Will Choosing Wisely change the way family physicians practice?

- Kenny Lin, MD, MPH

As phase 3 of the Choosing Wisely campaign draws to a close, it's time to start assessing its impact. Family physicians have been at the forefront of this clinician-led movement to reduce waste and prevent harm from unnecessary medical interventions, beginning with Dr. Howard Brody's call for organized medicine to develop "Top Five" lists of such services:

I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty's “Top Five” list. ... The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.

The American Academy of Family Physicians responded to the Choosing Wisely campaign by participating in all three phases, ultimately contributing 15 clinical recommendations that span the full scope of the specialty of family medicine. However, Dr. Nancy Morden and colleagues observed in a recent New England Journal of Medicine editorial that some societies avoided selecting services that are major contributors to their incomes:

The American Academy of Orthopaedic Surgeons, for example, named use of an over-the-counter supplement as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.

Although patient advocacy groups such as Consumer Reports are also participating in Choosing Wisely, the ultimate success or failure of the campaign will depend on how well physician societies can convince their members to curtail commonly accepted but nonbeneficial services, such as the annual physical examination in healthy adults. Earlier this month, American Family Physician unveiled an online tool that allows readers to search for primary care-relevant recommendations by keyword and topic area. We hope that you will bookmark this tool and use it often to Choose Wisely in your practice.

Does metformin prevent recurrent events in diabetic patients with CAD?

- Jennifer Middleton, MD, MPH

Metformin can help reverse pre-diabetes, improve fertility in women with polycystic ovarian disease, and may even limit weight gain due to antipsychotic medications. We may be able to add prevention of recurrent cardiovascular disease to that list, as a POEM reviewed in last week's AFP describes.

The POEM reviews a study from China which enrolled approximately 300 diabetics with known coronary artery disease (CAD). The researchers randomized participants into 2 groups; the groups continued their medications for CAD and any other co-morbid conditions, but for their diabetes each group initially received only one medication. One group received metformin, and the other glipizide. Eventually, about a quarter of these participants did require insulin to bring their A1Cs near the researchers' goal of 7.0 %. After at least a three-year follow-up, the participants in the metformin group had a lower incidence of the study's composite outcome of heart attack, stroke, and death (hazard ratio 0.54 [0.30-0.90]; p=0.026) compared to participants in the glipizide group, with a number needed to treat (NNT) of only 9.4 for five years. In diabetic patients who already have CAD, metformin decreased the risk of a further cardiovascular insult.

Overall, this study's design is solid, but it raises some interesting questions worthy of future research. The dosing for both medications in this study was three times a day (TID), but patients typically prefer once or twice daily dosing to more frequent dosing patterns. Metformin is more commonly used once or twice daily. Could metformin dosed less frequently still yield the same CAD protective benefit as taking it TID?

Along the same lines, the authors did not describe any measure of participants' adherence to these TID medication regimens. That decision has some positives, as it may best simulate "real life" practice, but I am curious to know how well these participants did with remembering to take all three doses of their medications day after day.

Lastly, what about patients who are taking other medications besides metformin (and, possibly, insulin)? Diabetics and their physicians have multiple drug classes to choose from these days - would metformin's benefit persist in patients who are also using a thiazolidinedione (such as pioglitazone), a dipeptidyl peptidase IV inhibitor (such as sitagliptin), and/or a glucagon-like peptide-1 receptor agonist (such as exenatide)? CAD is not a strict contraindication for any of these medication classes (thiazolidinediones, however, are only to be used with caution in patients with CAD).

Despite these research opportunities, this study helps to reinforce that metformin (rather than a sulfonylurea) is the right choice when initiating treatment for type 2 diabetes. What to add when additional glycemic control is needed, however, remains up to each physician's clinical judgment, as this is yet another area in need of further studies. You can read more about metformin, and other treatments for type 2 diabetes, in this AFP By Topic.

Will this study change how you prescribe metformin for patients with both type 2 diabetes and CAD?

Are drugs the best medicine for children with ADHD?

- Kenny Lin, MD, MPH

Data from the Centers for Disease Control and Prevention document a steady rise in diagnoses of attention deficit hyperactivity disorder (ADHD) since its first national survey in 1997. Since stimulant medications are widely considered to be first-line therapy for ADHD, it is not surprising that by 2011, more than 3.5 million U.S. children were taking these medications. Guidelines for ADHD, such as one from the American Academy of Pediatrics, prefer prescription drugs over behavioral interventions due in part to the results of an influential 1999 study sponsored by the National Institute of Mental Health that compared these treatments and declared drugs to be superior.

However, a recent article published in the New York Times reported that some of the original study investigators are now openly questioning this conclusion. Since the primary outcomes were short-term impulsivity and inattention symptoms, rather than academic and social outcomes that may be affected more by behavioral skills training, the study's design inherently favored drug therapies. And the manufacturers of these drugs were happy to promote the results to boost sales:

Just as new products ... were entering the market, a 2001 paper by several of the study’s researchers gave pharmaceutical companies tailor-made marketing material. For the first time, the researchers released data showing just how often each approach had moderated A.D.H.D. symptoms: Combination therapy did so in 68 percent of children, followed by medication alone (56 percent) and behavioral therapy alone (34 percent). Although combination therapy won by 12 percentage points, the paper’s authors described that as “small by conventional standards” and largely driven by medication. Drug companies ever since have reprinted that scorecard and interpretation in dozens of marketing materials and PowerPoint presentations. They became the lesson in doctor-education classes worldwide.

There are, of course, practical challenges to providing behavioral therapy for ADHD, including a lack of resources in many communities and high costs, which, unlike drug therapies, are often not paid by health insurance. One way family physicians may facilitate therapy is to integrate behavioral health specialists into their practices. Our AFP By Topic collection on ADHD reviews other issues that often come up in clinical practice, including cardiovascular risks of stimulant medications and managing ADHD in adults and preschool-age children.

That "sinus" headache could be a migraine

- Jennifer Middleton, MD, MPH

My differential for patients complaining of a sinus headache used to be uncontrolled allergic rhinitis versus an upper respiratory tract infection ("common cold").  Sinusitis rarely merits treatment with antibiotics, so I'd look for one of these presumably underlying causes to treat.

It turns out that an important diagnosis has been missing from my differential, and an article in last month's Journal of Family Practice reviews evidence that many, if not most, patients complaining of sinusitis may have a migraine instead.

This article reviewed three cross-sectional studies and and one systematic review.  Two of the cross-sectional studies enrolled patients complaining of "sinus" headaches and classified their headaches using the International Headache Society's (IHS) criteria.  In both studies, researchers re-classified >80% of enrollees as migraineurs.

The third cross-sectional study divided enrolled headache patients into migraineurs and non-migraneurs, asked about their symptoms, and found the following 5 criteria distinguished those participants with migraines:

• pulsating quality
• duration between 4-72 hours
• unilateral location
• nausea and/or vomiting
• disturbance of daily activity

Photo- or phonophobia, presence/absence of nasal discharge, and aggravation by activity did not distinguish between migraine and sinus headaches in this study.

The systematic review, which was originally published in JAMA, verified those 5 criteria and turned them into a mnemonic, "POUND:"

• Pulsatile in quality
• Duration 4-72 hOurs
• Unilateral location
• Nausea and/or vomiting
• Disabling intensity

This systematic review found that, when 4 or 5 of these criteria are present, the likelihood ratio of a migraine is 24 (which is quite high).  An AFP Point-of-Care guide on "Diagnosis of Migraine Headache" includes the POUND criteria along with another clinical decision rule and is definitely worth a read.

Several practical questions remain about applying these findings in practice.  Does treating patients complaining of "sinus" who meet IHS migraine criteria with migraine therapies help their headaches?  Are patients who felt that they've had "sinus" problems for years accepting of a migraine diagnosis?  What about patients who meet IHS criteria for both migraine and sinusitis?  I'm hopeful that researchers will address these questions soon.

In the meantime, though, I will add migraine to my differential for patients who complain of a "sinus" headache.  Will these studies change how you assess patients complaining of a "sinus" headache?