Friday, November 11, 2011

Universal cholesterol screening in children: what is the evidence?

New guidelines released today by the American Academy of Pediatrics and the National Heart, Lung, and Blood Institute recommend replacing risk-based approaches to cholesterol testing with universal screening for all children at ages 9 and 17. To inform the debate that is sure to follow, we note that AFP has previously published commentaries that review the potential benefits and harms of different screening strategies. Below is our blog post on this topic from September 1, 2010.


The September 1 issue of American Family Physician inaugurates a new editorial feature that presents two opposing views on a controversial clinical topic and asks readers to post comments online. In this issue, Dr. Robert Gauer argues that because atherosclerosis begins in childhood, using cholesterol-lowering drugs in children with hyperlipidemia is essential to prevent coronary events and cardiovascular mortality in later life. On the other hand, Dr. Michael LeFevre contends that since only 40 to 55 percent of children with elevated cholesterol levels will have persistent hyperlipidemia as adults, and the potential benefits and harms of decades of drug therapy are unknown, physicians should demand a high "evidence bar" for instituting screening and treatment.

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

Graham Center: Integrate mental health into primary care

Based in part on a positive recommendation from the U.S. Preventive Services Task Force, the Centers for Medicare and Medicaid Services recently announced that it will cover annual depression screenings for Medicare patients in primary care settings "that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up." However, as the below Figure illustrates, translating the USPSTF guideline into practice has been challenging for many primary care physicians.

A Policy One-Pager from researchers at the Robert Graham Center, published in the November 1st issue of AFP, details the obstacles that clinicians face in identifying and treating depression and other mental health problems. As Dr. Robert Phillips and colleagues observe, "Current health care policy makes it difficult for most primary care practices to integrate mental health staff because of insufficient reimbursement, mental health insurance carve-outs, and difficulty of supporting colocated mental health professionals, to name a few."

On a related note, an editorial in the November 1st issue discusses strategies for improving adult immunization rates, which have historically lagged far behind rates of immunizations in children. According to Dr. Alicia Appel, immunization registries and electronic clinical decision-support systems can complement low-tech interventions such as patient reminders and standing orders. What has been your experience with incorporating depression screening and immunizations into routine care for adult patients?