Thursday, May 23, 2019

Counseling families about water safety

- Jennifer Middleton, MD, MPH

Memorial Day weekend traditionally marks the opening of outdoor pools across the United States, and balmier temperatures mean that recreational boating, swimming, and other water activities will begin to increase. With nearly 4,000 drowning deaths in the U.S. annually, now is the time of year to counsel families regarding safety in and around natural or man-made bodies of water.

A 2016 AFP article on “Prevention and Treatment of Drowning” reminded readers that “[d]rowning is rarely caused by a single factor” and “prevention strategies should not be pursued in isolation.” The American Academy of Pediatrics (AAP) recently updated its policy statement on prevention of drowning, noting that the highest death rates occur in children 12 to 36 months of age, followed by adolescents age 15 to 19 years, with alcohol consumption being a leading risk factor. The AAP has created an online Drowning Prevention Toolkit that features resources for physicians and child safety advocates, including public service announcements, infographics, information for parents, and sample social media posts with the hashtag #DrowningPrevention.

The American Red Cross encourages swimming lessons and avoidance of alcohol around pools and bodies of water for persons of all ages. They further recommend fences around home pools and to “actively supervise kids whenever around the water.” There’s even a “Swim” IPhone app by the American Red Cross (also available on Google Play) that can track progress through swim lessons and includes educational games for children that reinforce water safety tips.

The Centers for Disease Control and Prevention (CDC) reminds swimmers to check for pool safety and cleanliness before getting in by ensuring that drain covers are intact and clear of debris, along with ensuring that no cleaning chemicals or supplies are accessible. If no lifeguard is present, swimmers should familiarize themselves with the location of first aid and rescue equipment.  The CDC also discourages urinating or defecating in a pool; all swimmers should take a break once an hour, which is perfect for checking younger children’s diapers and encouraging older children to take a restroom break. You can find patient education handouts on water safety on the AFP website and the American Red Cross website.

Monday, May 20, 2019

Reducing medication cost burden in primary care: challenges and opportunities

- Kenny Lin, MD, MPH

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) finalized a new rule requiring that pharmaceutical companies disclose drug list prices in direct-to-consumer television advertisements for drugs that cost more than $35 for a month's supply or usual course. A fact sheet further explaining the rule noted that "the 10 most commonly advertised drugs have list prices ranging from $488 to $16,938 per month or usual course of therapy." Although pricing transparency could push patients to select more affordable or non-pharmacologic alternatives, and help clinicians improve high-value prescribing, it unfortunately does not make these drugs any less expensive.

In an editorial in the April 1 issue of AFP, Dr. Randi Sokol discussed four strategies for helping patients with type 2 diabetes mellitus afford insulin while providing evidence-based care: 1) Relax A1c goals to 8% or less; 2) Switch to human insulins instead of insulin analogues; 3) use Health Resources and Services Administration-certified 340B pharmacies and patient assistance programs; and 4) join advocacy efforts to reduce the high cost of insulin and other drugs, such as the Lown Institute's Right Care Alliance and the American Medical Association's Truth in Rx.

Family physicians can take a systematic approach to reducing prescription costs for all of their patients. In an article published in FPM, Dr. Kevin Fiscella and colleagues described the approach taken by 7 primary care practices in New York, Georgia, and California. Office staff screen patients for prescription cost concerns by privately asking them, "Is the cost of any of your medications a burden for you?" For patients who answer yes, clinicians briefly explore the circumstances (e.g., unmet deductible, use of brand name drugs) and employ several cost-reducing strategies, including deprescribing unnecessary medications, using extended (90-day) prescriptions, and substituting lower-cost medications or referring patients to large chain pharmacy discount programs (e.g. "$4 lists").

In a preliminary study published in a supplement to the Annals of Internal Medicine, Dr. Fiscella's team found that a single 60-minute training for clinicians and staff on cost-of-medication importance, team-based screening, and cost-saving strategies increased the frequency of cost-of-medication conversations from 17% to 32%. Other helpful articles in the same supplement supported by the Robert Wood Johnson Foundation included "The 7 Habits of Highly Effective Cost-of-Care Conversations" and "Tools to Help Overcome Barriers to Cost-of-Care Conversations." The American College of Physicians offers several additional cost-of-care conversation resources on its website.

Monday, May 13, 2019

Should physicians de-prescribe statins in older adults?

- Michael J. Arnold, MD

I work hard to de-prescribe unnecessary medications in my older patients, but I have never known what to do with statins. Are they preventing cardiovascular events or just causing trouble? Published studies included limited numbers of participants aged 75 years and older, so it has been difficult to know what to recommend.

A recent meta-analysis in The Lancet divided the subjects of 28 statin randomized trials by age groups, and identified over 14,000 who were over 75 years old. The analysis found that older adults benefit from statins for prevention of recurrent cardiovascular events (secondary prevention), but did not see a benefit for primary prevention. In the 6,000 older patients without a prior cardiovascular event, those taking statins weren't any less likely to have an event within 5 years than those taking placebos.

Unfortunately, the results aren’t definitive for primary prevention in older adults. Patients had less than a 3% risk of a cardiovascular event in the 5 years, leading to fewer than 100 events in each group - numbers too small to make firm conclusions. However, the low event rate should reassure primary prevention patients who wish to stop statins that any potential benefit is small. In addition, a large retrospective cohort study found that adults 75 years or older without vascular disease or diabetes did not benefit from statins. An ongoing primary prevention trial involving 18,000 adults over 70 years old will hopefully settle this question.

Even statins for secondary prevention in adults over 75 years old are not as valuable as in younger patients. The number needed to treat (NNT) is 125 to prevent a recurrent vascular event in 5 years, higher than the NNT for any other age group.

Another issue relevant to the decision to deprescribe a statin is the legacy effect. There is evidence of a significant benefit from having taken statins in the past, even in patients who have stopped taking them. Numerous studies have shown long-term benefit from taking statins during trials lasting only a few years. Another meta-analysis suggested that the legacy effect could be stronger for primary prevention.

Outside of the cardiovascular benefit, there isn’t much other evidence of statin benefits for older adults. The Lancet meta-analysis saw no difference in cancer incidence with statins. A Cochrane review showed that statins have no benefit for decreasing incidence of dementia.

Yet the argument for stopping statins is not strong either. Trials show that statins don’t have many adverse effects. They aren’t more likely to be associated with myalgia, rhabdomyolysis, hemorrhagic stroke or liver enzyme elevations than placebo. They do seem to increase the risk of developing diabetes at higher doses.

Deprescribing decisions will still require individualized shared decision making. An older adult without vascular events can likely stop a statin with minimal effect on risk, while a patient with a prior event will still benefit from continuing the statin, provided that he or she isn't experiencing adverse effects. You can find more in-depth information about statin use in this 2017 article on hyperlipidemia and the Practice Guidelines in the May 1 issue of AFP.

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Dr. Arnold is AFP's 2019-20 Jay Siwek Medical Editing Fellow. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, nor the U.S. Government.

Sunday, May 5, 2019

Team doctor or Grandma's doctor?

- Barry D. Weiss, MD

The Association of American Medical Colleges reports that there are only 39 family medicine geriatrics fellowships in the U.S. The combined total of family medicine and internal medicine allopathic and osteopathic physicians graduating from U.S. residency programs who entered geriatrics fellowships in 2019 was only 84, with more than 80% of fellowship positions remaining unfilled.

At the same time, there were 180 primary care sports medicine fellowships, the majority of which (140) are offered by family medicine programs. More than 90% of these programs filled in the 2019 Match, with 188 allopathic and osteopathic U.S. residency graduates entering these fellowships.

What’s wrong with this picture?

In the 2010 U.S. Census, 13% of the population (one of every eight people) was 65 years of age or older. This year, the number is closer to 17% (one of every six). By 2050, just 30 years from now – well within the working careers of current family medicine residents – close to a quarter of the population will be 65 or older. Moreover, these older adults are big users of the medical system. The number of physician office visits/100 persons by older adults is more than double the rate in any other age group.

Based on these statistics, it’s not likely that our current residency graduates will be devoting their careers to being team doctors or focusing on sports medicine. Rather, it is inevitable that they, and indeed all practicing generalist physicians, will spend a substantial portion of their practice time caring for older adults.

Why, then, is there so little interest in geriatrics in family medicine training programs? Pretty much all our current trainees are going to do in their future practices is take care of aging baby boomers. Why isn’t geriatrics front and center in our training programs?

Furthermore, it’s not only students and residents who lack interest in geriatrics. One of my professional roles is serving as medical editor of AAFP’s FP Essentials monographs. When we issued a call for authors for an upcoming monograph on a musculoskeletal/sports medicine topic, we received proposals from 18 teams of family medicine authors interested in writing the monograph. In contrast, a call for authors for a geriatrics monograph brought in only a handful of proposals.

Key reasons for a lack of interest in geriatrics have been identified – among them are a preference for treating less complex patients who have curable conditions, and the relatively low compensation for geriatric care. But, we also know that providing exposure to and education about care of older adults can increase physicians’ interest in geriatrics. Geriatrics rotations should expose trainees to a broad range of older adult populations, from institutionalized adults to vigorous, physically active seniors.

Working with students, residents, colleagues, and our communities, we all have a responsibility to increase awareness of the special issues involved in providing high-quality care for older adults, and to highlight the rewards and satisfaction gained from providing that care. Family physicians can be the leaders in geriatric care. All we need to do is: do it.

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Dr. Weiss is an AFP Associate Medical Editor and Editor of FP Essentials.

Sunday, April 28, 2019

Hypertension management: can lifestyle interventions replace ARBs?

- Kenny Lin, MD, MPH

Since July 2018, the U.S. Food and Drug Administration (FDA) has issued more than 20 recalls of the angiotensin-receptor blockers (ARBs) valsartan, irbesartan, and losartan because they contained potentially carcinogenic contaminants. As a result, there are now widespread shortages of these anti-hypertensive drugs. Although the FDA's internal analyses and published studies suggest that the excess cancer risk is small even with long-term use, and the FDA has posted a list of currently available ARBs that have been tested and found safe, identifying substitutes may be difficult. Many patients prescribed ARBs may already take other first-line anti-hypertensive drugs at maximum doses and/or be unable to tolerate angiotensin-converting enzyme (ACE) inhibitors due to cough.

One underutilized alternative is motivating patients with high blood pressure to make therapeutic lifestyle changes. In a Lown Right Care article in the March 15 issue of AFP, Drs. Ann Lindsay, Ajay Sharma, and Alan Glaseroff observed that "physicians ... often go straight to telling patients what to do without listening to what the patient thinks or is willing to do." Evidence suggests that patients are more likely adhere to treatment plans if physicians first get to know the patient's story and health goals, and that five key clinician behaviors are associated with better health outcomes: "(1) emphasizing patient ownership—work on patient goals; (2) partnering with patients on what they are willing and able to do; (3) identifying small steps to ensure success; (4) scheduling frequent follow-up visits to cheer successes or problem solve; and (5) showing care and concern for the patient."

A recent commentary in the Annals of Internal Medicine noted that the 2017 ACC/AHA hypertension guideline barely mentioned the value of lifestyle interventions for persons with hypertension or the barriers to providing them in primary care settings:

Practices that are not structured and staffed to systematically assess patient lifestyle factors, support behavior modification counseling, and provide follow-up will face obstacles to implementation. Clinicians in these practices also must be supported by relevant competencies; professional guidelines; routine feedback; and on-site training in practice change, such as academic detailing and practice facilitation. ... Ensuring that clinicians knowledgeable in behavior change theory and evidence-based lifestyle interventions are part of the primary care team is even more important.


Clinicians and patients may question if exercise programs have the same blood pressure-lowering benefits as medications. Although no randomized, controlled trials have directly compared exercise against medication, a systematic review and network meta-analysis of 391 trials found that in persons with hypertension, endurance or dynamic resistance exercise was equally effective for lowering systolic blood pressure as ACE inhibitors, ARBs, beta-blockers, and diuretics.

Monday, April 22, 2019

Preventing lawn mower injuries with simple safety steps

- Jennifer Middleton, MD, MPH

Although lawn mowers don't seem to get a lot of press, over 80,000 persons in the United States are injured by them every year; children under the age of 19 make up a substantial minority of these injuries (estimates range from 4,000 to 13,000 children per year). Most injuries are lacerations or burns, but some lead to serious skin infections, and some are severe enough to require limb amputation. Lawn mower injuries are largely preventable with some simple safety measures. With spring weather upon us in the U.S., it's worth discussing lawn mower safety with patients, especially parents of young children and teens.

Young children (ages 1-3 years) and adolescents are the most likely youth to be injured by a lawn mower; young children are more likely to be accidentally struck when a lawn mower is put into reverse or hit by objects discharged into the air by a lawn mower in use, such as sticks, stones, or toys; teenagers are less likely to follow standard safety measures when operating a lawn mower themselves. The American Academy of Orthopedic Surgeons advises parents to forbid children from playing on a lawn as it is being mowed; they also discourage children from riding on riding lawn mowers with adults. The American Academy of Pediatrics recommends that children be at least 12 years of age before independently operating a push lawn mower and 16 years of age before using a riding lawn mower. Checking and clearing the lawn of debris prior to mowing, ensuring that children are playing elsewhere while mowing, and wearing closed-toed shoes, hearing protection, and eye protection are crucial safety actions for all operators of lawn mowers.

Adults sustain the largest numbers of injuries, however, and need to follow appropriate safety measures for themselves as well. The American Society for the Surgery of the Hand advises keeping blades in good condition and avoiding alcohol prior to or during mowing. They also discourage putting hands or feet into the mower to clear debris, lifting the mower from the bottom, and tampering with safety devices and guards. The mower's engine should be turned off, and the blades should stop moving, before crossing a gravel path, removing the grass catcher, or walking away from the mower.

With these simple safety steps, mowing the lawn can be an enjoyable and healthy activity. Pushing a lawn mower is beneficial aerobic exercise, which qualifies as an activity requiring at least 4 METs of functional capacity. Certainly many homeowners enjoy the calm rhythm of lawn mowing, too. You can find more safety tips for spring and summer activities in this 2018 post by Dr. Lin and a previous AFP article on prevention of unintended childhood injury.