Monday, May 2, 2016

Don't delay palliative care in heart failure

- Kenny Lin, MD, MPH

For me, the words "palliative care" bring to mind a picture of a patient suffering from incurable cancer, perhaps one that has spread to the bone or brain. Avoiding death from cancer, even via screening tests or therapies that increase the risk of death from other causes (thus providing no overall health benefit) is a reason that physicians sometimes cite for continuing cancer screening long beyond what guidelines recommend. Clinicians may be less likely to view patients with non-cancer diagnoses, such as end-stage heart disease, as potentially eligible for palliative or hospice care, Dr. Marc Kaprow wrote in a 2010 editorial in American Family Physician. In a 2013 editorial, Drs. Rebecca McAteer and Caroline Wellbery encouraged readers to take a broader view of this underutilized service:

Palliative care improves the quality of life for patients with a life-threatening illness and for their families. It aims to relieve suffering by identifying, assessing, and treating pain and other physical, psychosocial, and spiritual problems. Palliative care can be provided whether an illness is potentially curable, chronic, or life-threatening; is appropriate for patients with noncancer diagnoses; and can be administered in conjunction with curative-aimed therapies at any stage of the illness.

Heart failure provides a good example of a condition that benefits from palliative care, especially in its advanced stages. Although increasing resources have been devoted to preventing heart failure readmissions, palliative care interventions remain poorly integrated despite the downward disease trajectory that nearly all patients experience. A 2009 review in Circulation concluded that palliative care improved patient and family satisfaction; facilitated communication between patients and health professionals; increased access to community support services; and was associated with a greater likelihood of patients dying at home. It also produced significant cost savings from fewer invasive end-of-life interventions and hospitalizations.

A more recent review in BMJ summarized the past 5 years of medical literature on palliative care in heart failure. Common symptoms that palliative care can address effectively include pain, breathlessness, fatigue, and depression. Older adults with heart failure have 4-5 comorbidities on average and are more likely to experience frailty than the general population. As rising numbers of these patients receive implanted cardioverter defibrillators and left ventricular assist devices, device deactivation is rarely discussed even when patients become critically ill. The American Heart Association encourages scheduling an "annual heart failure review" to provide time for shared decision-making around these topics and to assure that treatment intensity and future plans are aligned with patients' goals and preferences.

Monday, April 25, 2016

Hyaluronic acid injections don't help knee DJD

- Jennifer Middleton, MD, MPH

Options for helping patients with knee degenerative joint disease (DJD) seem to be getting more limited. A POEM in the April 15 AFP reviews a meta-analysis showing that hyaluronic acid injection is no better than sham injection for treating pain from knee DJD. This meta-analysis confirms what other recent studies have found; hyaluronic acid injections don't meaningfully help patients with knee DJD.

The meta-analysis included 19 randomized controlled trials comparing hyaluronic acid injections to sham injections (14 trials), usual care (2 trials), or combined with some other treatment (3 trials). The non-blinded trials did show modest improvement in pain scores, but the double-blinded trials showed negligible improvements, if any. Although early studies of hyaluronic acid suggested it was effective, these studies tended to be small and were frequently unblinded or inadequately blinded. Higher quality double-blinded studies, especially when considered in aggregate in this meta-analysis, did not confirm this benefit.

The placebo effect can be powerful, as evidenced by participants' perceived improvements in the non-blinded trials compared to the double-blind trials. And, perhaps, that is not always a negative; I suspect those participants who did feel better in the non-blinded trials were pleased with the improvements they noted in their pain. Unfortunately, the placebo effect with hyaluronic acid comes with cost and risk; injections can cost hundreds of dollars for one dose, and typical therapeutic regimens involve a series of 3-5 injections over several weeks. Injecting into a joint is also not a zero-risk procedure; although rare, serious complications like joint infection can occur.

Hyaluronic acid injections' limitations should not come as a surprise; a web search of "hyaluronic acid knee injections" reveals many critical lay press articles over the last couple of years, and the American Association of Orthopedic Surgeons (AAOS) even states "We cannot recommend using hyaluronic acid for symptomatic arthritis of the knee" in their Summary of Recommendations for Treatment of Osteoarthritis of the Knee (which was cited in this 2014 AFP article). I suspect, though, that I am not alone in seeing this intervention still commonly offered for patients, both by family physician colleagues and local orthopedists. 

With glucosamine and chondroitin also now out of favor for treating knee DJD, non-surgical options for helping patients are currently limited to oral analgesics and, possibly, intra-articular corticosteroid injections - though the AAOS cites a lack of data regarding corticosteroid injections' efficacy in their summary statement as well. Given the prevalence of knee DJD, we can only hope that researchers are investigating novel treatment methods to help those patients who are not yet (or will never be) candidates for knee joint replacement.

You can read more at the AFP By Topic on Arthritis and Joint Pain, and you might also want to check out the Choosing Wisely recommendations from the AAOS (though Dr. Lin critiqued the limitations of these recommendations in this post from last year). The AFP Choosing Wisely search tool is a handy way to review other interventions shown to be of little utility for orthopedic conditions as well as other specialties; you can access it from the AFP home page or bookmark it on your personalized AFP Favorites page.

How are you treating knee DJD in your office?

Tuesday, April 19, 2016

Obstacles to stopping cancer screening in older adults

- Kenny Lin, MD, MPH

I recognized a glitch in my electronic medical record's decision support software when it prompted me to consider prostate and colorectal cancer screening in a 93 year-old man, who, though remarkably vigorous for his age, was unlikely to live for the additional 10 years needed to benefit from either test. Although deciding not to screen this patient was easy, determining when to stop cancer screening in older patients is often more challenging. In the April 15th issue of American Family Physician, Drs. Brooke Salzman, Kathryn Beldowski, and Amanda de la Paz present a helpful framework for decision making in these clinical situations, where population-level guidance derived from studies of screening younger patients "generally do not address individual variations in life expectancy, comorbid conditions, functional status, or personal preference."

The authors recommend that clinicians take into account not only average life expectancy at a given age, but also significant variations in life expectancy linked to functional impairment and comorbid conditions, using one or more validated prognostic tools. Although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence about screening mammography in women 75 years or older, modeling studies suggest that women with projected life expectancies of greater than 10 years may still benefit from this test - with these important caveats:

Although the sensitivity and specificity of mammography increase with age, overdiagnosis also increases because of reduced life expectancy and an increased proportion of slower-growing cancers. In other words, women with breast cancer diagnosed at an older age are more likely to die of something else, compared with younger women. In addition, treatment of breast cancer in advanced age is associated with greater morbidity, including an increased risk of postoperative complications and toxicity from chemotherapy.

Similar considerations apply to screening for colorectal cancer, which the USPSTF made a "C" grade recommendation (small population-level benefit, use individual decision making) for adults 76 to 85 years of age and recommended against screening adults older than 85 years, when the harms clearly exceed the potential benefits. Nonetheless, surveys have found that 31% of adults age 85 years and older, and 41% of adults with a life expectancy of less than 10 years, received screening colonoscopies. To discourage overuse of cancer screening without alienating patients, the authors advise: "It is important to convey that a decision to stop cancer screening does not translate into decreased health care. Rather, discussions can focus on health promotion strategies that are most likely to benefit patients in the more immediate future, such as exercise and immunizations."

A recent qualitative study in JAMA Internal Medicine explored the reluctance of primary care clinicians to explicitly incorporate long-term prognosis in the care of older adults. Most study participants relied on their own clinical experience, rather than validated tools, to estimate a patient's life expectancy, and were reluctant to stop screening in relatively younger patients even with limited life expectancies. Barriers mentioned by participants included inadequate training, time constraints, concern about negative patient reactions, competing practice incentives, and fear of lawsuits. Do you share these concerns? What strategies do you use to communicate with an older adult whose age or life expectancy suggests stopping cancer screenings?

Monday, April 11, 2016

What we say when we don't give an antibiotic matters

- Jennifer Middleton, MD, MPH

Most patients with upper respiratory infections (URIs) and/or sinusitis don't need an antibiotic, but many physicians still receive requests for one. Physicians may use language to describe the viral nature of the infection, stating perhaps that it's "only a virus" or otherwise implying that the illness is not serious enough to mandate an antibiotic. This type of wording may, paradoxically, increase some patients' belief in the utility of antibiotics, as demonstrated by a recent qualitative study published in the Annals of Family Medicine.

Cabral et al video-recorded 60 encounters of children, ages 3 months to 12 years, seen in primary care offices in the United Kingdom with URI symptoms. They then interviewed some of the children's parents after the visit to learn more about their beliefs regarding antibiotics and URIs. They found that parent belief regarding the lack of utility of antibiotics for viral infections was overall high, but this belief did not always translate into reassurance when one was not provided. Parents who felt that their child's illness was minor were reassured, but parents who felt that their child was significantly ill (which typically correlated with disrupted sleep and/or length of illness) felt oppositely, that their physician was trivializing their child's illness by not deeming it "serious enough" to justify an antibiotic.

Interestingly, physicians in this study used different language with parents to describe the child's illness according to their decision to prescribe antibiotics. If not prescribing antibiotics, they would often describe concrete physical exam findings and observations that they felt were reassuring about a lack of a bacterial cause; if prescribing antibiotics, they would instead describe more subjective concerns about worrisome symptoms, especially if these symptoms were worsening. The researchers deduced that this symptom-driven language further reinforced the parents' beliefs that antibiotics are needed for more serious illness, as most parents found the descriptions of concrete physical exam findings in children not receiving antibiotics reassuring.

This study will change the way I speak with parents - and adult patients - about my decision not to prescribe antibiotics. I will make sure not to trivialize their concerns or refer to an illness as "just" a virus, and I will aim to use objective language to describe my rationale either way. Despite rigorous evidence showing that antibiotics insignificantly aid recovery and can cause adverse effects, as many as 80% of patients who present with an URI and/or sinusitis are prescribed one.  The Choosing Wisely campaign reminds us to avoid prescribing antibiotics for URIs in adults and in children. Besides recommending supportive care, nasal corticosteroids are a treatment option in adults with acute sinusitis as well. This 2012 AFP article reviews other treatment options for URIs in adults and children.

You can find AFP's Choosing Wisely search tool here, and there's also an AFP By Topic on Upper Respiratory Tract Infections if you'd like to read more. Family Practice Management featured an article last year, co-authored by Dr. Lin, on implementing the Choosing Wisely recommendations in your office, and they also published this handy resource on coding URIs using ICD-10.

How are you responding to requests for antibiotics from patients with URIs?

Tuesday, April 5, 2016

Patient-centered diabetes research needs primary care perspectives

- Kenny Lin, MD, MPH

A Letter to the Editor in AFP's March 15th issue pointed out that a simplified management algorithm in a previous article on noninsulin therapies for type 2 diabetes could have been misinterpreted to suggest the non-recommended combination of a dipeptidyl-peptidase-4 (DPP-4) inhibitor and a glucagon-like-peptide-1 (GLP-1) receptor agonist. According to the American Diabetes Association's 2016 Standards of Medical Care in Diabetes, however, there is little comparative data to guide second-line drug choice after metformin. Few other medications have been shown to lower mortality in patients with type 2 diabetes, and even then only in specific populations, as Dr. Middleton discussed in a recent AFP Community Blog post.

The National Institutes of Health is currently recruiting patients for a multicenter randomized trial, the Glycemia Reduction Approaches to Diabetes: A Comparative Effectiveness (GRADE) study, that will compare the benefits and harms of four medications commonly combined with metformin: 1) glimepride (a sulfonylurea); 2) sitagliptin (a DPP-4 inhibitor); 3) liraglutide (a GLP-1 receptor agonist); and 4) glargine insulin. Since the GRADE study was planned, the sodium glucose cotransporter 2 (SGLT-2) inhibitor class has come on the market, and a randomized trial found that empagliflozin reduces cardiovascular and all-cause mortality in patients with established cardiovascular disease and type 2 diabetes. This surprising result led some experts to suggest that SGLT-2 inhibitors be added to the GRADE trial or incorporated into some other comparative research study.

This kind of pragmatic diabetes research would seem to be a perfect fit for the Patient-Centered Outcomes Research Institute (PCORI). Created by the Affordable Care Act, PCORI's mission is to "improve the quality and relevance of evidence available to help patients, caregivers, clinicians, employers, insurers, and policy makers make informed health decisions" by funding comparative clinical effectiveness research and research methods. However, PCORI received criticism recently after an independent analysis of its first 6 funding cycles by the American Academy of Family Physicians' Robert Graham Center concluded that "less than one-third of PCORI studies involve or are relevant to primary care."

Last month, I represented the AAFP in the PCORI stakeholder workshop "Prioritizing Comparative Effectiveness Research for Second-Line Type 2 Diabetes Treatment." Other workshop participants included fellow primary care clinicians and representatives from relevant subspecialty societies, patient groups, benefits managers, clinical investigators, and the pharmaceutical industry. After listening to presentations on recent trials and the GRADE study, we were asked to formulate a research question in the PICO (Population, Intervention, Comparator, Outcome) format, keeping in mind the following criteria: patient-centeredness, health impact of the condition, assessment of current options, likelihood of implementation in practice, and durability of information.

I was impressed by the high quality of the discussion and the group's determination to come up with practical research questions that would provide meaningful answers to better inform family physicians and other clinicians who care for patients with type 2 diabetes. PCORI Executive Director Joe Selby, MD, MPH, who is also a family physician, told me how important it was to him that Family Medicine be actively engaged in shaping the organization's research agenda and priorities. For interested readers, PCORI offers many opportunities to get involved that range from suggesting new research questions, to providing input on current questions and methods, to serving on standing advisory panels on various cross-cutting topics.

Monday, March 28, 2016

Counseling patients to eat less meat: should we bring climate change into the conversation?

- Jennifer Middleton, MD, MPH

The current issue of AFP features a Practice Guideline summarizing the Dietary Guidelines Advisory Committee's 2015-2020 Dietary Guidelines for Americans, and its contents are unlikely to surprise readers: 1) choose mostly nutrient-dense foods, 2) don't over-consume them, and 3) limit sugar, saturated fats, and salt intake. An accompanying AFP editorial by Dr. Caroline Wellbery, however, brings up what may be a more controversial angle; reducing meat intake would not only be beneficial for our nation's health, but it may also slow climate change.

This topic seems to be a hot one, lately, with the Washington Post running a similarly themed article this past week asserting many of the same points Dr. Wellbery does. The Washington Post article reviews a recent study titled "Analysis and valuation of the health and climate change cobenefits of dietary change," which ran predictive models of various population diet patterns to see how they might affect healthcare costs and greenhouse gas emissions. The study authors predicted that if we all ate less meat, the longer we would live, the less we would spend on health care, and the less we would contribute to greenhouse gases.

This issue tends to stir up heated emotions on both sides of the climate change debate, as a quick glance at the online comments for both the Washington Post piece and Dr. Wellbery's editorial reveals. Stepping back from the precipice of soapboxes and unbridled passions for a moment, though, how might we as family physicians choose a thoughtful approach to counseling our patients about their nutrition?

I suspect most of us would agree that encouraging our patients to adopt healthier dietary habits is a good thing (even if we disagree about some of the reasons why); unfortunately, our patients receive a lot of mixed messages about just what those habits should be, and finding the time to incorporate that counseling into our busy days can be challenging. Helping our patients focus on evidence-based recommendations, such as consuming less sugar and eating less meat while choosing more fruits, vegetables, and whole grains is a good start; working with them to set even one behavioral change goal (such as drinking less soda pop or eating one less serving of meat a week) per visit may feel more realistic to both docs and patients alike, too.

Here are some additional resources that might make nutrition counseling feel a little more doable:


(Remember that you can add any of these links to your AFP home page "Favorites" button if you'd like to be able to refer to them quickly on the fly.)

What office strategies have you found successful in helping patients choose healthier diets?