Tuesday, February 21, 2017

Guest Post: On the front lines of the opioid epidemic

- Catherine Shafts, DO and Mort Glasser, MD

As a Federally Qualified Health Center in northeastern Connecticut, our mission is to improve the health of the towns we serve. In 2007, we were known as a place where one could easily get prescription opioids. At the same time, opioid abuse, addiction and overdoses were being recognized as a national epidemic. We decided to make a change. All chronic pain management plans were reviewed. Medications were not benefiting patients and often being diverted. This led to a complete reversal of prescribing practices and overhaul of how we managed chronic pain.

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. It was difficult at first. Patients complained to the medical staff, administration, chief medical officer, and Department of Public Health that their needs were not being met. Everyone realized we were not abandoning our patients but rather offering better, healthier treatments. Our efforts were supported.

Since much of our population is transient, including homeless persons, migrant farm workers, former prisoners, and patients with mental health and substance abuse disorders, we wanted a system in place that did not discriminate based on appearance or history. The policy is the same for a 70-year-old woman with osteoarthritis as a 35-year-old man with chronic low back pain.

Patients were offered help at addiction treatment centers, referred to pain management, and given non-addictive options to treat pain. It led to a cultural shift. In time, we experienced less staff stress, fewer irate phone calls, and fewer calls to police. A variety of patients began to come to the community health center instead of only those desiring opiates. Newborns, seniors and families began seeking care. Our child patient population increased significantly. We became a true Family Medicine practice.

Many patients ultimately have been thankful for the changes. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus. Each patient is screened for substance abuse. ACE (Adverse Childhood Experience) scores are being used and discussed. Consistently addressing opioids with preteen and teen patients to prevent use is paramount. With this policy and these new practices, we hope to continue to impact opioid abuse and overdoses and make our small part of the world healthier.

Wednesday, February 15, 2017

Vaccines in the news: controversies & updated recommendations

- Jennifer Middleton, MD, MPH

Vaccine safety concerns continue to make headlines, with another physician garnering attention for voicing his opinions in the last few weeks. Although his healthcare system has vehemently disavowed his statements, some physicians may fear that his claims will complicate the discussions we have with patients about vaccination. It's within this context that AFP's current issue reviews the Advisory Committee on Immunization Practices' (ACIP) updated recommendations for 2017, with articles focusing on children and adults. There are several changes for physicians to be aware of - and having strategies at the ready to respond to concerns evoked by current events may prove useful when discussing them with patients.

Some highlights from the ACIP recommendations:

* Live attenuated influenza vaccine is no longer recommended following studies showing its relative ineffectiveness. This change unfortunately eliminates what was an attractive influenza vaccine option for our needle-phobic patients.

* Only 2 doses of human papillomavirus (HPV) vaccine are now needed for healthy adolescents as long as the series is started before age 15; if started at or after age 15, then 3 doses are still required.

* Pregnant adolescents and women should receive a tetanus toxoid, reduced diptheria toxoid, and acelluar pertussis (Tdap) vaccine between 27 and 36 weeks gestation, regardless of when they last received Tdap vaccination.

* Speaking of infants, ACIP changed their language regarding the first hepatitis B vaccination to emphasize that it should be given "within 24 hours of birth."

* The new vaccine for serotype B meningococcal disease is available for adolescents between ages 16-23.

* Everyone with chronic liver disease - including non-alcoholic fatty liver disease - should receive the hepatitis B vaccine series.

It's likely that, in the course of discussing these changes with patients, that some patients will share their hesitancy to receive a vaccination themselves and/or vaccinate their children. Several techniques may be useful in overcoming vaccine hesitancy. I've written on the blog before about how eliciting our patients' specific concerns and then tailoring our message accordingly can be successful. Dr. Lin has previously provided recommendations about discussing HPV vaccination with parents. A recent editorial in AFP shared "Strategies for Addressing and Overcoming Vaccine Hesitancy," and this excellent article provides useful information about vaccinations and common concerns to share with patients as well. There are AFP By Topics on Immunizations (excluding influenza) and another on Influenza with editorials, patient information, and review articles at your fingertips. If you have concerns about reimbursement related to providing vaccines in your office, check out this 2015 article from Family Practice Management.

Recent outbreaks in the United States of measles and pertussis serve as vivid reminders of how dangerous these diseases can be. Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.

Monday, February 6, 2017

Guest Post: Innovating connections in family medicine

- Brian Champagne, MD

Two years ago I chose family medicine not only to develop a diverse skill set and knowledge to handle almost any patient concern, but also to build a connection with numerous patients of different ages to learn from them as they learn from me.

Fast-forward to now. I’m in the depths of a busy clinic, stabilizing a crying baby’s ear and desperately searching for a reflective hue amid a narrow tunnel of earwax. I’m not finding it. I glimpse for 2 seconds before the child’s war cries rattle my own tympanic membranes and I abort the mission. On my third try, I hit the jackpot and visualize a reflective drum. My job is done. I instill some confidence in the mom that her baby will do fine without a goodie bag of antibiotics. We share a bonding laugh at the absurdity of spending over an hour out of her day for a one-second examination with a magnifying glass.

I scamper to my computer and slam in some orders for vaccines, glance at my schedule, and then briskly walk to the next room down the hall. Behind the door is a 70-year-old woman seated in the infamous tripod pose, hunched over with retracting neck muscles, swollen legs and appearing worried. She was discharged just 2 weeks ago for heart failure. I examine her and order 40 mg of IV Lasix. A half of an hour later she’s still retracting. I kneel to tell her she’s going to get through this and she nods appreciatively, hoping I’m right. I send her to the hospital for more diuretics as I tap on the door of my next patient.

It’s a wiry 60-year-old man who describes brief spouts of right upper quadrant pain so severe that he swears it’s worse than childbirth. I examine him and explain the possibility of a problem in his liver or gallbladder. After ordering some labs and a right upper quadrant ultrasound, he thanks me for my care. Days later, my suspicion is confirmed. Gallstones are present and off to surgery he goes.

While I enjoy these hectic days and the meaningful connections I find through them, I also understand that in 10 years, my family medicine clinic will likely run differently.

For the screaming baby with possible otitis media, if mom had sent in photos of her baby’s eardrum with a smartphone, perhaps a 10-minute video call would have provided all information that supportive care is appropriate.

For the 70-year-old woman with persistent CHF exacerbations, perhaps if she were plugged into a system of communicating nurses trained in heart failure management, maybe she wouldn’t be in need of another hospitalization.

For the 60-year-old man with right upper quadrant pain, if a quick bedside ultrasound by the physician were possible, perhaps he could have been referred to surgery that day.

With small improvements in patient care, we have the opportunity to develop a more efficient and inexpensive health care system with better health outcomes. While I delight in new technology that enhances our care for patients, some aspects of family medicine won’t change. Technology won’t change the reassuring words we can offer to a worried parent or acutely ill patient. It won’t alter the power of our receptive ears being present for a scared patient. And it definitely won’t replace the wisdom, laughs, perspectives, and connections we encounter with our patients each day. And that’s a good thing.

**

This post won first place in the Society of Teachers of Family Medicine 2016 Resident/Fellow Blog competition. It was originally published on the STFM Blog.

Tuesday, January 31, 2017

Obstructive sleep apnea: screening and home testing news

- Kenny Lin, MD, MPH

According to a recent article in AFP, obstructive sleep apnea (OSA) is present in 2 to 14 percent of the general adult population, with a higher prevalence in older and obese persons. Most people are unaware of their diagnoses, either because they do not recognize symptoms or do not report them to physicians. Since it is hard to make an asymptomatic person feel better, is there any good reason to screen for OSA in asymptomatic adults? Screening advocates suggest that treating patients with moderate to severe OSA with continuous positive airway pressure (CPAP) reduces hypoxic episodes that could trigger cardiovascular events in patients with known vascular disease. A POEM in the January 15th issue summarized a randomized trial that seemed to refute this hypothesis. After almost 4 years of follow-up, the group that received CPAP reported slightly less daytime sleepiness, but had the same frequency of cardiovascular events as the control group.

The U.S. Preventive Services Task Force (USPSTF) considered this study and others in issuing a new recommendation statement on January 24th that concluded "the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults." The USPSTF found inadequate evidence that validated questionnaires (such as STOP-BANG) accurately identify who will benefit from polysomnography (PSG) in asymptomatic populations (as opposed to those with suspected OSA). The Task Force also could not determine if CPAP or mandibular advancement devices improve health outcomes (mortality, cognitive impairment, motor vehicle crashes, and cardiovascular or cerebrovascular events) other than sleep-related quality of life.

Although an insufficient evidence statement is not necessarily a recommendation to not screen, Drs. Sachin Pendharkar and Fiona Clement argued in an editorial in JAMA Internal Medicine that the costs of screening for OSA (not considered by the Task Force) warrant clinicians doing just that. Based on the sensitivity and specificity of one widely used screening tool, and an OSA prevalence of 26% in the Medicare population, the authors estimate that $21 billion would be wasted on negative PSG tests, or $4.4 billion if less expensive home-based sleep studies were used instead.

On a related note, the comparative accuracy of home-based tests versus laboratory PSG in diagnosing OSA has been an actively studied topic. A 2014 practice guideline from the American College of Physicians recommended that portable sleep monitors (limited-channel sleep studies) only be used to diagnose OSA when PSG was not available. However, a randomized non-inferiority trial published last week in Annals of Internal Medicine found that patient outcomes after limited-channel studies were similar to those after PSG. This finding may be a blow to the for-profit sleep testing industry, but it is undoubtedly good news for our patients.

Saturday, January 21, 2017

After emergency contraception: what next?

- Jennifer Middleton, MD, MPH

Developing a regular, ongoing contraception plan when women request emergency contraception (EC) makes intuitive sense, and the updated Centers for Disease Control and Prevention (CDC)'s Practice Recommendations for Contraceptive Use, as described in the January 15 issue of AFP, includes several points for physicians to consider when doing so. One important discussion point involves the risks and benefits of simultaneously providing a ulipristal (ella) prescription and initiating long-acting hormonal contraceptive methods.

Women desiring EC in the U.S. currently have three oral medication options, in addition to the copper IUD, to choose from: the Yupze method and levonorgestrel are approved up to 72 hours after unprotected intercourse, and ulipristal is approved up to 120 hours after unprotected intercourse. Patients requesting EC are often willing to initiate a regular contraceptive method at the same visit. Initiating hormonal contraception at the same time as levonorgestrel or the oral contraceptives used in the Yupze method poses no drug-drug interaction risk, but how ulipristal's antiprogestin effect might impact outcomes is less clear.

Hormonal contraceptive methods, regardless of delivery mode (oral, implant, or IUD) may decrease ulipristal's efficacy, and, conversely, ulipristal may also decrease the initial efficacy of a regular hormonal method. The CDC recommends waiting at least 5 days after taking ulipristal before beginning a hormonal contraceptive method. This delay, however, can be inconvenient for women and can increase the risk of them not initiating a regular contraceptive method at all. Discussing these risks and benefits with patients at the time of providing EC is a must.

Ulipristal has definite positives; it's the most effective oral medication for EC, it only requires one dose, and it works up to 5 days after unprotected intercourse. The potential negative of these interaction risks, however, drives the CDC to encourage transparent discussion with patients. Patient-centered decision making is one framework well-suited to such conversations:
The health care provider's role includes provision of information, facilitating the identification of patient preferences, ensuring that preferences are not based on misinformation, helping patients to think about how their preferences relate to the available options, and coming to a mutually acceptable decision.
Women want their preferences included in discussions of contraceptive choice, and they also want to have the final decision in what method they will use. Discussions about EC should include options for initiating a regular form of contraception along with information about ulipristal's effectiveness and possible interactions. 

Family physicians should not dismiss ulipristal as an option for EC given its convenience and efficacy, but considering the possible decreased effectiveness of both ulipristal and whatever new contraceptive method patients choose is important. Providing this information to women in the context of patient-centered decision making will allow them to choose both an EC method and a regular contraceptive method that best fit their priorities and wishes. If you'd like to read more about ulipristal, there's an AFP STEPS article that outlines its use, and this Update on Emergency Contraception describes use of the Yupze method, levonorgestrel, and the copper IUD. There's also an AFP By Topic on Family Planning and Contraception that contains in-depth information about a variety of contraceptive methods.

How do you counsel women about EC?

Tuesday, January 10, 2017

What's in a name? Obesity, ABCD, and prediabetes

- Kenny Lin, MD, MPH

A recent position statement from the American Association of Clinical Endocrinologists and the American College of Endocrinology proposed replacing obesity with the term "adiposity-based chronic disease," or ABCD for short. The authors argued that this new term emphasizes that most persons with obesity will struggle with weight gain for their entire lives; encourages a complications-centric as opposed to body mass index-based management approach; and "avoids the stigmata [sic] and confusion" associated with obesity in popular culture. They also asserted that ABCD is more amenable to interventions based on the Chronic Care Model, which explicitly recognizes that screening and office-based management need to be adapted to the patient's unique environment.

None of these concepts should surprise family physicians, though, and after reading through the AACE/ACE statement, I was not sold on the benefits of the new term. Some patients with body mass indexes above 30 don't like the obesity label, but would they respond any more positively to the disease acronym ABCD? There are potential harms to consider, too. One of my AFP physician colleagues felt that the new term was "intimidating" and "not at all patient centered," while another thought that it "only hides the issue [of obesity] instead of confronting it."

This discussion brought to mind another medical term often associated with overweight and obese patients: prediabetes. On one hand, being classified as "prediabetic" or at risk for this exceptionally common diagnosis may motivate obese patients to lose weight through improved diet and physical activity. On the other, the term prediabetes is misleading: many of these patients will not develop diabetes, and the diagnostic accuracy of the most common screening tests (hemoglobin A1c and fasting glucose levels) is poor, according to a systematic review published in the BMJ. Due to the tests' low sensitivity and specificity, some persons are incorrectly diagnosed with prediabetes, and others who might actually benefit from interventions to prevent diabetes are falsely reassured. Therefore, the review authors concluded, "'screen and treat' policies alone are unlikely to have substantial impact on the worsening epidemic of type 2 diabetes."

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.