Monday, April 24, 2017

Rethinking how we use office blood pressure measurements

- Jennifer Middleton, MD, MPH

The accuracy of medical office blood pressure (BP) measurements is coming under increased scrutiny, possibly affecting how we treat our patients. Basing hypertension diagnosis and treatment on the BP values we obtain in our offices is routine for many of us as family physicians, but checking BP several times during an office visit may more appropriately guide diagnosis and treatment decisions.

In its March/April issue, the Annals of Family Medicine includes a study on "Thirty-Minute Office Blood Pressure Monitoring in Primary Care." The researchers examined every patient over a six-month period who received automated office BP monitoring over a 30 minute period (OBP30) in a practice in the Netherlands. This method has been previously studied there and was found to yield more useful BP data than a single measurement. The researchers then compared the OBP30 readings to these same patients' previously obtained single BP measurements and asked their physicians if they found a clinically meaningful difference: did they make different diagnosis and treatment decisions because of the OBP30 readings?

There were clinically significant differences in both systolic and diastolic BP comparing the single office BP measurement with the OBP30 measurements; the mean systolic OBP30 measurement was 22.8 mmHg lower than the single office BP measurement (95% CI, 19.8–26.1 mm Hg), and the mean diastolic OBP30 measurement was 11.6 mmHg lower (95% CI, 10.2–13.1 mm Hg). The physicians stated that they would have initiated or intensified BP treatment in 79% of patients based on the single office BP measurement, compared to only initiating or intensifying treatment in 25% of these same patients once they had their OBP30 measurements.

These sizable differences imply that we are at risk of overtreating, and possibly incurring undesirable medication side effects, if we base decisions only on single office BP measurements. SPRINT already encourages more aggressive BP goals in some patients; if aiming for a BP of less than 120/80, the risk of over-treatment could be magnified if medication increases are made solely based on solitary BP readings. Additionally, a study reviewed in the current AFP article on "Severe Asymptomatic Hypertension: Evaluation and Treatment" cites a study finding that "[i]n more than 30% of patients with severe asymptomatic hypertension, blood pressure lowers to an acceptable level (mean of 160/89 mm Hg) without intervention following a 30-minute rest period." Even when BPs are first alarmingly high, waiting and rechecking can prevent over-treatment.

An editorial accompanying the above Annals article reviews the challenges of changing our office workflow to accommodate improved BP measurements. Allowing a patient to sit for even 5 minutes before a single BP measurement can be a challenge, let alone keeping them there for 30 minutes. Dr. Lin has written previously on the blog about the usefulness of home BP measurements in adjusting treatment in patients with established hypertension, so that might be an alternative. Either way, if our goal is to treat the patients who need treatment - and not treat those who don't - expanding beyond a single office BP measurement to guide our decisions may help.

There's an AFP By Topic on Hypertension which includes several resources to assist with diagnosis and treatment if you'd like to read more. This recent Family Practice Management article on "Improving Blood Pressure Control with Strategic Workflows" might also be of interest.

Monday, April 17, 2017

Safety net doesn't shield patients from low-value care

- Kenny Lin, MD, MPH

During my residency training and for parts of my career, I practiced in several "safety net" clinics, defined as clinics that serve a patient population where at least 25% have no health insurance or are insured with Medicaid. As family physicians who work in these settings well know, resources are often limited, and arranging for patients to receive necessary care at an affordable price can be a major challenge.

While on telephone hold one day for the umpteenth prior authorization request for a medication my patient had been taking for years, I remember consoling myself that at least these maddening financial constraints provided protection against low-value care. Unlike the concierge practice on the other side of town, I couldn't get patients with acute low back pain into a magnetic resonance imaging (MRI) scanner the next day or order huge panels of unnecessary laboratory tests at health maintenance exams.

As it turned out, my perception was more myth than reality. In a recent cross-sectional analysis of national survey data on nearly 200,000 office visits from 2005 to 2013, Dr. Michael Barnett and colleagues examined performance on quality measures for low- and high-value care among uninsured patients, patients with Medicaid, and privately insured patients. Sample low-value care measures included computed tomography (CT) for sinusitis, screening electrocardiogram during a general medical examination, and CT or MRI for headache. High-value care measures included aspirin, statin, and beta-blocker use in patients with coronary artery disease and tobacco cessation and weight reduction counseling in eligible patients. The authors analyzed the data by insurance type and by physicians classified as practicing in a safety net population. They found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.

This study's findings underline the importance of involving clinicians and patients in underserved practices in the Choosing Wisely campaign against medical overuse. For example, the Connecticut Choosing Wisely Collaborative used a foundation grant to study patient-clinician communication about care experiences and incorporate the Choosing Wisely "5 Questions" at two federally qualified health centers. Lessons learned from these pilot projects included providing patients with context for the "5 Questions" materials and offering ongoing role-specific training and support for everyone on the care team.


Monday, April 10, 2017

More information on NSAIDs & CV risk

- Jennifer Middleton, MD, MPH

Have your patients been asking about non-steroidal anti-inflammatory drug (NSAID) safety? I've seen several lay press articles recently regarding a couple of new NSAID safety studies, and they are definitely prompting patients to ask questions in my office. Both studies reinforce the cardiovascular risks we already know about NSAIDs.

The first study scrutinized four European countries' population health registries for an association between current oral NSAID use and risk of admission to a hospital for acute heart failure. The authors matched individuals in these databases who were admitted with heart failure and had been using an NSAID in the last 14 days ("current" use) to individuals of a similar age, gender, and health risk who were not admitted and had used NSAIDs previously ("past" use, defined by use at least 183 days prior). Those individuals with "current" use of any NSAID were more likely to be admitted with heart failure compared to those with "past" use (odds ratio 1.19 [95% confidence interval 1.17-1.22]). Regarding particular NSAIDs, ibuprofen, naproxen, indomethacin, and diclofenac all increased the risk of heart failure admission while celecoxib, etodolac, and meloxicam did not.

The second study, conducted in Denmark, examined the association between out of hospital cardiac arrest and oral NSAID use in the 30 days prior. All cases of cardiac arrest in Denmark are entered into a registry, and the researchers excluded individuals with obvious non-cardiac causes of arrest (trauma, overdose, etc). Every prescription in Denmark is tracked via another registry, and most NSAIDs used there are prescribed; over the counter NSAID availability in Denmark is quite limited (only small quantities of low dose ibuprofen may be purchased without a prescription). The researchers found the use of any NSAID to increase the risk of out of hospital cardiac arrest (OR 1.31, 95% confidence interval 1.17-1.46), which was mostly driven by ibuprofen and diclofenac's effect - by far the most commonly prescribed NSAIDs there.

NSAID safety concerns are nothing new; this 2009 AFP article advises us to be cautious before prescribing NSAIDs to patients at increased risk of bleeding along with chronic heart, liver, and/or kidney problems. I've written previously on the blog about a large meta-analysis published in 2013 showing that long term NSAID use increased the risk of heart failure. These two new studies, however, may cast even short term safety of NSAIDs in a questionable light. Neither set of researchers commented on how long patients had been taking NSAIDs who were "current" users, but it seems possible that at least some of the individuals in these cohorts were not using them long-term.

These studies provide us with more information to discuss with patients when considering options for acute or chronic pain relief. Although oral NSAID use increased cardiovascular risks in both of these studies, the odds ratios in each study were not terribly high; this increase in risk might be more acceptable to many patients - and physicians - than the risks of opioids. With the ever-growing awareness of opioid misuse, we'll have to decide with each patient which set of risks and benefits are the most acceptable. Topical NSAIDs may also be worth including in conversations about treating acute musculoskeletal pain.

Will these new studies change how you discuss NSAIDs with patients?

Tuesday, April 4, 2017

AAFP and ACP confront the opioid epidemic

- Kenny Lin, MD, MPH

Although I rarely initiate opioid therapy, my practice has inherited an increasing number of patients for whom previous physicians have prescribed potentially dangerous doses of opioids for chronic musculoskeletal or neuropathic pain. What is the best approach to take to this situation? As Dr. Jennifer Middleton discussed in an earlier AFP blog post, I could follow the Centers for Disease Control and Prevention guideline and try to reduce their pain prescriptions to safer levels by substituting alternative treatments, such as cognitive behavioral and physical therapy. I could choose to stop prescribing opioids for chronic pain, as one federally qualified health center did with notable success. I could also seek out additional training to become certified to treat opioid addiction with buprenorphine.

Last year, Surgeon General Vivek Murthy called on every physician in the U.S. to pledge to work with him to "turn the tide" on the opioid epidemic. Writing in New York Magazine, columnist Andrew Sullivan recently called it "this generation's AIDS crisis" - an epidemic that, by being highly concentrated in one demographic (AIDS in urban gay men, opioids in rural, white working-class persons), was invisible to most Americans:

For many of us, ... it’s quite possible to live our daily lives and have no connection to this devastation. And yet its ever-increasing scope, as you travel a few hours into rural America, is jaw-dropping: 52,000 people died of drug overdoses in 2015. That’s more deaths than the peak year for AIDS, which was 51,000 in 1995, before it fell in the next two years. The bulk of today’s human toll is related to opioid, heroin, and fentanyl abuse. And unlike AIDS in 1995, there’s no reason to think the worst is now over.

The April 1 issue of AFP featured a Practice Guidelines summary of the American Academy of Family Physicians' position paper on management of chronic pain and opioid misuse, which noted that "in addition to physicians, there are opportunities to help at the practice, community, education, and advocacy levels." In an accompanying editorial, two family physician authors of the position paper argued that family physicians should take a leading role in responding to the opioid crisis:

Family physicians are committed to advancing population and community health, and we must take the lead in reducing opioid misuse and overdose before outside entities mandate practice strategies that may not be patient-centered. Substance abuse disorders remain a stigma, and physician offices must be safe places for nonjudgmental diagnosis and treatment. Although we certainly cannot tackle this challenge alone, we have a clear opportunity to combat the problem of opioid misuse.


Similarly, the American College of Physicians recently published a position paper on prevention and treatment of substance use disorders that observed that only 18% of people in the U.S. with a substance use disorder are receiving treatment, far short of treatment rates for other chronic conditions in primary care: hypertension (77%), diabetes (73%), or major depression (71%). The authors concurred with the AAFP that multi-pronged efforts will be required to reduce the rising toll of opioid misuse:

Multiple stakeholders should cooperate to address the epidemic of prescription drug misuse, including the following strategies: implementation of evidence-based guidelines for pain management; expansion of access to naloxone to opioid users, law enforcement, and emergency medical personnel; expansion of access to medication-assisted treatment of opioid use disorders; improved training in the treatment of substance use disorders, including buprenorphine-based treatment; establishment of a national prescription drug monitoring program (PDMP); and improvement of existing monitoring programs.

Monday, March 27, 2017

Simplifying treatment of acute asthma

- Jennifer Middleton, MD, MPH

A 2 day course of oral dexamethasone emerged as an alternative to a 5 day prednisone course for acute asthma treatment in adults a few years ago, and now a POEM (patient-oriented evidence that matters) reviewed in the current issue of AFP suggests that just one dose of dexamethasone might also be an option.

The study researchers enrolled 465 adults between the ages of 18-56 who were diagnosed with acute asthma in an emergency department (ED). The participants were randomized to either 60 mg of prednisone for 5 days or 12 mg of oral dexamethasone once (followed by four days of placebo). This study used a noninferiority design; the researchers wanted to see if both regimens were equally efficacious regarding the reduction of relapses requiring additional days of steroid treatment. 9.8% of the prednisone group had a relapse compared with 12.1% of the single dose dexamethasone group, which was a statistically significant difference. There was no difference in hospitalization rates or adverse treatment effects between the two groups. Although 5 days of prednisone was more effective at preventing relapse, the researchers felt that the difference between the two treatment arms was small enough, and the benefits of better compliance high enough (since the dexamethasone was given in the ED), to still make it a viable option.

Shorter courses of dexamethasone may also be an option for our patients under the age of 18 with acute asthma. A meta-analysis published last year found that short courses (1-2 days) of dexamethasone were equivalent to longer courses of oral prednisone or prednisolone for children presenting to the ED with acute asthma in preventing relapse. 1-2 day treatment courses are likely easier for children and parents to adhere to, and children may additionally find oral dexamethasone to be more palatable than oral prednisolone. Inhaled anticholinergics are also a useful adjunctive treatment for children with acute asthma (and possibly for adults with severe exacerbations) as reviewed in this 2011 AFP article on the Management of Acute Asthma Exacerbations. The article mentions a 2008 study that found 3 days of prednisone to be equivalent to 5 days for outpatient treatment of acute asthma.

A 2016 Cochrane review on corticosteroid options for acute asthma in adults and children found that existing evidence was insufficient to state whether one type of oral corticosteroid therapy - regardless of specific medication or treatment duration - was superior to another for outpatient treatment of acute asthma, calling for larger, more rigorous trials. It is reassuring, at least, that they did not find any "convincing evidence" that one type of treatment was worse than another regarding rates of relapse, hospitalization, and adverse drug effect. For the time being, we'll need to use patient-centered decision making to arrive at the best treatment plan for each patient with acute asthma, though it certainly seems reasonable to consider shorter durations of oral corticosteroids in uncomplicated pediatric and adult patients. There's an AFP By Topic on Asthma if you'd like to read more.

Having a reliable source for potential practice-changers, like this 1-dose dexamethasone study, can help busy family physicians stay up to date. At the bottom of this most recent AFP POEM are links to several such resources. There's an archive of AFP's published POEMs, complete with a tool to quickly search them by discipline, topic, and/or keyword. The AFP Podcast regularly reviews the POEMs published in AFP like the one above, often adding additional information, angles, and/or resources along the way. The POEM of the Week Podcast with AFP Editor Dr. Mark Ebell is another audio resource that provides concise, thoughtful reviews of studies relevant to primary care.

How do you decide which corticosteroid to prescribe - and for how long - in acute asthma treatment?

Tuesday, March 21, 2017

The influence of residency training on high-value care

- Kenny Lin, MD, MPH

The American Academy of Family Physicians last week celebrated the results of the 2017 Match, which saw a record 3,237 medical students and graduates fill first-year positions in family medicine residency programs. Although there is ample evidence that providing primary care improves population health, it is less clear how residency training specialty or location influences future health care quality and spending.

As Dr. Jennifer Middleton and I mentioned in prior posts, the AAFP was an early adopter of the American Board of Internal Medicine Foundation's Choosing Wisely campaign against questionable or unnecessary medical interventions, but so far, studies have shown limited effects of the campaign in primary care. Since an estimated 30 percent of health care spending is wasted on unnecessary services, and a recent case study in JAMA suggested that "excessive resource utilization" may be considered an adverse event, it is worth studying if residency training spending patterns persist in clinical practice.

In a research paper in this month's Annals of Family Medicine, Dr. Robert L. Phillips, Jr. and colleagues at the American Board of Family Medicine and the Robert Graham Center analyzed spending patterns of a nationally representative sample of 3,075 family physicians and general internists who graduated from residency between 1992 and 2010 and who cared for a total of more than 500,000 Medicare patients. The physicians' residency program locations were matched with Hospital Service Areas (HSAs) and categorized by spending per patient into low-, average-, and high-cost groups. The researchers found that the "imprint" of residency training spending patterns persisted regardless of where physicians ended up providing primary care:

Physicians trained in high-cost HSAs spent significantly more per patient than those trained in low-cost HSAs, no matter what the spending category of the practice HSA. Averaged across all practice HSAs, this difference was $1,644. ... This relationship held true for family physicians and general internists in our multivariable analysis; general internists, however, made up two-thirds of sample physicians trained in high-cost HSAs, and family physicians made up two-thirds of those trained in low-cost HSAs. [Residency] graduates were significantly more likely to be low-cost physicians if their sponsoring institution produced fewer total physicians, more rural physicians, or more primary care physicians.


The researchers found no relationship between spending patterns and diabetes quality measures, suggesting that lower spending did not lead to worse health outcomes. And it is important to note that family physicians who trained in high-cost HSAs were as likely to be big health care spenders as general internists from high-cost programs; in other words, there did not appear to be anything inherent in family medicine training that caused graduates to spend less. However, more general internists provided costlier care by virtue of having trained in high-cost areas - most likely, those with tertiary academic medical centers. I agree with Dr. Phillips and colleagues' conclusion that their study "supports efforts to test interventions in residency training that may bend imprinting toward teaching and modeling behaviors that improve value in health care." One intervention has borne fruit for the past 8 years in a row: attracting more medical students to the specialty of family medicine.