an MDI/spacer instead of a nebulizer. Children using an MDI/spacer had less tremor, and both children and adults using an MDI/spacer had less tachycardia.

(If you'd like to read more about asthma, check out this AFP By Topic on asthma. You can also brush up on spacer techniques here.)

This is not new information; several randomized controlled studies and the original 2003 Cochrane review demonstrated similar findings. If your office and/or hospital setting is anything like mine, though, nebulizers are everywhere, despite a decade's worth of research showing that MDIs offer equivalent therapy with fewer side effects and less cost. Why the continued love affair with nebulizers when they're not only therapeutically equivalent to MDIs with spacers but also cause more side effects, cost more per dose, and result in longer ED visits?

Well, a study from last year found that 80% of COPD patients and their families felt that using a nebulizer was better than using an MDIA small study of pediatricians found that most would benefit from "better training" regarding spacer use. These small studies may not be generalizable to an American family medicine office, but it's still possible that patients like using nebulizers and that physicians are more comfortable ordering nebulizers. And, I have to confess that it's much more efficient in my office for my nurse to give an albuterol nebulizer treatment than it is to track down a clean spacer and educate a patient on how to use it.

UItimately, the nebulizer epidemic is part of a larger problem in medicine: physicians are slow to change their practice to accommodate new evidence-based findings. Debate exists as to how long it takes for evidence-based research to percolate into widespread physician behavior changes, but estimates around 10-20 years are not hard to believe. Physician leaders have hypothesized the reasons behind this lag, including this NEJM editorial likening local physicians' practices as "where the [information] highway reaches its end and divides into a number of smaller avenues and lanes, and it is also where...concepts may get lost." One team of researchers theorize that just reading about new evidence is insufficient for physicians to place that information in the proper context when applicable patient situations arise; they advocate for more case-based learning in continuing medical education (CME).

Perhaps the first step for each of us is to just acknowledge that the lag exists; perhaps the next step is to think about how each of our "avenues and lanes" might systematically ensure that evidence-based changes become routine care faster. Perhaps we also must advocate for innovation in how CME is delivered.

How do you translate evidence-based changes into your daily practice?

Tuesday, July 15, 2014

Palliative care consists of more than pain control

- Kenny Lin, MD, MPH

In inpatient settings, family physicians frequently care for patients with progressive, incurable conditions that cause severe pain. Interventions aimed at slowing the progress of a disease often add to patients' physical distress; therefore, pharmacologic management of pain is a key component of end-of-life care, as outlined in an article in the July 1st issue of American Family Physician. However, as Drs. Timothy Daaleman and Margaret Helton discuss in an accompanying editorial, providing analgesia is only the starting point for effective palliative care:

Palliative care generally begins with diagnosis of a life-limiting disease and initiation of an ongoing conversation on the goals of care and treatment. This often begins in patient-centered medical homes, continues through acute hospitalizations, and may conclude in long-term care facilities. At each point, family physicians may be called on to provide primary palliative care and can expect to encounter nonpharmacologic challenges in managing pain.

Misconceptions about palliative care are common. For example, many believe that palliative care, like hospice care, cannot be offered to patients who are still pursuing "aggressive" treatments such as chemotherapy for cancer. On the contrary, one of the American Academy of Hospice and Palliative Medicine's Choosing Wisely recommendations states, "Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment." Palliative care does not necessarily increase patient comfort at the cost of shortening life; in a randomized trial of patients with metastatic non-small-cell lung cancer, patients assigned to early palliative care not only experienced better quality of life and fewer symptoms of depression than patients receiving standard care, they actually lived more than two months longer.

The recent announcement by a large health insurance company in the Pacific Northwest that it will prioritize palliative care by training physicians and caregivers about having appropriate end-of-life conversations; and pay for previously unreimbursed home health services and counseling about advanced directive planning suggests that policymakers are finally recognizing the value of improving the availability of palliative care to appropriate patients. What have been your experiences with connecting patients or loved ones to palliative care services?

Monday, July 7, 2014

Behavioral interventions to help motion sickness

- Jennifer Middleton, MD, MPH

When my father tells the story of his parents' second honeymoon, which was a cruise, he relates how my grandmother had a delightful time sailing the seas while my grandfather sat in the cabin feeling irritable and dizzy in between bouts of emesis. (This story inevitably seemed to come up right after my sister had vomited in the car during a family road trip; a recent study estimated the prevalence of motion sickness in cars among children aged 7-12 at 43%.)

For as prevalent as motion sickness is, the recent AFP review article on this topic, Prevention and Treatment of Motion Sickness, reminds us that there is much we can do to help our patients overcome this discomfort. The article reminds us that prevention is the mainstay of treatment, and beyond the multiple pharmacologic options (nicely summarized in Table 3) the authors also point out important behavioral strategies (Table 2).

Two of the cited studies regarding behavioral interventions looked at how music and deep breathing may help. Denise et al investigated the use of controlled breathing as participants were upside-down, rightside-up again, and tilted to the side while watching an asynchronous 180 degree video screen; in all positions, controlled breathing lowered sickness ratings and prolonged participants' tolerance to movement.

In the second study, Sang et al had healthy participants listen "to music audiotape designed to reduce motion sickness symptoms," do breathing exercises, or neither (control group) while undergoing a lab simulation to evoke motion sickness symptoms. The participants began the music or deep breathing after the onset of mild motion sickness symptoms, and both interventions prolonged the development of moderate motion sickness symptoms for about ten minutes compared with placebo. Another just published study found that "pleasant music" reduced motion sickness symptoms overall to participants exposed to symptom-inducing stimuli. While it's unclear in this latter study who decided what "pleasant music" was, it's probably reasonable to extrapolate that "pleasant" is in the ear of the beholder.

Listening to music and controlled breathing exercises are simple, zero-risk interventions that would require only brief counseling in the office to recommend to patients, and they may complement the prescription therapies described in the article.

How do you discuss motion sickness prevention with your patients?

Tuesday, July 1, 2014

Skip the annual pelvic examination? How about the whole checkup?

- Kenny Lin, MD, MPH

An American College of Physicians practice guideline released yesterday has garnered attention for recommending against clinicians performing screening pelvic examinations in asymptomatic, nonpregnant women. Although the new guideline has been called "controversial," its findings should not be a surprise to readers of American Family Physician. An editorial and blog post published in AFP early in 2013 argued that this longstanding tradition is "preventive time not well spent," since the pelvic examination doesn't actually prevent anything (screening for ovarian cancer does more harm than good and accurate testing for chlamydia and gonorrhea can be done on urine samples) and is associated with increased cost, inconvenience, and patient discomfort. With Pap smears only recommended every 3 to 5 years in most women, it also seems prudent to redirect time saved from not performing extra pelvic exams to effective preventive services such as counseling for tobacco and alcohol misuse.

But why stop at the pelvic examination? Last September, the Society of General Internal Medicine included the following item in its Choosing Wisely Top 5 List of potentially unnecessary tests or procedures: "Don't perform routine general health checks for asymptomatic adults." They cited a Cochrane review of 14 randomized controlled trials that found that the annual physical increases new diagnoses but "do not decrease total, cardiovascular-related, or cancer-related morbidity or mortality."

The physical examination may not improve outcomes in asymptomatic patients, but what about the cardiovascular risk assessment and lifestyle counseling that goes along with it? A randomized trial published this year in BMJ casts doubt on the benefits of this preventive service. In nearly 60,000 residents of Copenhagen, Denmark between the ages of 30 and 60 years, four or more sessions of individual lifestyle counseling over a 5-year period produced no effect on rates of coronary artery disease disease, stroke, or mortality after 10 years of followup. In an accompanying editorial, the Cochrane review authors state flatly: "General health checks don't work. It's time to let them go."

As the U.S. faces a worsening shortage of primary care clinicians, are today's family physicians prepared to abandon annual pelvic examinations and well-adult checkups in general? If not, why not?

Monday, June 23, 2014

Acute Complaints: 3 of The 2013 Top 20 AFP articles

- Jennifer Middleton, MD, MPH

AFP recently posted its 20 most-read articles from last year here. The topics run through much of the full spectrum of Family Medicine, from health maintenance to acute complaints, from initial work-up to chronic management. Here are three articles that explore acute complaints:

1. Approach to Acute Headache in Adults (5/15/2013)
This article provides a practical approach to differentiating benign headaches (age <30, "features typical of primary headaches," prior similar headaches, normal neurologic exam, no high-risk comorbidities) from dangerous headaches (worst headache ever, headache triggered by exertion, mental status change, age > 50, papilledema, sudden onset, systemic illness, temporal artery tenderness). The authors review the classic "primary" headache syndromes (tension, migraine, cluster) and include a helpful table regarding choice of radiographic testing should 1 or more dangerous headache signs be present.

2. Diagnosis and Management of Acute Diverticulitis (5/1/2013)
This article provides likelihood ratios for common physical exam findings that can help to rule in or rule out diverticulitis (LLQ tenderness + absence of vomiting + CRP >50 = LR+ of 18). The authors review guidelines for laboratory and radiographic evaluation as well as recent evidence arguing against antibiotic use in patients with mild, uncomplicated diverticulitis. Weight loss, smoking cessation, fiber, and exercise help to prevent recurrences but avoidance of seeds, nuts, etc. does not.

3. Outpatient Diagnosis of Acute Chest Pain in Adults (2/1/2013)
Only 1.5% of patients presenting to a primary care office with chest pain have unstable angina or acute coronary syndrome, but identifying who these patients are can be challenging. The authors review likelihood ratios of clinical symptoms more likely to be associated with serious cardiac disease (among others, radiating pain and use of a term other than "pain" - such as "tightness" or "squeezing" increase the pre-test probability). Pleuritic chest pain and "sharp" or "stabbing" chest pain, on the other hand, are less likely to be due to acute coronary syndrome. The authors also present a validated clinical decision rule to assist with diagnosis (Table 2). They review the more common, and typically less serious, diagnoses of chest wall pain, GERD, and anxiety along with the less common, but more serious, possibilities of pericarditis, pneumonia, CHF, or pulmonary embolism.

By my count, half of the Top 20 articles from 2013 dealt with evaluation of new and/or acute complaints. Given how much of 21st century Family Medicine is chronic disease care, it's interesting that acute complaints caught so much of the attention of AFP readers, though certainly family doctors experience both on a daily basis.

What AFP articles dealing with acute issues have changed your practice lately?

Monday, June 16, 2014

Guest Post: The Future of Family Medicine - Some Sacrifices Required

- Matthew Loftus, MD

The American Academy of Family Physicians is collecting thoughts now on the future of Family Medicine in America; I shared mine and thought that I would post them here for discussion.

Right now the health care cost curve is being broken across the backs of hospitals & specialists. I think that they'll come for primary care next. If we're not prepared, we'll find our payments decreased and our specialty torn apart as the hospital systems that own us realize that the reimbursable services provided by physicians can often be provided by other types of health professionals. Fighting against nurse practitioner independence wastes time, money, & energy — we need to do more and define all of the roles that work together to create a vigorous primary care system. We're calling on some of our specialist colleagues to sacrifice some of their income and independence for the good of our patients as we try to restrict unnecessary or harmful procedures and tests. However, we have to lead the way by sacrificing a few things of our own — and if we do it now, we’ll get to do it on our terms.

I think that Family Medicine needs to recognize that most primary preventive care doesn't belong in the medical silo at all. While all of us are family physicians because we recognize the value of preventive care, it is important to recognize that our value to our patients and to the population does not come from our ability as physicians to deliver preventive care. Routine preventive care and basic primary care for simple diseases can be done thoughtfully and efficiently by other providers. Rather, our role as physicians is best used doing things that no other provider can do — coordinating care across inpatient and outpatient systems, guiding patients through difficult decisions, managing complex medical problems involving multiple organ systems, and helping to shape policies affecting whole communities. These are challenges uniquely suited for family physicians to address, which give us unique satisfaction even as we give up the often comfortable routine tasks of preventive care. When we are being paid for these services and have the systems in place to support this work, we can expect both our satisfaction with our jobs and our value to our patients to increase.

To this end, we should support the development of community health worker programs made up of residents local to a particular area who are responsible for giving vaccinations, doing basic health education for simple chronic diseases, and following the protocols for screening that clutter our computer screens. While providing preventive care and talking to patients who don't have very many medical problems is an enjoyable part of practice, we must recognize that our medical degrees overqualify us for such tasks and we should be doing them about as often as we are teaching our patients how to give themselves insulin —  it happens and we can do it well because we understand how it works, but it shouldn't be our bread and butter.

Family physicians should then focus on mastering the knowledge and expertise that we have acquired during our medical education and embrace our role as experts at managing multiple complex chronic diseases, especially with psychosocial co-morbidities. We should be supervising and leading teams of community health workers, health coaches, care coordinators, nurses, pharmacists, physician assistants, and nurse practitioners who are managing the simpler medical issues, as is often the case in many other countries around the world. We should also embrace a more active role in coordinating care across the inpatient/outpatient divide; more family doctors should seek inpatient privileges and care for their patients in the hospital. This is one of the ways that we can avoid becoming aloof consultants ourselves. We should learn as much as possible about diseases such as sickle cell anemia & cystic fibrosis so that we can help transition these patients from their pediatric specialists to adult ones.

Another important aspect to our role as family doctors is embracing public health and population health; we should be spending our time not just in seeing very sick patients but also addressing the structural issues pertaining to our local neighborhoods where our patients live. Capitation-based payment may be one way to help tie particular doctors to particular communities, but it is not necessary if we are living in the same places as our patients and getting to know their neighborhoods & leaders. Our residency programs should emphasize leadership training as well as opportunities to engage local communities. I wrote about this in my Family Medicine Educational Consortium "This We Believe" essay titled Proximity, Vulnerability, Faith, & Love.

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care. This is not just about surviving health care reform — it’s about leading it so that our patients get the best care possible.


Matthew Loftus (@matthew_loftus) is a recent graduate of Medstar Franklin Square Family Medicine Residency. He lives with his wife and daughter in Baltimore, MD, where he will soon begin practicing at Healthcare for the Homeless.