Is routine stress testing necessary for resolved chest pain?

- Kenny Lin, MD, MPH

Last week, the family medicine residency inpatient service that I supervise admitted several patients from the emergency department with acute chest pain that had resolved. Most of them had no history of cardiovascular disease, but were deemed to have enough risk factors to undergo pre-discharge cardiac stress testing after they had "ruled out" for acute coronary syndrome with normal cardiac enzymes. Rationales for the American Heart Association's recommendation for routine stress testing in patients with resolved chest pain include reducing malpractice liability, improving cardiac risk stratification, and initiating appropriate interventions earlier in high-risk patients. Although this practice is widely accepted, there is no evidence that it  improves patient-oriented outcomes compared to outpatient management, and some researchers have argued that randomized trials are needed to prove that the benefits actually exceed the harms.

A recent study published in JAMA Internal Medicine adds fuel to this debate by presenting prospectively collected outcomes of adult patients evaluated in the emergency department chest pain unit of Mount Sinai Medical Center from 2004 to 2010. A total of 4181 patients underwent stress testing (512 with exercise ECG tests and the rest with nuclear perfusion imaging), and 470 tests suggested potential myocardial ischemia. 123 patients underwent cardiac catheterizations; 60 of these patients were found to have normal coronary arteries. Of the 63 patients whose catheterizations showed obstructive coronary artery disease, only 28 had lesions that warranted stenting or coronary artery bypass grafting according to expert consensus guidelines.

There are at least two ways to view this study's results. A positive interpretation is that cardiac stress testing led to in the presumptive diagnosis of coronary artery disease in more than 10 percent of patients, who could then have received medical interventions shown to improve outcomes. On the other hand, the high false positive rates on coronary angiography suggest that up to half of these diagnoses were incorrect (and, consequently, that more than 150 patients would have received therapy inappropriately). Nearly 90 percent of patients were exposed to significant radiation doses through nuclear imaging, but less than 1 percent had coronary artery lesions that warranted revascularization. So are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?

Are IUDs a reasonable option for birth control in adolescents?

- Jennifer Middleton, MD, MPH

What kind of contraception options do you discuss with adolescents?

A study by Rubin, Davis, and McKee from the Annals of Family Medicine's last issue explored the views of family physicians, pediatricians, and OB/GYNs on this issue.  Some might be tempted to dismiss this study because the n only equaled 28 docs, but this study was a qualitative study, not a numbers-crunching quantitative study.  The researchers used a semi-structured interview guide and interviewed as many physicians as it took to reach saturation, or the point where they were not recording any new themes.  (Low ns are fairly typical of qualitative studies.)

Although this study discussed both the intrauterine device (IUD) and implantable contraception (Implanon), I'm going to focus on the IUD findings for today's post.

It turns out that only about half of these physicians were recommending IUDs to their teenage patients.  The researchers found that this was due to "knowledge gaps" and "limited access to the device."

The "knowledge gaps" mostly related to the suitability of an IUD for a teen.  We know that 1 in 4 teens get a sexually transmitted infection (STI) each year.  IUDs were previously thought to increase the risk for pelvic inflammatory disease following an STI, but more recent research disputes that assumption with the current IUD devices available in the US.(1,2) And, despite all of the levonorgestrel-releasing intrauterine system (Mirena) commercials stating that it's only for women who have "had at least one child," the American College of Obstetrics and Gynecology reasonably asserts that IUDs are safe and reasonable to use in nulliparous women of all ages.

The "limited access to the device" is exactly what it sounds like; only 60% of the family docs, and none of the pediatricians, were providing this service in their offices.  Pediatricians, especially, were uncomfortable with any type of birth control besides oral contraceptive pills.  Long-acting contraception like the IUD, though, is a perfect fit for many teens who may be less than reliable at remembering to pop a pill every day. (Let's face it - many adults aren't any better at remembering to take daily meds.)

A look at the recent evidence regarding IUD use in adolescents shows that IUDs are easily inserted in most teens and nulliparous women, though the insertion process can be more uncomfortable. (3)  NSAIDs are a reasonable option for controlling this discomfort. Adolescents may be at slightly higher risk for IUD expulsion than older women, but current data suggests that the difference is probably not very large. (4,5)

There is a useful AFP By Topic collection on family planning and contraception available at http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=71.  The IUD article does date to 2005, so please take its recommendations in the context of the evidence cited above, but the collection has many helpful resources to assist busy family doctors regarding this increasingly complex topic.

What are your thoughts about the IUD for teens?  If you are recommending it, what spurred you to do so?  If not, what is making you hesitate?

1. Faundes A, Telles E, Cristofoletti ML, Faundes D, Castro S, Hardy E. The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998;58:105–9.
2. Skjeldestad FE, Halvorsen LE, Kahn H, Nordbo SA, Saake K. IUD users in Norway are at low risk for genital C. trachomatis infection. Contraception 1996;54:209–12.
3. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994;49:56–72.
4. Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contraception 2009;79:418–23.
5. Lyus R, Lohr P, Prager S. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Board of the Society of Family Planning. Contraception 2010;81:367–71.

How do family physicians provide cost-effective care?

- Kenny Lin, MD

Research studies have documented strong associations between U.S. primary care physician supply, better population health outcomes, and lower health care spending. Among adult primary care specialties, national survey data suggest that family physicians provide more cost-effective care. However, little research has examined how family physicians provide effective care at lower cost than other physicians. Is it because we are more likely to follow evidence-based guidelines? Order fewer inappropriate imaging tests? Are less likely to offer non-beneficial tests and treatments?

In the May issue of Family Medicine, Dr. Richard Young and colleagues reported a qualitative analysis of interviews with 38 Texas family physicians about decision-making practices that may contribute to delivery of cost-effective care. Participants provided examples of experiences that they felt exemplified differences in the ways they approached patients compared to approaches of less cost-effective specialists. Two major themes emerged from these interviews: 1) cost-effective care is an inherent value in family medicine; 2) knowledge of the whole patient through continuous relationships enabled efficient decision-making.

Family physicians in this study emphasized the importance of the history and physical examination, conservative testing strategies in low-risk patients, being comfortable with managing complexity, and assigning less importance to "making the diagnosis" than relieving patients' symptoms. Physicians were also attuned to potential behavioral causes of physical symptoms and placed considerable weight on financial and medical harms that could result from aggressive care.

As the authors point out, these findings are limited by the relatively small number of participants, who may or may not represent the general attitudes of family physicians in other areas of the U.S. Do you think that Dr. Young and colleagues identified all of the important ways that family physicians provide cost-effective care? If not, what other factors would you add from your own patient care experiences?

Skin procedures for the family physician: old and “new”

- Jennifer Middleton, MD, MPH

Seeing a skin procedure on my schedule always makes my day.  I enjoy providing patients with small epidermal (sebaceous) cysts and worrisome lesions the convenience of removal in the office.

Traditionally, epidermal cysts are removed by making an incision parallel to the skin lines over the widest part of the cyst.  The cyst is dissected away from the subcutaneous tissue, and after it’s removed the incision is sutured.  

Traditionally, worrisome skin lesions are removed by inking an ellipse (1:3 ratio of width to length ensures optimal closure) around the lesion.  The ellipse is then incised and lifted away from the subcutaneous tissue and closed with sutures.

In the last year, I’ve learned about an alternative technique for each of these procedures.   They are much faster than the traditional methods above.

Minimal excision technique for epidermal cysts

Make an incision of 2-3 mm over the cyst.  Then use a hemostat to keep this incision open and squeeze out all of the cyst’s contents using your thumbs (wear eye protection!).  Use the hemostat to lift out the cyst shell.  No sutures are necessary given the tiny size of the incision.

(Avoid this technique for cysts that are/were infected or inflamed, as the adhesions surrounding the cyst will make lifting out the cyst shell impossible.)

Thorough technique description and excellent pictures here: http://www.aafp.org/afp/2002/0401/p1409.html

Saucerization (“scoop”) excision for worrisome skin lesions

This procedure uses a common shave biopsy (razor) blade but “scoops” deep into the skin.  The blade should enter the skin at a 45-degree angle and penetrate to at least the mid-dermis.

Thorough technique description and excellent pictures here:

http://www.aafp.org/afp/2011/1101/p995.html

When described to me within the last year, both of these procedures were billed as “new,” yet the AFP articles above cite sources that are more than 10 years old.  It was a bit disconcerting to find how out of date my surgical techniques were.

Given that the dissemination gap between research-based practice recommendations and the actual implementation into clinical practice is around 20 years, though, perhaps I shouldn’t have been so surprised.

Are you using the minimal excision technique and/or saucerization in your practice?  I welcome comments about when you learned about these techniques and how they're working.  Or, if not yet, would these techniques change your practice?