Monday, July 25, 2016

Stepping up counseling about sun safety

- Jennifer Middleton, MD, MPH

The U.S. Preventive Services Task Force (USPSTF) is currently updating its 2012 recommendations regarding counseling to prevent skin cancer, and it couldn’t come at a better time, as the incidence of malignant melanoma continues to rise. The USPSTF found previously that counseling fair-skinned individuals aged 10-24 increases the use of sun-protective behaviors, but this counseling isn’t happening frequently enough in primary care.

A 2004 study of family physicians found that only 60% were routinely providing counseling about sun protection and skin cancer prevention; commonly cited barriers to doing so included lack of time and limited information about the effectiveness of counseling. A more comprehensive survey in 2014 found that family physicians provided sun safety counseling far less frequently, and usually only in association with specific patient diagnoses such as actinic keratosis or a history of other skin problems. In contrast to what the evidence supports, the age group most likely to receive counseling in this study was adults in their 70s; counseling at child and young adult visits was rare. Since only 30% of adults regularly follow sun safety practices, and tanning in young adults remains highly prevalent, there are ample opportunities for family physicians to make a difference for our patients by providing this counseling.

Other effective interventions may be worth incorporating into your practice as well. Mailing personalized handouts about skin cancer prevention increased sun safety behaviors (use of sunscreen, protective clothing, hats, and sun avoidance) more than providing generic handouts in one study. In another study, calculating a melanoma risk score (SAMScore) and targeting counseling to patients at higher risk decreased sunbathing. Counseling young adults about tanning should elicit the specific reasons why they tan; physicians can then target their messages, such as discussing sunless tanning products, alternative methods to relax, or debunking the myth that a tan protects against further skin damage. 

Helping patients adopt healthier behaviors is an important part of the primary care clinician's role, and applying motivational interviewing techniques along with tailoring our counseling to each patient’s stage of change may be useful. Having a structured practice intervention to help patients adopt sun safety measures may also reduce the burden on individual clinicians.

Monday, July 18, 2016

25 podcast episodes every family physician should listen to

- Marselle Bredemeyer

As an associate editor in the AFP editorial offices in Leawood, KS, I work alongside our authors and other non-physician staff to help craft each issue of the journal. We use checklists, stylebooks, and calculators to prepare articles for press, guided by our readers and their needs throughout the process. More than merely gauging the readability of a sentence, this means visualizing the big picture: the information we provide being used at the point of care, as research material, or for continuing education. This picture comes together over time, by staying tuned in to comments we receive on the website, phone, through e-mail, and via social media (Twitter and Facebook), where I love to see replies and messages about the content I am sharing.

My sketch of the family medicine specialty has largely been shaped by these experiences, but the voice that sticks in my mind as I work comes from a podcast, an early episode of Slate’s “Working” that featured a family physician from Washington, D.C. Whether you’re new to podcasts or a long-time listener, the format’s storytelling power and lasting impact are what make it stand out.

As the number of podcasts continues to grow, so has an emphasis on the deep-listening strategies that can improve patient care in the office setting. Shared decision making is often a central part of care, from screening practices to end-of-life planning. Hearing what patients are saying and communicating with them in a way that meets their needs can transform their health, even at routine visits.

With that in mind, podcasts, and their ability to make us engage with others’ stories, might be useful to physicians as they look for ways to take in new information, and above all, try to stay tuned in to the underlying messages their patients are sharing. Want to start listening or add new favorites to your queue? With the help of AFP Podcast hosts Steve Brown, MD, Jake Anderson, DO, and Luke Peterson, DO, the four of us have come up with a family medicine podcast playlist that features a variety of shows talking about medicine, public health, and patient relationships. If the tweet might help medical students learn better note-taking, the podcast might help us all be better listeners.

What are you listening to? Share this post and add your own favorite episodes when you do!

AFP Podcast
Bonus Episode with J. Lloyd Michener, MD

Only Human
Doctor Stories: The Patient I’ll Never Forget
How to Stop an Outbreak

This American Life
Something Only I Can See

The House
The Hospital

Questioning Medicine
The Dexa Scam

Sawbones: A Marital Tour of Misguided Medicine
Heroes of Patent Medicine

The Secret History of Thoughts
The Problem with the Solution

Best Science Medicine
Televised Medical Talk Shows (paid subscription required; listen to new episodes for free on iTunes)

The Cathedral
Staph Retreat
Patient Zero: Updated

A Gobbet o’ Pus 810
Occam and Fallacies

99% Invisible
Fountain Drinks

Planet Money
The Experiment Experiment
Black Market Pharmacies
Your Organs Please
Clipping Coupons for Health Care

How to Become Great at Just About Anything
How Many Doctors Does It Take to Start a Healthcare Revolution?

Monday, July 11, 2016

Point-of-care tests reduce antibiotic use for acute respiratory infections

- Kenny Lin, MD, MPH

In last week's blog post, Dr. Jennifer Middleton discussed the strengths and limitations of rapid strep testing for patients with acute sore throats. In patients with an intermediate pre-test probability of having streptococcal pharyngitis, a negative rapid strep test lowers the post-test probability enough to feel comfortable withholding antibiotics. Wouldn't it be nice if other point-of-care tests could effectively rule out bacterial infections and reduce antibiotic prescribing rates in patients with acute respiratory symptoms?

A FPIN Clinical Inquiry published in the July 1st issue of AFP evaluated the effects of a procalcitonin-guided antibiotic therapy algorithm on antibiotic use and clinical outcomes. A Cochrane review and meta-analysis of 14 randomized, controlled trials (RCTs) comparing procalcitonin-guided to standard care in European adults with acute respiratory infections found that patients in the procalcitonin group received 3.47 fewer days of antibiotic therapy with no differences in 30-day mortality or treatment failure. In a single RCT of 337 children presenting to pediatric emergency departments in Switzerland, patients in the procalcitonin group were as likely as the standard care group to receive antibiotic prescriptions, but received nearly 2 fewer days of therapy.

A 2015 Cochrane for Clinicians examined the performance of point-of-care measurement of C-reactive protein (CRP) on similar outcomes. Although treatment thresholds varied, most studies considered a CRP level of less than 20 mg per L to suggest a viral infection and no need for antibiotics. A Cochrane review of 6 RCTs conducted in primary care settings (mostly in adults) in Europe and Russia found that groups assigned to CRP-assisted evaluation were 22 percent less likely to receive antibiotic prescriptions for acute respiratory infections, with no differences in clinical improvement at day 7, complications, or mortality. However, Dr. Irbert Vega observed in the Practice Pointers that "the meta-analysis did not identify an optimal algorithm and therefore should be considered proof of concept until further research can be performed, including research in the U.S. population."

Upcoming editorials and features in AFP will discuss the effectiveness of other interventions aimed at reducing unnecessary antibiotic use for respiratory infections in primary care settings, including those evaluated in a recent systematic review from the Agency for Healthcare Research and Quality.

Tuesday, July 5, 2016

To rapid strep test or not to rapid strep test?

- Jennifer Middleton, MD, MPH

My medical assistant will routinely ask me if I want a rapid strep test for patients presenting with sore throat. I'm pleased that she asks, because it doesn't seem that long ago that every patient who walked in the door with a sore throat got tested. As the authors of Common Questions About Streptococcal Pharyngitis review in the July 1 issue of AFP, only patients with an intermediate risk of strep pharyngitis should get a rapid strep test; point-of-care tools can help physicians quickly make that assessment.

The authors assert that:
Results from rapid antigen detection testing (RADT) should be used in conjunction with a validated clinical decision rule such as the modified Centor score or the FeverPAIN score. Patients at low risk of GABHS pharyngitis can be treated symptomatically, RADT should be ordered for those at intermediate risk, and empiric antibiotics are an option for those at high risk.
Unfortunately, the rapid antigen test for streptococcal pharyngitis is not perfect. A recent meta-analysis found a combined sensitivity for the various types of rapid strep tests of 80% (95th confidence interval [CI] 77-82%) for pediatric patients and 94% (95th CI 80-99%) for adult patients; for specificity, use of rapid tests in pediatric patients was 93% (95th CI 92-93%) and in adults was 69% (95th CI 54-81%). Because this test can result in either a false positive or a false negative result a significant minority of the time, it is most useful in patients with an intermediate pre-test probability of having strep pharyngitis. If you're clinically convinced that the patient does or does not have strep pharyngitis, this imperfect test shouldn't change your clinical management.

The AFP article authors review the scoring systems most commonly used to assess the pre-test probability of strep pharyngitis, the Centor score and the modified Centor score. Both of these clinical decision rule scores are available in several point-of-care applications ("apps") for smartphones and tablets: MediMath, Qx Calculate, and MDCalc all include the Centor and modified Centor scores, to name a few. Scrolling through the scores and risk calculators on these apps, I'm continually surprised by what I see; often, I'm reminded of something that I had once heard of, intended to use in my practice, and then promptly forgot about.

Since many of these calculators involve inputting basic clinical information, office staff could easily be trained to use them. Integrating them directly into an electronic health record (EHR) system makes a lot of sense, too - wouldn't it be useful if your EHR could calculate the Centor score based on the history and exam you've documented while assessing the patient?

Family Practice Management has an ongoing feature that uses the "SPPACES" criteria to rate the quality of medical apps; you can find the collection of their app reviews here if you're interested in learning more about what's available for your smartphone and/or tablet. Of course, you can also link to online reference calculators using the AFP home page "Favorites" feature if you prefer to work off your desktop or laptop computer.

How are you using point-of-care tools in your practice?

Monday, June 27, 2016

Is the best colorectal cancer screening test the one that gets done?

- Kenny Lin, MD, MPH

In 2008, the U.S. Preventive Services Task Force recommended routinely screening adults aged 50 to 75 years for colorectal cancer using fecal immunochemical testing (FIT), flexible sigmoidoscopy, or colonoscopy. At that time, it did not endorse two newer strategies, computed tomographic (CT) colonography and fecal DNA testing. But data from the National Health Interview Survey indicated that in 2013, only 60 percent of non-Hispanic white adults in the target age group was up-to-date on one of the three recommended colorectal cancer screening tests, with lower percentages for ethnic and racial minorities. Proponents of CT colonography and fecal DNA testing argued that more widespread insurance coverage of these "noninvasive" tests could potentially increase screening rates.

Earlier this month, JAMA published a USPSTF-commissioned systematic review of more recent studies and an analytic modeling study that compared the effects of different screening tests and strategies. The Task Force's updated recommendation statement said to screen adults aged 50 to 75 years, but expressed no clear preference about the "best" test or tests. A Figure that accompanied the statement showed that assuming perfect adherence, each screening strategy produces a similar number of life-years gained, with a colonoscopy-first strategy predictably leading to more total colonoscopies and procedure-related harms. Rather than recommending that eligible patients undergo a specific test, the USPSTF advised:

Given the lack of evidence from head-to-head comparative trials that any of the screening strategies have a greater net benefit than the others, clinicians should consider engaging patients in informed decision making about the screening strategy that would most likely result in completion, with high adherence over time, taking into consideration both the patient’s preferences and local availability.

Shared decision making is all well and good, but I am concerned about the communication challenges of expanding my standard discussion of colorectal cancer screening options from FIT versus colonoscopy (since physicians in my area no longer perform flexible sigmoidoscopy for colorectal cancer screening) to choosing between FIT, fecal DNA, CT colonography, and colonoscopy. I wish that the Task Force had provided more practical guidance about how primary care physicians can help individual patients select the "best" test for them.

Surprisingly for a group that typically has required the highest degree of evidence to justify an "A" rating, the USPSTF did not emphasize stool guaiac testing and flexible sigmoidoscopy, the only screening strategies that have reduced colorectal cancer deaths in randomized controlled trials. Earlier this year, the Canadian Task Force on Preventive Health Care did not recommend screening colonoscopy because it had not met that standard. (As Dr. Rita Redberg wrote in an editorial published simultaneously in JAMA Internal Medicine, "It would be interesting to know how many patients would undergo colonoscopy if they knew that there were no data to suggest that this procedure results in longer life.")

Finally, although the USPSTF reiterated that it "does not recommend routine screening for colorectal cancer in adults age 86 years and older," it omitted its previous "D" (don't do) recommendation against this unnecessary and potentially harmful practice. I think that this was a mistake. Plenty of octo- and nonagenarians still receive colorectal cancer screening tests; in a 2015 editorialAFP editor Jay Siwek related his 90 year-old father-in-law's complications from a "routine" colonoscopy as an example of the harms caused by overscreening. The best test isn't only the one that gets done, but gets done in a patient who has a chance of benefiting from that test.

Monday, June 20, 2016

Chronic opioid therapy - who, when, how?

- Jennifer Middleton, MD, MPH

A significant portion of the June 15 issue of AFP is devoted to chronic opioid use in patients with non-malignant pain. The issue provides an overview of Weighing the Risks and Benefits of Chronic Opioid Therapy along with reviewing the Centers for Disease Control's (CDC) new guideline for opioid prescribing with accompanying editorials from the CDC and the American Medical Association (AMA). The messages from these sources are consistent: the evidence base supporting the efficacy of chronic opioid use is limited but certainly some patients benefit, other modalities should be our first choice when possible, and monitoring for misuse or addiction is of critical importance. None of these recommendations are likely to come as a surprise to family physicians, but the challenges with identifying the right patients to treat, being aware of alternative modalities to offer, and providing effective monitoring may still remain for many practices.

The Risks and Benefits article provides guidance regarding the initiation, maintenance, and discontinuation of chronic opioid therapy. Assessing for risk of overdose and counseling patients regarding risks of opioid use are reviewed in Tables 3 and 4. Patients at lower risk of overdose, who have failed alternative treatments, and are willing to comply with ongoing monitoring are more ideal candidates for chronic opioid therapy.

Alternatives to using opioids for treating chronic pain have been studied with various degrees of rigor depending on the underlying source or cause. For chronic low back pain, several non-pharmacologic methods have evidence of at least short-term efficacy, but, unfortunately, acetaminophen does not  help in the short- or long-term, and NSAIDs should be used with caution.

Physical therapy and tai chi help knee osteoarthritis (OA) pain as does general exercise and weight loss; corticosteroid injections may help, though hyaluronic acid injections and glucosamine/chondroitin supplements don't. For upper body OA sites, splinting reduces hand pain, and corticosteroid injections and manipulation can help shoulder pain.

Exercise reduces fibromyalgia symptoms, and aquatic therapy helps stiffness and quality of life but doesn't necessarily reduce pain. Counseling, especially cognitive behavioral therapy, can be quite beneficial for patients with fibromyalgia, and several non-opioid medications can also provide some relief. The data to date for opioids in treating the chronic pain of fibromyalgia does not show any benefit.

A Family Practice Management (FPM) article from 2014 reviews helpful office protocols for monitoring patients on chronic opioids. The authors share their office policies for prescribing controlled substances, including opioids, and also discuss the use of patient pain questionnaires, risk assessment tools such as SOAPP, controlled substance agreements, urine drug screening, and prescription drug monitoring programs. Each office will want to tailor its plan to best meet its population's needs, but there are a lot of useful resources in this article to help you do so.

Identifying the most appropriate patients for chronic opioid therapy, trying alternative treatments, and monitoring patients can be challenging and time-intensive and, ideally, engages your entire office team. For more resources, there's an AFP By Topic on Pain:Chronic that includes the above referenced AFP and FPM articles and also includes information about neuropathic pain, more office-based tools, relevant Curbside Consultation features, and patient education materials.