Addressing family medicine's "Top 5" list

Last week, the journal Archives of Internal Medicine published "The 'Top 5' Lists in Primary Care," a physician-authored consensus statement that recommended five activities each for the specialties of family medicine, internal medicine, and pediatrics to pursue to reduce waste and improve quality. Here is the top 5 list for family physicians, together with related online resources from AFP By Topic collections:

1) Don't do imaging for low back pain within the first 6 weeks unless "red flags" are present.

AFP By Topic: Muculoskeletal Care - Neck and Back

2) Don't routinely prescribe antibiotics for acute sinusitis.

AFP By Topic: Upper Respiratory Tract Infections - Treatment

3) Don't order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients.

AFP By Topic: Coronary Artery Disease - Screening and Diagnosis

4) Don't perform Pap tests on women younger than 21 years or in women status post hysterectomy for benign disease.

AFP By Topic: Cancer - Cervical Cancer

5) Don't use DEXA screening for osteoporosis in women under age 65 years or in men under 70 years with no risk factors.

AFP By Topic: Osteoporosis - Screening and Diagnosis

As a reminder, AFP By Topic is also available as a free mobile app in the Apple Store and the Android Market.

Autism spectrum disorders: increasing prevalence or diagnosis shift?

A physician reader of AFP submitted the following post.

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The recent editorial “The Changing Prevalence of the Autism Spectrum Disorders” in the March 1st issue discusses many of the challenges surrounding autism and the apparent increase in prevalence of this diagnosis. Having spent 30 years as the medical director of a private residential facility for children with developmental disabilities, I have some additional observations to add.

Many years ago, the most common diagnosis at our school was “mental retardation.” Subsequently, this diagnosis fell out of favor and was replaced by “static encephalopathy.” I seldom see these admitting diagnoses any more from referring neurologists and developmental pediatricians. Instead, some children are labeled as having “global developmental delay,” but virtually all children are also diagnosed as being on the autism spectrum. I am convinced that a great deal of what we are seeing in this population is a shift in diagnosis rather than a real change in prevalence.

In the past, children with known genetic disorders such as Down syndrome, Fragile X syndrome, or tuberous sclerosis were excluded from the diagnosis of autism. Now, autism is usually the second or third diagnosis. In my mind, this is like diagnosing a patient with a broken leg as having a gait disturbance. Although it may be technically true, it adds little to the diagnosis. Children with developmental disabilities typically have difficulties with social interaction, communication and behavior. Although some of these behaviors may be similar to those of children with autism, I believe that the supplemental diagnosis is not helpful.

A wide variety of services, including medical assistance, early intervention, and wraparound services, are available to children with autism which are not available to the same children if the diagnosis is mental retardation. I have often encountered parents who insist on the diagnosis of autism for their child even if I believe that the child does not fit in the autistic spectrum, because they want their children to have access to the benefits and services that accompany this diagnosis.

Many children who were previously diagnosed as having minimal brain dysfunction or being emotionally disturbed (or even just considered “odd”) are now rightfully recognized as belonging in the high functioning end of the autistic spectrum. Once again, I believe much of the increase in prevalence we are seeing is diagnosis shift.

Richard G. Fried, MD

The Camphill Special School

Glenmoore, PA

CME that makes a difference in patients' lives

Surveys of American Family Physician's readers and website visitors have consistently reported that the journal contains useful, evidence-based information that is applicable to daily practice. But as valuable as AFP is for providing continuing medical education to clinicians, does it actually save patients' lives? That's the question that primary care researchers from Sweden asked about a specific CME intervention in this month's issue of Annals of Family Medicine. Dr. Anna Kiessling and colleagues conducted a randomized trial comparing long-term outcomes in patients with coronary heart disease who received care from generalist physicians who attended repeated case-based trainings in the management of hyperlipidemia, or received usual care. Ten years later, the results were clear: the overall mortality rate in the intervention group (22%) was half of the mortality rate in the control group (44%).

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 afpedit@aafp.org.

Can inappropriate MRI use be stopped?

A physician reader of AFP submitted the following post.

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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
Orlando, Florida

Screening colonoscopies performed more often than necessary

According to guidelines from multiple expert groups, including those of the American College of Gastroenterology and the U.S. Preventive Services Task Force, the appropriate interval between colonoscopies for colorectal cancer screening is 10 years. But a study published today in the Archives of Internal Medicine found that nearly 1 in 4 Medicare patients who had a normal screening colonoscopy examination from 2001 to 2003 underwent another colonoscopy within 7 years with no other medical indications. This study confirmed previous reports of endoscopists advising patients to return for repeat colonoscopies at substantially shorter intervals than those recommended in current guidelines.

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?

Redefining Alzheimer's dementia: for better or for worse?

Two weeks ago, the National Institute on Aging and the Alzheimer's Association published new criteria for the diagnosis of Alzheimer's disease that include biomarker measurements in addition to traditional clinical criteria. The rationale for the new guideline was that more sensitive criteria were needed in order to test interventions to prevent Alzheimer's disease; by the time symptoms are obvious, proponents argue, it is likely too late to alter the patient's prognosis. However, the downside to creating a new category of "pre-symptomatic Alzheimers" is that many otherwise healthy adults could now receive an Alzheimer's diagnosis when there is no effective treatment - a label that leads to no health benefit and possible psychological harm. Therefore, experts recommend that this category only be used for patients who are enrolled in clinical trials of Alzheimer's prevention.

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.