Monday, October 16, 2017

Interview with AFP's incoming editor-in-chief

- Jennifer Middleton, MD, MPH

On February 1, 2018, AFP will have its first new editor-in-chief in 29 years. In an interview this past week, Dr. Sumi Sexton shared some of her ideas with me about the journal's online presence (hyperlinks below are my additions):

How do AFP's online platforms (Facebook, Twitter, Community Blog, podcast, website) fit into your overall goals for the journal going forward?
I'd like to engage readers through the various platforms to generate discussion ranging from comments on various articles or AFP features to feedback on what we can do to improve.  We don't always have room to include everything we want on a topic in print, so it is nice to be able to include some of these online. I love the concept of Twitter chats, and how the most recent one on antibiotic prescribing incorporated an AFP editorial, a Cochrane for Clinicians, an AHRQ review, and was mentioned on the Community Blog. I look forward to seeing more of that.
AFP's Facebook page, Twitter feed, podcast, and Community Blog offer several different ways for readers to connect with us online, but the number of readers who engage with us on those platforms is a relatively small proportion of total AFP subscribers. How might AFP encourage more readers to connect with these platforms?
I intend to brainstorm with the AFP team on how we can enhance an article on a clinical topic through these platforms. For example, the "Diabetes Self-Management" article in the September 15 issue could be enhanced by a more personal story akin to Diary from a Week in Practice which I used to edit and dearly miss. Another example would be to provide information to family docs on what their colleagues are doing; in the September 1 issue, for example, the article on "Aseptic and Bacterial Meningitis" mentions the meningococcal type B vaccines. How many of our readers are giving this vaccine and why or why not?
In your recent AAFP news interviewyou mentioned wanting to speak with readers "in person and online to see how we can better meet their needs." How do you envision connecting with readers online? What information would you like to learn from them?
It would be interesting to see responses from readers to online polling for certain features like editorials (for example, Controversies in Family Medicine) or articles on more controversial topics (like the article and editorial on "Testosterone Therapy" in the October 1 issue). While it may take a little time to post a comment, it is easy to click on a link to answer a quick yes or no on Twitter or Facebook. In addition to knowing what our readers think about medical topics, I'd like to know how they like to receive information. How could AFP be more accessible at the point of care? Is there anything we can do to make CME through the journal easier for them?
AFP's online presence will certainly continue to grow under Dr. Sexton's leadership, and we'll keep you updated about new tools and ways to connect. In the meantime, what additions would you like to see in AFP's online content? 

Monday, October 9, 2017

Key updates in preventive services from the USPSTF

Kenny Lin, MD, MPH

In the third installment of a series that began in 2015 and continued with last year's one-page Preventive Health Care schedule, American Family Physician recently published "USPSTF Recommendations: New and Updated in 2016," authored by Deputy Editor and former U.S. Preventive Services Task Force (USPSTF) member Mark Ebell, MD, MS. Dr. Ebell's editorial summarized 15 recommendations released by the USPSTF in 2016 and provided more details about several key updates.

1) Colorectal cancer screening: "the USPSTF now recommends that physicians offer any one of seven options for colorectal cancer screening:

- Annual fecal immunochemical testing (FIT);
- Colonoscopy every 10 years;
- FIT plus fecal DNA (Cologuard) every one to three years;
- Computed tomographic colonography every five years;
- The combination of flexible sigmoidoscopy and FIT;
- Flexible sigmoidoscopy alone every five years; or
- Annual guaiac-based fecal occult blood testing."

The recommended duration of routine screening remains from ages 50-75, with selective screening advised for adults aged 76-85 years, based on the patient's overall health, prior screening history, and personal preferences.

2) Aspirin for primary prevention of cardiovascular (CV) disease and colorectal cancer: "the USPSTF now recommends aspirin use only in adults 50 to 69 years of age who have a 10-year risk of a CV event of at least 10%, are willing to take aspirin for at least 10 years, and are not at increased risk of bleeding."

3) Statins for prevention of CV disease: "Like the [2013 ACC/AHA guidelines], the USPSTF recommendations for statin use base the decision on the patient's 10-year CV risk and do not identify specific low-density lipoprotein targets. They differ from the ACC/AHA guidelines in that they give a B rating for a low- or moderate-dose statin for patients with a 10-year CV risk event of 10% or greater, but a C rating for those with a 7.5% to 10% risk."

4) Depression screening in adults: "The recommendation ... now explicitly includes pregnant and postpartum women. The Edinburgh Postnatal Depression Scale is the recommended screening tool."

5) Screening for autism spectrum disorder (ASD): "Although there have been several small clinical trials showing the benefit of treatment in children with ASD, all trials were conducted in children who were identified by parents or caregivers and who have relatively severe symptoms. The USPSTF [insufficient evidence] recommendation covers screening in asymptomatic children whose parents and teachers have not identified any concerns."

For a complete list of Task Force recommendations on clinical preventive services, family physicians can consult the USPSTF's website or the Agency for Healthcare Research and Quality's Electronic Preventive Services Selector (ePSS) tool. For easy reference, AFP and the American Academy of Family Physicians have also collected USPSTF recommendations for children, adolescents/young adults (ages 11-26), and adults (ages 18 and older).

Monday, October 2, 2017

Learning about our patients via their pets

- Jennifer Middleton, MD, MPH

A Close-up on Pet Therapy in the October 1 issue of AFP shares one patient's benefit from caring for her dog through the challenges of an abusive relationship and subsequent homelessness. The patient's family physician helped her find low-cost veterinary care and allowed the dog to accompany the patient to visits; the patient's appreciation of these acts is clear in her narrative. Asking about pets as part of the social history can not only provide family physicians with important information about our patients' personal health but may also help us develop meaningful wellness strategies with patients that incorporate their pets.

Pet ownership correlates with several health benefits; pets can provide meaningful social support, encourage regular physical activity, and possibly even improve cardiovascular health. Pets may help children develop compassion and enjoy a higher quality of life. Similar to the Close-up mentioned above, the homeless youth who own pets report that they help them to not only feel safe but also help to attenuate loneliness.

Knowing about our patients' pets may help us understand their health better, but we can also incorporate our patients' pets into treatment plans for mental health conditions and cardiovascular disease. Regular time with pets can increase anxious individuals' willingness to engage with themselves and others in treatment. Creating an exercise routine that involves a pet may appeal to some patients. Discussing the risk to pets of second-hand tobacco smoke may motivate some patients to quit.

We can also work with our veterinary colleagues to ensure that pet ownership is healthy for pets and humans alike. This 2016 AFP editorial about the One Health initiative describes this partnership between veterinary and human medicine to reduce the prevalence of zoonotic infections such as rabies, ringworm, and toxoplasmosis. Here's a link to AFP articles that include the keyword Animal-Related Diseases if you'd like to read more.

Encouraging our patients who don't have pets to consider obtaining one, however, may be ill-advised; it's likely beyond our scope to investigate whether patients have the resources and ability to care adequately for a pet. If we feel interacting with animals might benefit a patient without a pet, we could suggest opportunities to interact with animals such as volunteering at a shelter or caring for a friend or family member's pet. Animal-assisted therapy may also be available in your community; this Curbside Consultation from 2016 describes animal-assisted therapy and its benefits in more detail.

What have you learned about your patients by asking about their pets? Have you incorporated patients' pets into their wellness strategies?

Tuesday, September 26, 2017

Medication-assisted treatment for opioid addiction: the family physician's role

- Kenny Lin, MD, MPH

Millions of Americans suffer from a potentially fatal disease that has become so common over the past decade that it has lowered the average life expectancy and has particularly devastated vulnerable populations, such as adults with mental health disorders. Although effective medications exist to treat this national health emergency, only a small fraction of family physicians can prescribe them, and even certified physicians face numerous obstacles to providing treatment where their services were most needed. Instead, most efforts have focused on disseminating guidelines to prevent this condition, mostly by reducing known risk factors. Unfortunately, most of what we know about prevention is only supported by low-quality evidence on patient outcomes.

I am writing, of course, about the epidemic of opioid use disorder and overdoses. In an editorial in the Sept. 15 issue of AFP, Dr. Jennifer Middleton argued that while reducing the risk of addiction through the selective and responsible prescribing of opioid medications for pain is important, it is not sufficient to turn the tide. Observing that there is a critical shortage of substance abuse subspecialists, she encouraged family physicians to obtain a Drug Abuse Treatment Act of 2000 (DATA 2000) waiver to prescribe buprenorphine:

Family physicians ... are already adept at combining behavioral interventions with medication management for chronic diseases such as diabetes, cardiovascular disease, and chronic obstructive pulmonary disease; addiction treatment requires a similar combination of lifestyle coaching and prescription oversight. ... 

Buprenorphine is no more complex or difficult to manage than many other treatments routinely used in primary care. Additionally, our specialty has historically embraced the needs of populations labeled as difficult or challenging, such as homeless persons, refugees, and those with developmental disabilities or mental illness. Patients who are struggling with addiction are no less deserving of our attention.

Whether or not medication-assisted treatment (MAT) for opioid use disorder should become part of every family physician's scope of practice is a subject of intense debate, most recently in a pair of Point/Counterpoint editorials in the Annals of Family Medicine. Echoing Dr. Middleton, Dr. David Loxtercamp wrote about his "conversion experience" - the 19 year-old patient with whom he realized that he needed to be able to prescribe MAT to provide adequate care to her and so many others like her. "I am still involved [in MAT]," he wrote, "because I am a doctor and this is the epidemic of our time, a social tsunami that can be traced to my prescription - and yours. ... Addiction is a chronic disease that is decimating our communities. We need no other reason to embrace its treatment within every primary care practice."

Taking the opposite view that not every family physician can "be at the front lines" of the fight against the opioid epidemic, Dr. Richard Hill outlined several other factors that weigh against most family physicians prescribing MAT: specialized treatment required, comorbid psychiatric illness, methods shortcomings of emerging models of care, and the risk that taking on this additional responsibility would create more job dissatisfaction and burnout. "Even if further research establishes an 'optimal' model of care for use in primary care," he asserted, "the nature of the disease [opioid use disorder] itself will place undue clinical burden on an already overextended clinical workforce. Perhaps future efforts and funding should be directed toward the development of readily accessible referral networks of mental health/addiction centers, both public and private."

Both sides of the debate make compelling points. What do you think the family physician's role should be in MAT for opioid addiction?

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.