Last year, AFP published the U.S. Preventive Services Task Force's updated recommendations on screening for osteoporosis, which advised dual-energy x-ray absorptiometry (DEXA) in "women 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors." However, the USPSTF statement left one important question unanswered: when should a woman be re-screened if her first test shows normal or slightly decreased bone mineral density (BMD)? Put another way, what are the chances that a woman without osteoporosis today will develop it in the future?
A research team led by former AFP medical editor Margaret Gourlay, MD, MPH recently shed light on this question by following nearly 5000 U.S. women age 67 years or older with normal BMD or osteopenia for up to 15 years. They defined the BMD re-testing interval as the estimated time it took for 10% of women to develop osteoporosis before having a hip or clinical vertebral fracture. According to their report in the January 19th issue of the New England Journal of Medicine, more than 90% of women with initially normal BMD or mild osteopenia did not develop osteoporosis after 15 years. As might be expected, women with moderate and advanced osteopenia progressed faster, with 10% of each group developing osteoporosis after 5 years and 1 year, respectively.
This study's results have substantial implications for family physicians and their patients. In the absence of new risk factors for osteoporosis (e.g., significant weight loss, corticosteroid use), a woman with normal BMD at age 65 may not need to be re-tested until age 80, an interval that is substantially longer than current clinical practice. That's good news, since as Dr. Gourlay pointed out in a previous AFP editorial, many U.S. women who are at risk for osteoporosis have yet to receive any screening at all. Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.
Wednesday, January 25, 2012
Wednesday, January 18, 2012
AFP Journal Club casts doubt on NEJM study
Do children younger than 2 years of age with acute otitis media (AOM) require antibiotics, or is a watchful waiting approach just as effective? A study designed to answer this question was published last year in the New England Journal of Medicine and concluded that a 10-day course of amoxicillin-clavulanate "tended to reduce the time to resolution of symptoms and reduced the overall symptom burden and the rate of persistent signs of acute infection on otoscopic examination." However, an analysis of this study by Drs. Andrea Darby-Stewart, Mark Graber, and Robert Dachs in the November 15, 2011 AFP Journal Club concluded that the results actually supported a watchful waiting strategy because the primary outcome (likelihood of treatment failure) was disease-oriented rather than patient-oriented:
The only clinically significant outcome was likelihood of treatment failure; yet, this was defined as the presence of any symptom of AOM and persistent otoscopic signs of AOM on day 10 to 12. Treatment did not fail in any children based on symptoms alone—all treatment failures were defined by persistent inflammation on examination. The treatment failed even if the patient was symptomatically better. Most of these asymptomatic children likely would never have presented for follow-up in routine practice. And, only four to six children had to be treated to cause diarrhea, rash, or diaper dermatitis.
The January 15th AFP Journal Club continues this story by reporting an apparent discrepancy between the predesignated primary outcomes in study's original protocol (published on ClinicalTrials.gov and posted to the NEJM's website) and those that were ultimately reported in the study abstract's conclusions:
There were only three primary outcomes planned and the fourth outcome, otoscopic resolution, was one of many planned secondary outcomes. ... What is even more concerning is that the otoscopic findings are only one of 22 secondary outcomes evaluated in this study. It amazes me that a significant number of these findings, the ones that just happen to support placebo, were never reported. The secondary outcomes that demonstrated no difference between placebo and amoxicillin/clavulanate were analgesia requirements in these children; number of needed follow-up visits to a primary care physician; number of visits to the emergency department; missed hours of work by the parents; and parental satisfaction.
The bottom line: family physicians should not conclude that this NEJM study showed that antibiotics are superior to watchful waiting for acute otitis media in young children. In fact, by showing that only 6 children needed to be treated with antibiotics to cause one additional episode of diarrhea, it suggests that the opposite conclusion may be true.
The only clinically significant outcome was likelihood of treatment failure; yet, this was defined as the presence of any symptom of AOM and persistent otoscopic signs of AOM on day 10 to 12. Treatment did not fail in any children based on symptoms alone—all treatment failures were defined by persistent inflammation on examination. The treatment failed even if the patient was symptomatically better. Most of these asymptomatic children likely would never have presented for follow-up in routine practice. And, only four to six children had to be treated to cause diarrhea, rash, or diaper dermatitis.
The January 15th AFP Journal Club continues this story by reporting an apparent discrepancy between the predesignated primary outcomes in study's original protocol (published on ClinicalTrials.gov and posted to the NEJM's website) and those that were ultimately reported in the study abstract's conclusions:
There were only three primary outcomes planned and the fourth outcome, otoscopic resolution, was one of many planned secondary outcomes. ... What is even more concerning is that the otoscopic findings are only one of 22 secondary outcomes evaluated in this study. It amazes me that a significant number of these findings, the ones that just happen to support placebo, were never reported. The secondary outcomes that demonstrated no difference between placebo and amoxicillin/clavulanate were analgesia requirements in these children; number of needed follow-up visits to a primary care physician; number of visits to the emergency department; missed hours of work by the parents; and parental satisfaction.
The bottom line: family physicians should not conclude that this NEJM study showed that antibiotics are superior to watchful waiting for acute otitis media in young children. In fact, by showing that only 6 children needed to be treated with antibiotics to cause one additional episode of diarrhea, it suggests that the opposite conclusion may be true.
Wednesday, January 11, 2012
Curbing overuse of CT scans
The urban public hospital where I completed most of my training as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present the patient's case to the on-call Radiology fellow and explain how the result of the scan would potentially change management. Since my attending surgeons were usually too busy to trudge down to the Radiology suite, they deputized their residents to do so, and most of the time my residents passed this thankless task down to the students. Thus, my classmates and I learned early on the difference between appropriate and inappropriate reasons for ordering CT scans.
Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, an editorial published last year in AFP reviewed the accumulating evidence that CT scans are highly overused in current medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.
Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published recently in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.
In their AFP editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommend that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:
1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.
Since 2007, AFP has published a series of articles in collaboration with the American College of Radiology on appropriate criteria for diagnostic imaging (including CT) in specific clinical situations. The ACR Appropriateness Criteria are periodically updated, and current versions are available on the ACR website.
Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, an editorial published last year in AFP reviewed the accumulating evidence that CT scans are highly overused in current medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.
Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published recently in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.
In their AFP editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommend that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:
1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.
Since 2007, AFP has published a series of articles in collaboration with the American College of Radiology on appropriate criteria for diagnostic imaging (including CT) in specific clinical situations. The ACR Appropriateness Criteria are periodically updated, and current versions are available on the ACR website.
Wednesday, December 28, 2011
First, do no harm: preventing elective inductions before 39 weeks
A recent article published in the Journal of the American Board of Family Medicine reported that fewer than 1 in 5 board-certified family physicians provide routine prenatal care, and just over 13 percent perform deliveries. Therefore, more family physicians are referring patients for maternity care and have less influence over troubling national trends, such as declining rates of vaginal births after previous Cesarean delivery (VBAC) and increasing rates of "late" premature delivery (between 34 and 38 6/7ths weeks gestation) due for the most part to elective inductions.
In an editorial in the December 15th issue of AFP, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:
The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.
If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.
In an editorial in the December 15th issue of AFP, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:
The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.
If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.
Tuesday, December 20, 2011
Screening mammography decisions are close calls
A physician reader of AFP submitted the following post.
**
I read with interest the December 1st Cochrane for Clinicians article by Dr. Joanne Wilkinson, "Effect of Mammography on Breast Cancer Mortality." On the first page of the article in big print is the "Evidence-Based Answer," which gives a SORT "A" recommendation in favor of mammography because of an approximate 15% reduction in mortality from breast cancer attributed to mammography screening. In small print inside are the conclusions from the Cochrane abstract, which note a 30% rate of overdiagnosis and overtreatment. The Cochrane authors write:
This means that for every 2,000 women invited for screening over 10 years, one will have her life prolonged, and 10 healthy women who would not have been diagnosed if there had not been screening will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false-positive findings. It is not clear whether screening does more good than harm.
Having read this - I wonder how many women would continue to opt for regular mammography screening if told that only 1 out of every 2,000 will benefit, whereas 10 out of 2,000 will be overtreated (some presumably with mastectomy), and 200 out of 2,000 (10%) will be temporarily overdiagnosed (and subject to important psychological distress for many months) because of a false-positive mammography reading. Given these statistics, observers outside of the medical community might wonder why "primary care physicians should continue to recommend mammography every two years in women 50 to 74 years of age," as the last paragraph of Dr. Wilkinson's commentary states.
As in much that the primary care clinician does, there are pros and cons to any intervention. For patients to give truly informed consent, it is essential for us to convey to them the numerical chance for life-prolonging benefit (1 in 2,000 for women who undergo yearly mammography for a decade) versus the 1 in 10 risk of a falsely positive mammogram report, and the 1 in 200 risk of overtreatment during that 10-year period. For some women who subscribe to the "n of 1" theory, screening mammography may be worth the risk, effort and cost because of the chance that it may save their lives. Others may decide that the odds of experiencing benefit are not in their favor. Shouldn't the choice to undergo mammography be up to the patient?
Ken Grauer, MD
Gainesville, Florida
http://ecg-interpretation.blogspot.com/
**
I read with interest the December 1st Cochrane for Clinicians article by Dr. Joanne Wilkinson, "Effect of Mammography on Breast Cancer Mortality." On the first page of the article in big print is the "Evidence-Based Answer," which gives a SORT "A" recommendation in favor of mammography because of an approximate 15% reduction in mortality from breast cancer attributed to mammography screening. In small print inside are the conclusions from the Cochrane abstract, which note a 30% rate of overdiagnosis and overtreatment. The Cochrane authors write:
This means that for every 2,000 women invited for screening over 10 years, one will have her life prolonged, and 10 healthy women who would not have been diagnosed if there had not been screening will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false-positive findings. It is not clear whether screening does more good than harm.
Having read this - I wonder how many women would continue to opt for regular mammography screening if told that only 1 out of every 2,000 will benefit, whereas 10 out of 2,000 will be overtreated (some presumably with mastectomy), and 200 out of 2,000 (10%) will be temporarily overdiagnosed (and subject to important psychological distress for many months) because of a false-positive mammography reading. Given these statistics, observers outside of the medical community might wonder why "primary care physicians should continue to recommend mammography every two years in women 50 to 74 years of age," as the last paragraph of Dr. Wilkinson's commentary states.
As in much that the primary care clinician does, there are pros and cons to any intervention. For patients to give truly informed consent, it is essential for us to convey to them the numerical chance for life-prolonging benefit (1 in 2,000 for women who undergo yearly mammography for a decade) versus the 1 in 10 risk of a falsely positive mammogram report, and the 1 in 200 risk of overtreatment during that 10-year period. For some women who subscribe to the "n of 1" theory, screening mammography may be worth the risk, effort and cost because of the chance that it may save their lives. Others may decide that the odds of experiencing benefit are not in their favor. Shouldn't the choice to undergo mammography be up to the patient?
Ken Grauer, MD
Gainesville, Florida
http://ecg-interpretation.blogspot.com/
Tuesday, December 6, 2011
AFP By Topic is your 24-7 virtual Scientific Assembly
Since we first introduced AFP By Topic in June 2010, this online and mobile-friendly collection of the journal's best current content selected by AFP's medical editors has grown to include 52 topics that family physicians and other primary care clinicians commonly diagnose and treat in their patients. Recently, we compared the list of AFP By Topic collections to the most popular sessions at the 2011 American Academy of Family Physicians' Scientific Assembly in Orlando, Fla. Of the clinical subjects of 13 non-plenary sessions with an attendance of at least 500 physicians, 10 regularly rank among our most widely viewed topic collections, encompassing a diverse spectrum of acute (e.g., abdominal pain, pulmonary embolism) and chronic (e.g., diabetes, kidney disease, hyperlipidemia) health conditions.
Also at the Scientific Assembly, David T. Walsworth, MD, gave a presentation titled “Medical Applications: Finding the Right App for That." In his presentation, Dr. Walsworth discussed the utility of mobile devices and tablets, including the many uses for related apps in a family physician’s day-to-day practice. Some of the criteria he uses in appraising a medical app include asking the following questions: Does the app do something that I will use frequently? Do I trust the source? and Does the value justify the cost? Ranking highly on all of these criteria, the free AFP By Topic Mobile App not only made his personal Top Ten list, but came in at number 2!
Whether you access AFP By Topic collections on the Web or your mobile device, content links are updated continually to ensure that they remain as current and as useful as possible. The collections include pertinent AFP articles and departments, summaries of practice guidelines from major medical organizations, articles from Family Practice Management, and the AAFP's METRIC practice improvement modules. In short, we aim for AFP By Topic to be your 24-7 virtual Scientific Assembly. Please let us know how we're doing.
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