The most popular posts from 2013

- Kenny Lin, MD, MPH

It's been a terrific year for the AFP Community Blog. Page views have exceeded 5000 every month, with a high of 6,172 in November. To put these numbers into perspective, readers visited the blog nearly as much this year as in 2010, 2011, and 2012 combined! Looking back at the top ten most-read posts of 2013, two key themes emerge: potential harms from over-the-counter drugs and supplements (acetaminophen, NSAIDs, and calcium); and questioning the benefits of preventive services (vitamin D and cancer screening, diet and exercise counseling). The most-read post of the year was viewed more than 1200 times.

1. Are IUDs a reasonable option for birth control in adolescents? (May 21)

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

2. USPSTF: Diet and exercise counseling not routinely recommended (June 17)

Given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is something more than just counseling necessary to effect behavior change?

3. Pros and cons of vitamin D screening (April 29)

No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone.

4. Steroids for pharyngitis? (July 15)

One dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4).

5. Is routine stress testing necessary for resolved chest pain? (May 29)

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?

6. Are calcium supplements bad for the heart? (February 5)

Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence might make you change your practice?
7. Does acetaminophen help nasal congestion from the common cold? (August 12)

A lack of high-quality studies supporting efficacy isn't the same as a high-quality study showing that it doesn't work. I still recommend acetaminophen for headache, myalgias, and fever, and if it gets some of those nasal symptoms, that'd be a nice bonus.

8. Providing culturally competent health care (January 25)

The increasing diversity of the U.S. population has made it more likely that family physicians will care for many patients with cultural backgrounds, beliefs, and practices that are dissimilar to their own.

9. Why don't physicians discuss cancer screening harms? (October 29)

If the results of this survey are representative of the practices of U.S. family physicians, then more than 90 percent of us aren't telling patients that there are any downsides to undergoing routine mammograms, colonoscopies, and Pap smears.

10. Another strike against NSAIDs? (July 1)

Long-term use of all non-steroidal anti-inflammatory drugs (NSAIDs), selective COX-2 or non-selective, doubled the risk of heart failure.

JNC 8 - hypertension management may never be the same

- Jennifer Middleton, MD, MPH

The Eighth Joint National Committee (JNC 8) released its "2014 Evidence-Based Guideline For the Management of High Blood Pressure in Adults" last week.  It's been 10 years since JNC 7, and I suspect that many family docs, like myself, have been eagerly awaiting its release.

In JNC 8, a group of experts from multiple fields, including Family Medicine, sifted through the enormous evidence base regarding hypertension treatment.  Where no or low-quality evidence exists, they stated as such and made an expert recommendation.  I appreciate their transparency in indicating these instances.

The committee sought to answer these 3 questions (directly quoted from the article):

1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

And made the following recommendations (summarized by myself):

1. For adults aged 60 and older, treat blood pressure (BP) to a goal of less than 150/90.  
2. For adults 18-59, treat BP to a goal of less than 140/90.  This includes patients with diabetes and/or chronic kidney disease (CKD).
3. Initiate treatment with a thiazide diuretic, an ACE inhibitor, an ARB, or a calcium channel blocker (CCB). This includes patients with diabetes.
4. No, there were no beta blockers on that last list.  Exhaust those other classes before adding a beta blocker.  JNC 8 backs this up with solid references; here's one to whet your appetite.
5. For African-American patients, consider initiating treatment with a thiazide or a CCB.  This includes patients with diabetes.
6. Patients with CKD should be on an ACE inhibitor or ARB, regardless of race or co-morbid diseases.

It's unclear, as of yet, how widely these recommendations will be adopted.  Will the American Academy of Family Physicians endorse them?  How about the American Heart Association and/or the American College of Cardiologists?  They will likely want time to examine JNC 8 before stamping a seal of approval upon it, along with the AAFP, who thoughtfully posted an overview of the guidelines along with their plan to review them last week.

I encourage you to check out the article for yourself and draw your own conclusions.  Should JNC 8 be the new standard of care?

Guest Post: To solve rural health shortages, train more family physicians

- Robert C. Bowman, MD

Training more family physicians is the obvious solution for all of the practice locations with low physician concentrations. Across 30 states behind in graduate medical education positions, across 40,000 zip codes with lower concentrations of physicians, across 2900 counties lower in physician concentrations, and especially for rural locations in need of workforce, family physicians are the multiple times solution.

It is a matter of mathematics. As concentrations of physicians decline due to health, economics, income, and other designs, the proportion of family physicians increases. Family medicine stays relatively constant at 30 per 100,000 while other specialties follow the pattern of higher concentrations found where other specialties are more concentrated. For rural workforce or for workforce where it is needed, family medicine is a 3 times greater solution.

Comparing the 2013 version of the American Medical Association Masterfile to the 2005 version, family physicians have increased to 28% of rural physician workforce and overall numbers are steady. Internists represent 13% of rural physicians and falling. Pediatricians are 6% of rural physicians. General surgery and obstetrics-gynecology each contribute 5%, and general orthopedics 3%, but all are declining. Rural areas have very specific workforce needs for generalists and general types of specialists: fields that are poorly addressed by current training designs.

Physicians coded by county concentrations yield the same proportions of physician specialty contribution for counties with lowest concentrations or less than 150 physicians per 100,000 (27% from family medicine, 13% from internal medicine, etc.). These 2438 urban and rural counties represent 28% of the American population most left behind. Typical training designs do not work well for counties lower to lowest in physician concentrations. Will the current recommendations to train more physicians actually result in care being provided where unmet demand is greatest?

To address physician shortages, the Council on Graduate Medical Education has recommended more trainees in internal medicine, in geriatrics, in psychiatry, and in general surgery. The evidence suggests that training more residents in internal medicine or general surgery will not resolve the major problem of few graduates remaining in general internal medicine or general surgery.

In rural America, it is most commonly the family physician who provides critically needed services in internal medicine, geriatrics, pediatrics, inpatient care, women’s health, emergency care, and mental health. In 1000 counties with the greatest rural workforce challenges, about 8% of the family medicine workforce serves this 8% of the U.S. population - the half of the rural population that is most disadvantaged in key areas such as health status, health access, education, income, employment, and insurance coverage.

The solution that can best increase the number of family physicians, add value to the care given, and increase family physicians where they are most needed is also common sense. All years of preparation, all training years, and all practice years must be specific to community-engaged family practice. Family physicians should guide middle school and high school children and patients and local family practice interest group students into a future of family medicine. Recent Graham Center Policy One-Pagers in AFP have demonstrated that comprehensive medical school rural programs targeting family medicine and support for in-state family medicine residencies produce family physicians where they are most needed.

We must not lose sight of family medicine's unique contribution to rural health care. We must also not lose sight of workforce solutions arising from rural areas that can benefit most Americans who remain in need of basic health care.

**

Dr. Bowman is a North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and a long term chair of the STFM Group on Rural Health. He maintains the World of Rural Medical Education and Physician Workforce Studies web sites and blogs at Basic Health Access.

Cervical cancer screening: USPSTF and ACOG align

- Jennifer Middleton, MD, MPH

Professional societies' disagreements regarding cancer screening have dominated the medical landscape of late.  USPSTF says some women may appropriately defer breast cancer screening until age 50, while the American College of Radiography and American Cancer Society both recommend starting at age 40.  USPSTF grades prostate cancer screening a "D" (not recommended) yet the American Urological Association advises shared decision making regarding the prostate specific antigen (PSA) test with all men aged 55-69 years.  21st century media-savvy patients are aware of these differences, and discussions about screening often occupy quite a bit of my time with patients these days.

How refreshing it is, then that the American College of Obstetrics and Gynecology (ACOG)'s new cervical cancer screening guidelines align well with the USPSTF's published last year.  Last week's AFP summarized ACOG's stance nicely:

• No screening before age 21.  EVER.
• Screen every 3 years between ages 21-29 only with cytology.  (Because the rate of incidental HPV infection is so high in this age group, add HPV testing only when the pap test is abnormal.)
• Screen every 5 years between ages 30-65 with cytology and HPV.  (Alternatively, screen every 3 years with just cytology.)
• No screening after age 65 unless 1 of the last 3 pap tests was abnormal or there is a history of high-grade dysplasia.

As Dr. Lin pointed out earlier this year, screening for cancer is not a zero risk proposition, and discussing cancer screening with patients is frequently more complex than a simple directive to "get a mammogram/PSA/etc." The AFP By Topic on Cancer includes several AFP articles from the last few years summarizing the evidence for multiple types of cancer screening if you'd like further reading.

Thankfully, the sensitivity and specificity of the pap test are both quite high, making the risks of a false positive or a false negative exponentially much lower than mammography or PSA.  The jury may still be out on breast and prostate cancer screening (as for me, I follow the USPSTF's guidelines and discuss this openly with patients), but for cervical cancer screening, at least, we have consensus and clear recommendations as above.

New statin guidelines and other notable medical reversals

- Kenny Lin, MD, MPH

The recently published American College of Cardiology / American Heart Association cholesterol treatment guideline, which updates the National Heart, Lung, and Blood Institute's Adult Treatment Panel III recommendations that have guided clinicians for more than a decade, has generated controversy for several reasons: primary care groups did not participate in development of the guideline; several panelists had financial conflicts of interest; its cardiovascular risk calculator may substantially overestimate risk in certain populations; and the lowered risk threshold for prescribing medication, if adopted worldwide, could potentially result in more than a billion people taking statin drugs. American Family Physician will provide readers with concise summaries and critical analyses of the ACC/AHA guideline in future issues.

Family physicians who have grown comfortable with ATP III's "treat to target" paradigm for cholesterol management were likely surprised by the new guideline's "fire and forget" approach, which advises prescribing fixed doses of statins based on cardiovascular risk assessments and not routinely rechecking cholesterol levels. The latter approach is more consistent with the evidence from randomized controlled trials, but this change is, nonetheless, a significant reversal of an established medical practice. Although such reversals are surprisingly common, they can be unsettling to clinicians.

In an editorial in the December 1st issue of AFP, Drs. Caroline Wellbery and Rebecca McAteer review reasons for other dramatic reversals such as hormone replacement therapy and tight glucose control in diabetes, which include poor design and small size; focus on disease-oriented evidence, application of findings to nonstudy populations; unidentified harms; and economic factors. They have several related suggestions to help physicians avoid pitfalls associated with currently accepted practices that may be vulnerable to later reversal:

To minimize the dizzying impact of changing recommendations, physicians should focus on patient-oriented evidence, and not be distracted by disease-oriented evidence. Physicians should become familiar with the basic principles of good research, and avoid drawing premature conclusions from observational studies or studies with design flaws. Physicians should also recognize the pharmaceutical industry's influence on research studies and practice recommendations.