Wednesday, December 28, 2011
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
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
Tuesday, December 6, 2011
Thursday, December 1, 2011
Friday, November 11, 2011
Since hyperlipidemia causes no symptoms, these views reflect in large part the dueling guidelines of the American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) on lipid screening in children. While the AAP recommends that screening for hyperlipidemia begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors, the USPSTF found insufficient evidence to recommend for or against screening in any group of children. [Editorial note: the AAP now recommends universal, rather than targeted, screening.]
This leaves family physicians and other clinicians who care for children with an important clinical dilemma. Should they act now based on disease-oriented evidence and extrapolation from studies of primary prevention of cardiovascular disease in adults, or should they instead wait for patient-oriented evidence from long-term followup studies of children with elevated lipid levels? Which approach do you take in your practice, and why? You are welcome to post comments here or on AFP's Facebook page; AAFP members can also post comments on the AFP web page. We look forward to the discussion!
Tuesday, November 1, 2011
Tuesday, October 25, 2011
Monday, October 17, 2011
Monday, October 10, 2011
The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information—“best” implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and “available” implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.
Friday, October 7, 2011
Monday, October 3, 2011
Tuesday, September 20, 2011
Monday, September 12, 2011
Monday, September 5, 2011
In fact, drug-company funded "ghostwriters" have been publishing articles in the medical literature for years. A study by the editors of JAMA found that from 2 to 11 percent of articles published in 2008 in six major journals (including the New England Journal of Medicine) were actually written by people who were not named as authors. While the study could not establish that these ghostwriters had been directly financed by industry, the practice of writing up a scientific study and then recruiting a lead author (usually an academic physician under pressure to "publish or perish") has been well-documented in the case of previous "blockbuster" drugs that were taken by millions of patients for common conditions but later turned out to have dangerous or fatal side effects, including Wyeth's Prempro and Merck's Vioxx.
Although there is no foolproof way for readers to detect undue industry influence, readers should be alert for marketing messages that disparage older, generically available drugs or that position newer branded (or upcoming) drugs as more effective, more convenient, safer, or filling an unmet need. The last sentence of the abstract is typically where the marketing spin is inserted. Readers should alert medical journals to suspicious articles by writing letters to the editor.
Wednesday, August 31, 2011
Although the American Academy of Family Physicians and the American Academy of Pediatrics recommend that mothers exclusively breastfeed infants for the first 6 months of life, and supports continuing breastfeeding to at least one year of age, data from the 2004-2008 National Immunization Survey document that only 73% of U.S. women attempt to breastfeed after birth, and only 42% and 21% are still breasfeeding at 6 and 12 months of life. The percentages are even lower for Black women: only 54% attempt breastfeeding, and just 27% and 11% are still doing so at 6 and 12 months.
Monday, August 22, 2011
To address areas of uncertainty beyond the 2009 USPSTF guidelines, the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial aims to answer a simple question with significant public health relevance: Does daily low-dose aspirin use maintain longevity without cognitive and functional disability in healthy men and women age 70 years or older? Currently, recruitment of 19,000 older adults who do not require aspirin for a cardiovascular condition is ongoing at over 20 sites in the U.S. in addition to general practices in Australia. In the U.S., results from ASPREE should hopefully provide insight on how aspirin works in all older persons, including members of minority groups. In order to succeed, ASPREE will require the engagement of family physicians and other primary care clinicians. Family physicians can make a significant contribution by identifying healthy, older persons from minority communities and providing them with information about how to participate in the study. More information about the study and locations of study sites in the United States can be found at www.ASPREE.org.
Rush University Medical Center
Disclosure: The author is a co-investigator on the ASPREE study.
Tuesday, August 16, 2011
1) What are the sensitivity and false-positive rate of the best screening test for ASDs available in an average clinical setting?
2) How much earlier can screening tests detect ASDs compared with an astute clinician who asks a few key questions about, and acts on, parental concerns regarding a child's communication and interactions?
3) What are the potential harms of testing?
4) Does earlier detection by screening result in meaningful and long-lasting improvements compared with detection through routine care?
Wednesday, August 10, 2011
Tuesday, August 2, 2011
Medical offices and hospitals can help by recycling; using recycled items and Energy Star certified appliances and computers; minimizing waste and waste transport by replacing single-use items with sterilizable or washable items; purchasing wind-generated electricity; and reducing energy use by turning off appliances, computers, and lights when not in use. In 2008, the U.S. health care sector spent $8.8 billion on energy to meet patient needs, not including the transportation of employees or patients to and from health care facilities, resulting in 8 percent of all U.S. greenhouse gas emissions.
Sunday, July 31, 2011
Monday, July 25, 2011
One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, “this fluid came down my face, this greenish liquid.” She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain.
Monday, July 18, 2011
Counseling in natural methods of fertility regulation is currently being provided by a growing number of trained physicians, nurse practitioners, and allied health professionals. ... These family planning methods should not be confused with calendar rhythm method and are not dependent on the regularity of a woman's cycle. Population-based surveys have shown a significant interest in NFP—approximately 25 percent of women and 40 percent of men are interested in using NFP to avoid pregnancy, and 33 percent of women are interested in using NFP to conceive. This interest is not associated with religion, education, age, or income level.
Monday, July 11, 2011
It is an unwritten law of medicine that patients tend to be less than entirely forthcoming when responding to queries regarding their intake of alcohol. I would guess that most physicians double or triple the number of alcoholic beverages patients admit to drinking daily. Similarly, when counseling patients with diabetes or obesity, I generally hear what I take to be gross underestimates of the amount of carbohydrates and total calories consumed. An individual might state with complete confidence (and often, indignation), "I eat almost nothing." He then might list his total food consumption for the previous day as "nothing for breakfast, an apple for lunch, a piece of chicken and a salad for dinner; that’s it."
I suspect that we all have an unintentional, perhaps uncontrollable, drive to appear better than we are in the presence of health professionals; we want to pass the test, so to speak. As a result, it is quite difficult to obtain accurate information regarding lifestyle habits such as diet, amount of exercise, tobacco use, substance abuse, sexual activity, etc. I congratulate patients who "come clean" and provide me with true descriptions of their daily habits. When asking them to keep food diaries, I explain that I am not grading them but, rather, collecting information about unhealthy aspects of their diet so that I can help them make adjustments.
Sometimes this approach works; often, it does not. After hearing another improbable tale of conscientious eating habits in a patient whose physical examination and laboratory tests suggest otherwise, I generally explain, “the laws of thermodynamics cannot be broken."
Bob Schwartz, MD
Chester Family Medicine
Wednesday, July 6, 2011
Friday, July 1, 2011
The first diagnosis of anthrax in the 2001 attack was in an emergency department. A salmonella outbreak in Oregon in 1984 that was later found to be bioterrorism-related was discovered after primary care physicians reported to their health department large numbers of patients with diarrhea who had eaten at two local restaurants. This type of passive surveillance is the early warning system for naturally occurring outbreaks, and for bioterrorism events. An astute physician who diagnoses a reportable illness and alerts the local health department may be detecting a bioterrorism attack, possibly saving his or her patient and many others.
Thursday, June 23, 2011
Thursday, June 16, 2011
Monday, June 6, 2011
Last July, a record-breaking heat wave affected most of the Northern Hemisphere and led to many cases of heat-related illness in the U.S. and abroad. As the summer of 2011 approaches, Drs. Jonathan Becker and Lynsey Stewart from the University of Louisville, Kentucky present an updated review of the evaluation and management of heat cramps, heat exhaustion, and heat stroke in the June 1st issue of AFP. In addition to using the suggested evaluation algorithm, family physicians should also be aware of the many conditions and substances that may increase the risk of heat-related illness. As the authors note, heat stroke is a true medical emergency that requires immediate assessment and lowering of core body temperature, preferably through cold water immersion.
Monday, May 30, 2011
Sunday, May 22, 2011
Monday, May 16, 2011
The editors of AFP would like to believe that our online collections of selected content on topics such as hyperlipidemia, hypertension, and coronary artery disease have similar lifesaving benefits for your patients, but the truth is, we don't know. So how can we find out? As recently reported in AAFP News Now, journal CME quizzes for content published after the July 1st issue must be submitted online only, in order to meet new AMA requirements regarding CME credit. Although this will be a change for many readers, it presents an opportunity to think about how we might redesign CME content to better meet physicians' needs and improve measurable outcomes for their patients. If you have any thoughts or suggestions, please post them in a comment or send an e-mail to firstname.lastname@example.org.
Thursday, May 12, 2011
A physician reader of AFP submitted the following post.
I enjoyed reading and cannot agree more with the editorial in the April 15, 2011 issue on the appropriate use of magnetic resonance imaging for evaluating common musculoskeletal conditions. In many ways, the overuse of MRI is like the overuse of antibiotics for viral syndromes. Everyone knows we shouldn’t do it, but nobody seems to be able to stop.
Almost every specialist I refer to orders an MRI, often requiring them before they will even schedule a consult. Patients come in demanding an MRI after watching a professional sports event in which the sideline reporter let folks know what the MRI showed on the star who was injured during the game.I’ve had many patients come in letting me know that their personal trainer, therapist, or next door neighbor as well as their neurologist, chiropractor or other health care professional had advised them to come in and request an MRI.
The radiologists where I practice review all MRI requests for appropriateness based on the clinical history and reported physical findings. This review process has significantly cut down on the number of MRIs that are being done at our facility, although the number of complaints has risen. In contrast, there are no financial disincentives to performing inappropriate MRIs in fee-for-service health systems.William T. Sheahan, MD
Orlando VA Medical Center
Monday, May 9, 2011
Overuse of screening colonoscopy provides no additional health benefits to patients, but increases the risk of adverse effects, causes unnecessary medical expenses, and diverts resources that might otherwise be available to assist the nearly 40 percent of eligible Americans who are not up-to-date on colorectal cancer screening. Although more adults are being screened today than ever before, much work remains to be done, as family physician Doug Campos-Outcalt wrote in a previous editorial in AFP:
Although [colorectal cancer screening] trends show improvement, significant disparities persist. Racial or ethnic minorities and those with no health insurance, low incomes, or less than a high school education have significantly lower rates of use of colorectal cancer testing. There are several hypothesized reasons to explain low adherence to recommendations. These include lack of a medical home, lack of health insurance, lack of awareness of the need, and failure of physicians to recommend screening. Family physicians can address the last two issues; policy makers need to address the first two.
Fecal occult blood testing and flexible sigmoidoscopy are also recommended options for reducing colorectal cancer mortality in adults 50 to 75 years of age. However, evidence suggests that colonoscopy has become the colorectal screening cancer test of choice for many family physicians. What has been your experience with referring patients for screening colonoscopy? Has your practice observed excessive colonoscopy use for patients without indications other than screening?
Sunday, May 1, 2011
In the May 1st issue of AFP, Drs. Carla Perissinotto and Victor Valcour review the numerous gaps in the evidence for preventing dementia that complicate public health strategies for reducing the rising incidence and morbidity from this chronic disease. They argue that current knowledge supports a tertiary prevention strategy:
It is reasonable to look to prior public health campaigns as models for our educational and prevention efforts for dementia. Educational efforts should first focus on ensuring that the public understands that a diagnosis of dementia represents a spectrum of cognitive impairment, and that Alzheimer disease is only one of several subtypes. Until strategies targeting primary and secondary prevention emerge, our greatest impact may be in tertiary prevention—in the prevention of dementia morbidity. Such work may require early recognition, in which strategies targeting home and financial safety have a clear impact on those at highest risk.
Family physicians have always played an important role in caring for patients with dementia and their caregivers. For more current information on the diagnosis and management of the various forms of dementia, see our AFP By Topic collection.
Monday, April 25, 2011
Recently, state legislatures in Vermont, Maine, and New Hampshire have passed laws that restrict access to a physician's prescribing profile for marketing purposes. Drug companies and other groups argue that these laws violate the First Amendment, equating a doctor's prescribing data to constitutionally protected "free speech." A news article in yesterday's New York Times reported that the Supreme Court will hear arguments this week in a lawsuit brought against Vermont's confidentiality law by prescribing data collection companies and the industry group Pharmaceutical Research and Manufacturers of America.
In order to balance the sometimes deleterious effects of aggressive drug marketing, AFP provides numerous online resources to support our readers in decision-making about prescriptions. These resources include a systematic eight-step approach to prescribing and individual reviews of new drugs that utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) approach. Are there other ways that we could help you and your patients make informed drug choices?
Wednesday, April 20, 2011
Sunday, April 17, 2011
American Medical News recently reported that the 2010 health reform law gave house calls a boost by mandating "Independence at Home," a Medicare demonstration project that will offer financial incentives to primary care teams performing house calls in selected high-cost areas of the U.S. starting in 2012. A similar program sponsored by the HealthCare Partners Medical Group in California, Nevada, and Florida led to a 20 percent drop in hospital use over its two years of existence, saving $2 million per year for every 1,000 members.
In addition to reductions in hospitalizations and costs, house calls produce other benefits for clinicians and patients, including improved continuity of care and new patient referrals, as family physician Samantha Pozner, MD argued in a 2003 article published in Family Practice Management.
As house calls appear poised to make a comeback, the April 15th issue of AFP delivers a timely, updated review of their effectiveness, essential elements (including a sample house call checklist), and practice management details such as current billing codes for house calls and domiciliary care.
Monday, April 4, 2011
The diagnostic evaluation of failure to thrive includes "a detailed account of a child's eating habits, caloric intake, and parent-child interactions," as well as observations of breast or bottle feeding technique. Unless the child presents with one or more red flag signs or symptoms suggesting a non-behavioral cause of failure to thrive, routine laboratory testing is not recommended. Treatment usually consists of nutritional counseling and supplementation to achieve catch-up growth, with frequent follow-up visits to monitor progress.
As a previously published AFP Curbside Consultation has illustrated, however, diagnosing a psychosocial cause of failure to thrive is often challenging. The difference between neglect and parental ignorance of appropriate feeding habits may not be clear, especially when parents delay seeking medical attention for a child with apparently obvious signs of malnutrition and growth delay. When you recognize a child with failure to thrive in your practice, under what conditions would you consider referring him or her to a child protective services agency for investigation of parental neglect?
Wednesday, March 30, 2011
Established harms of PSA testing include excessive worry over false-positive results and morbidity from interventions, including infection, bleeding, pain, long-term sexual dysfunction, and urinary incontinence. A recent analysis showed that PSA testing does not attain the likelihood ratios necessary to qualify as a screening test, regardless of the cutoff value used. The inventor of the PSA test said the test's popularity has caused “a hugely expensive public health disaster.”Despite the preponderance of evidence that this test is not effective, and frequently results in harm to patients, data from the National Health Interview Survey published earlier this week in the Journal of Clinical Oncology demonstrate that PSA screening is becoming more common in the U.S., not less. 45 percent of men age 70 to 74 years, and 25 percent of men age 85 years or older, report being screened.
The U.S. Preventive Services Task Force and the AAFP recommend against screening for prostate cancer in men age 75 years or older, due to their limited life expectancies and the high likelihood of death from a cause other than prostate cancer. Nonetheless, clinical practice remains far out of step with the evidence. What approach do you take to discussing prostate cancer screening with your patients?
Monday, March 21, 2011
Graham Center Policy One-Pagers
U.S. Preventive Services Task Force statements
Pro/Con Editorials (only members and paid subscribers can post comments)
AAFP News Now
Close-Ups: A Patient's Perspective
These sections of the journal were selected because they are intended for our patients or the wider medical community, and most are freely available on other sites.
We hope that AFP's new "selected open access" policy will benefit family physicians and their patients by allowing the journal to reach a wider online audience, while continuing to reserve continuing medical education-associated content to members and paid subscribers.
Wednesday, March 16, 2011
Although achieving widespread adoption of system-wide changes is a daunting task, family physicians can begin by taking small steps to improve the preventive and well-child care services they provide to their patients. By using chart review or abstraction and identifying key measures to improve (e.g., immunization rates, anticipatory guidance on select topics), family physicians and their staff can assess how well they currently deliver these services, then set improvement goals. Family physicians and their staff can also work together to use well-studied quality improvement techniques, such as the PDSA (plan, do, study, act) cycle, to identify and develop practice-specific ways to improve well-child services.
Since preventive care guidelines for children and adults are updated frequently, we are pleased to provide two new AFP By Topic Collections on Health Maintenance and Counseling and Immunizations. In addition to cutting-edge clinical content, be sure to check out valuable Improving Practice articles from Family Practice Management on subjects such as the recent Medicare preventive services expansion, working with behavioral health specialists, and coding sports physicals.