Monday, January 14, 2019

AFP Clinical Answers at the point of care

- Jennifer Middleton, MD, MPH

Family physicians have an average of 15-20 clinical questions every day while caring for patients. Identifying trustworthy sources of online or app-based content requires family physicians to identify "whether the reference clearly states how strong the evidence is to support recommendations about patient care." If AFP is one of your trusted sources of answers, you may find our new department, AFP Clinical Answers, of particular interest.

The January 1, 2019 issue of AFP includes the first AFP Clinical Answers article covering nausea in pregnancy, knee osteoarthritis, hormone therapy, and the shingles vaccine. Each content area has a brief paragraph providing key information along with a hyperlink to a more in-depth AFP article. As AFP Editor-in-Chief Dr. Sumi Sexton writes introducing the department, "The goal of this department is to share key clinical questions and their evidence-based answers directly from the journal's content. Our hope is that readers will find these answers useful for patient care and serve as a reminder of the topics we've covered."

If you're interested in further expanding your point of care resources, AFP's Point-of-Care Guides collection provides one-page commentary on the latest evidence base pertinent to many common patient care issues. FPM's (formerly Family Practice Management) SPPACES: App Reviews Department includes reviews for both point-of-care apps for clinicians as well as useful apps for patients. The Agency for Healthcare Research and Quality (AHRQ) also has a "Practical Tools for Primary Care Practice" website with tools and guides on everything from clinical practice guidelines to becoming a high-performing team. 

Don't forget about the "Favorites" feature on the top of the AFP home page, where you can bookmark common resources (from AFP and/or anywhere on the internet) for quick access. You can connect to the Evidence-Based Medicine toolkit from the home page for a refresher on reviewing strength of evidence terms, and you can access the AFP podcast from the home page, too, which frequently features suggestions for additional resources related to content in the print journal.

How are you planning to expand your point of care acumen in 2019?


Tuesday, January 8, 2019

When deprescribing is the best medicine

- Kenny Lin, MD, MPH

Physicians who care for older adults or other patients with multiple chronic conditions understand that deprescribing unnecessary or inappropriate therapies is central to providing high-quality care and improving patient safety. An editorial by Drs. Barbara Farrell and Dee Mangin in the January 1 issue of AFP reviewed the health risks associated with polypharmacy (taking five or more chronic medications) and provided a table of resources for each step of the deprescribing process, including several evidence-based guidelines co-written by the authors. AFP's Practice Guidelines department summarized their guideline on deprescribing antipsychotics for dementia and insomnia last September and reviewed how to taper benzodiazepine receptor agonists for insomnia in adults in the January 1 issue.

A 2018 systematic review in the British Journal of General Practice reviewed data from 27 randomized, controlled trials of deprescribing a range of drug classes in adults aged 50 years or older in primary care settings. In 19 studies, at least half of patients in the intervention groups were able to stop their medications completely, and adverse effects were uncommon. However, the risk of "relapse" (needing to resume the drug after completely discontinuing it) ranged from 2 to 80 percent.

Patient expectations, medical culture, and organizational constraints can present barriers to deprescribing. A qualitative study of New Zealand primary care physicians in the Annals of Family Medicine described deprescribing as "swimming against the tide." Study participants recommended several practice and system-level interventions to support deprescribing that could also be applied to practices in the U.S.:

- Targeted funding for annual medicines review
- Computer alerts to prompt physicians’ memories
- Computer systems to improve information sharing between prescribers
- Improved access to non-pharmaceutical therapies
- Research to build the evidence base in multimorbidity, education and training
- Ready access to expert advice and user-friendly decision support
- Updating guidelines to include advice on when to consider stopping medicines
- Tools and resources to assist in the communication of risk to patients
- Activating patients to become more involved in medicines management and alert to the possibility that less might be better

Along those lines, the AFP editorial also provided a Table of examples of language that family physicians can use to discuss deprescribing with patients and facilitate shared decision-making.

Tuesday, January 1, 2019

Approaches to behavior change that work

- Jennifer Middleton, MD, MPH

It's time for New Year's resolutions, and many of our patients will ask us for help implementing them. The December 15 issue of AFP includes the timely article on "Counseling Patients in Primary Care: Evidence-Based Strategies" which reviews several useful counseling techniques. This article adds to the growing literature of simple methods that can help our patients make healthy changes.

The AFP authors review key tenets of FRAMES, motivational interviewing, BATHE, the stages of change, and the 5A's, providing recommendations about choosing techniques and examples of phrasing to use with patients. All techniques share an emphasis on empathetic patient engagement. The authors also advocate for addressing multiple issues within a visit (such as tobacco use, weight loss, and hazardous alcohol use) and cite data demonstrating that doing so leads to increased change for all of the behaviors addressed.

A 2016 study examined which physician techniques best increased patients' activation scores, a proxy measure for behavior change. More successful physicians used an average of 4 out of the 5 following strategies: "emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients." Less successful physicians reported instead "telling patients the negative health outcomes they can expect if they do not change their unhealthy behaviors." In this same study, more successful physicians also reported spending more time counseling and had higher interest in behavior change than those physicians whose patients had lower activation scores. 

Additional studies' findings are along similar lines. Spending more time counseling patients correlates with higher rates of behavior change regarding weight loss and tobacco cessation. Patients are more willing to engage in counseling related to behavior change with tobacco and alcohol use when their overall health, and not their undesirable habit, is emphasized. Although leveraging our longitudinal relationships with patients is valuable, it's encouraging to note that just one motivational interviewing session can result in meaningful change, too.

You can read more in the AFP By Topic on Health Maintenance and Counseling. I'm adding this new AFP article to my AFP Favorites page for easy reference. Which of these techniques are you adding to your repertoire for 2019?

Monday, December 17, 2018

The top ten AFP Community Blog posts of 2018

- Kenny Lin, MD, MPH

This year's list includes (#1 and #2) two of the top five most-viewed posts since this blog began in 2010. (In case you are wondering, the best-read post of all, on acetaminophen for nasal congestion from the common cold, has been viewed nearly 10,000 times.)

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1. PSA screening: USPSTF recommendations changed, but the evidence did not (October 22) - 3061 views

The first question family physicians ought to ask is: what new evidence compelled the Task Force to move from recommending against PSA screening in all men to determining that there was a small net benefit for screening in some men?

2. Acute Flaccid Myelitis: what family physicians should know (October 29) - 3018 views

Although still quite rare, occurrences of acute flaccid myelitis (AFM), a polio-like condition that results in sudden limb weakness, have been increasing in the United States. Family physicians can aid the CDC's investigation by recognizing AFM's presentation and reporting suspected cases to their local health departments.

3. Guest Post: Practicing what I preach about generic drugs (May 30) - 1152 views

I am a cancer survivor. I am alive today because of the love and support of my family, friends, and co-workers. I am alive because of the incredible doctors and medical staff at Walter Reed. I am also alive because of generic drugs. Generic drugs saved my life.

4. For hypertension and diabetes, lower treatment targets not necessarily better (March 21) - 891 views

Primary care clinicians often chose to intensify glycemic control in an older adult with a HbA1c level of 7.5% and multiple life-limiting comorbidities. As family physicians look for opportunities to improve care for patients with hypertension and diabetes, we should not miss opportunities to avoid harm.

5. Continue to Choose Wisely: updates to the AAFP Choosing Wisely recommendations (September 10) - 806 views

Developed by the AAFP's Commission on Health of the Public and Science, each of these evidence-based recommendations focuses on a practice that is either harmful or has very little supporting evidence of benefit.

6. For mild hypertension in low-risk adults, harms of drug therapy outweigh benefits (November 6) - 712 views

After a median follow-up duration of 5.8 years, there were no differences in all-cause mortality, stroke, myocardial infarction, acute coronary syndrome, or heart failure. However, the treated group had an increased risk of hypotension (number needed to harm = 41 at 10 years), syncope (NNH = 35), electrolyte abnormalities (NNH = 111), and acute kidney injury (NNH = 91).

7. Summer travel tips for you and your patients (June 18) - 667 views

Readers of American Family Physician should know about all of the resources available in our archives for prevention and management of medical conditions in travelers, the best of which are included in our Travel Medicine collection.

8. Supporting our patients' health outside of the office (May 7) - 661 views

Our patients' incomes, neighborhoods, and educational levels impact their health at least as much, if not more, than the interventions we discuss with them within our practice settings.

9. Increasing pneumococcal vaccination rates (April 9) - 649 views

In persons with COPD, the number needed to treat (NNT) for pneumococcal vaccination is 21 to avoid an episode of community-acquired pneumonia and 8 to avoid an acute COPD exacerbation.

10. Top research studies of 2017 for primary care practice (April 30) - 589 views

This year's top 20 studies included potentially practice-changing research on cardiovascular disease and hypertension; infections; diabetes and thyroid disease; musculoskeletal conditions; screening; and practice guidelines.

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On behalf of all of us at AFP, happy holidays and many blessings for the New Year.

Monday, December 10, 2018

Creating a welcoming office for LGBTQ patients

- Jennifer Middleton, MD, MPH

The current issue of AFP highlights "Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know" along with an accompanying editorial describing "The Responsibilities of Family Physicians to Our Transgender Patients." Both articles discuss the importance of tangibly demonstrating openness to transgender and gender-diverse persons by displaying "transgender-affirming materials," training staff regarding inclusive language and behavior, and adopting intake forms to offer more than just binary descriptors of "male" or "female." Several additional resources are available to family physicians to ensure that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals feel comfortable accessing healthcare in our offices.

The American Medical Association's Population Care website includes a page on creating an LGBT-friendly practice. The AMA emphasizes providing visual clues that your office is LGBTQ-friendly such as brochures, posters, and a nondiscrimination statement. There's a link to a podcast with more suggestions and information about listing your practice in the Gay and Lesbian Medical Association (GLMA) Provider Directory.

The United States Department of Health and Human Services' Adolescent Health website includes a section on Ensuring Inclusivity of of LGBTQ Youth. Their resources focus on inclusivity regarding contraception access and teen pregnancy prevention efforts. One handout stresses that "sexual identity is separate from sexual behavior" and cites data that LGBTQ teens are at higher risk of pregnancy than their heterosexual, cisgender peers.

Your office might also consider participating in a "Safe Zone" training session, described in more detail at the Safe Zone Project's website. LGBTQ individuals may seek out signs such as a "Safe Zone" emblem as a visual clue that they are in an accepting and affirming healthcare site.

We cannot deliver the best care to our communities if some members of our communities feel unsafe entering our offices. Educating ourselves - and our residents - is essential. The AAFP has a curriculum guide for family medicine residencies on Lesbian, Gay, Bisexual, and Transgender Health, citing data that the majority of family medicine residents rate their training on LGBTQ health as "fair or poor."  The AFP By Topic on Care of Special Populations also includes a subheading on Gay, Lesbian, Bisexual, and Transgendered Persons if you'd like to read more as well.

Tuesday, December 4, 2018

Improving care transitions for formerly incarcerated patients

- Kenny Lin, MD, MPH

A young man with schizophrenia, opioid use disorder (OUD) and chronic hepatitis C infection recently completed a 5-year prison sentence and was discharged back into the community. While he was incarcerated, he received antipsychotic medications and periodic laboratory monitoring of his liver disease; medication-assisted treatment for OUD was unavailable. At the time of his release, he was given a 30-day supply of pills and told to follow up with a primary care physician. The next few weeks will be a critical time for this patient's health, according to an article on care of incarcerated patients in the November 15th issue of American Family Physician:

Most inmates are discharged from correctional facilities without a supply of medications or referrals to primary care, mental health services, or substance abuse treatment. Lack of care coordination directly affects the health of former inmates. In the two weeks following release, former inmates are 129 times more likely to die of a drug overdose and 12 times more likely to die of any cause than members of the general public.

Former inmates face two significant obstacles to accessing primary care: affording care, and the reluctance of some clinicians to accept formerly incarcerated patients. Before 2014, an estimated 80 percent of incarcerated persons lacked health insurance or the financial resources to pay for basic health care. Even after the expansion of Medicaid to single and childless adults earning up to 138% of the federal poverty level in 36 states and the District of Columbia, many patients continue to slip through the cracks. A 2016 article in Kaiser Health News recounted the case of Ernest, a man with severe mental illness who served prison time in Indiana for killing his 2 year-old daughter during a psychotic delusion. Even though Indiana had expanded Medicaid by the time of Ernest's release and set up a system to enroll all eligible prisoners, records show that he was forced to enroll in the program on his own, wasting valuable time and delaying his transition of care:

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled. “Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Having health insurance does not necessarily mean that a patient will be able to access care, as illustrated in a recent Canadian study published in the Annals of Family Medicine. Researchers posing as prospective patients telephoned all family physicians listed as accepting new patients in British Columbia. The only difference between the patient roles was that one set mentioned that he or she had been released from prison a few months before. Among the 250 family physicians who answered the phone and were still providing primary care, control patients were twice as likely to be offered an appointment compared to persons recently released from prison (absolute risk difference = 41.8%).

In 2017, the American Academy of Family Physicians published a position paper on Incarceration and Health that suggested "family physicians can promote the health of individuals during the transition from correctional facilities to the community by supporting reentry processes that begin prior to release; collaborations between prison and community health services; integrated models of care; and linkages to housing, employment, and mental health support." To that, I would add that we should not discriminate against patients with a history of incarceration.