Aspirin for primary prevention: who and when?

- Jennifer Middleton, MD, MPH

It seems that the pendulum on aspirin use for primary cardiovascular disease (CVD) prevention has swung back and forth over the last few years. Dr. Lin wrote about the debate regarding aspirin's risks and benefits on the blog when the United States Preventive Services Task Force (USPSTF) had last updated their guidelines in 2011; at that time, the evidence was mixed regarding the net benefit for aspirin. Fast forward to 2016, and the current issue of AFP reviews the latest USPSTF recommendation: aspirin likely benefits adults aged 50-59 who meet certain criteria.

The USPSTF now recommends that adults aged 50-59 with at least a 10% 10-year-CVD risk, without risk factors for serious bleeding, and with the willingness to take aspirin for at least 10 years take aspirin to reduce the risk of both CVD and colorectal cancer. This is a B recommendation (USPSTF recommends this service, net benefit is moderate to substantial). The data they reviewed is less convincing for adults of other ages; aspirin use for adults aged 60-69 has a C recommendation (selectively offer or provide this service, net benefit is small), while aspirin use for those under 50 and over 70 are both I recommendations (current evidence is insufficient to assess balance of harms and benefits).

Increasingly, recommendations about preventive care becoming less general and more personalized. Calculating CVD risk is already commonplace in assessing which patients might benefit from statins (though the controversies surrounding the most recent 10-year-risk calculator continue). Screening mammography may benefit only high-risk women under the age of 50. The benefit of colorectal cancer screening for those aged 76-85 is likely limited to patients without limited life expectancy and/or multiple co-morbid conditions. Keeping track of who needs what preventive service and when is more complex when sweeping generalizations ("everybody over age 50 should take an aspirin/get colorectal cancer screening/have an annual mammogram") no longer apply.

Apps such as the Agency for Healthcare Research and Quality Electronic Preventive Services Selector (AHRQ ePSS) can provide a quick, convenient way to search for relevant recommendations at the point-of-care with patients. The AHRQ ePSS app is free and provides a search tool that displays current USPSTF recommendations stratified by age, gender, tobacco history, and sexual activity. Pre-visit planning can help make preventive care a whole-office endeavor as can using Electronic Health Records (EHR) to identify those patients who may be overdue for services via registries or other population health tools. Regardless of the system used, having a systematic way to identify which patients might benefit from preventive services can leave more time for physicians to provide counseling about these increasingly complex recommendations.

Underperforming big ideas in diabetes and breast cancer

- Kenny Lin, MD, MPH

Management of type 2 diabetes and screening for breast cancer make up a large portion of most family physicians' practices, including my own. Care and prevention for these patients is based on straightforward underlying theories of disease causation and behavior. Patients with type 2 diabetes have high blood glucose levels; treatment involves normalizing blood glucose through lifestyle modification and medication. Small, nonpalpable breast cancers eventually become large, symptomatic tumors. Smaller tumors are more likely to be curable, so undergoing regular screening mammography is preferable to not doing so.

But what if these underlying theories are wrong?

In a recent editorial in JAMA, Drs. Michael Joyner, Nigel Paneth, and John Ioannidis explored how the "big idea" or narrative that investments in genetics and information technology will lead to a revolution in health care has captured a large share of biomedical research funding and journal publications. They then illustrated how this big idea has "underperformed," as central assumptions of precision/personalized medicine have not been borne out in studies and tens of billions of dollars invested into electronic health records since 2009 have not made patient care measurably better or patient data more accessible to researchers.

Is tight glycemic control for patients with type 2 diabetes mellitus an underperforming clinical big idea? In an analysis in Circulation: Cardiovascular Quality and Outcomes, Drs. Rene Rodriguez-Gutierrez and Victor Montori compared clinical policy statements and practice guidelines for patients with type 2 diabetes between 2006 and 2015 with evidence from randomized controlled trials. Despite little or no evidence that tight glycemic control (hemoglobin A1c <6.5 or 7.0%) improves microvascular or macrovascular outcomes compared to less strict hemoglobin A1c goals, the majority of guidelines continued to endorse tight control for one or both of those outcomes. (In contrast, AFP editorials and articles have long asserted that "Physicians should not let well-intentioned but misguided concern for glucose levels distract them from attending to other interventions that more profoundly affect mortality [in patients with type 2 diabetes]: smoking cessation, blood pressure control, metformin therapy, and lipid reduction.")

And do small breast tumors detected by mammograms become large, lethal ones? Sometimes, but not as often as most patients and physicians think, according to an observational study in the New England Journal of Medicine that concluded: "Women [with tumors detected on mammography] were more likely to have breast cancer that was overdiagnosed than to have earlier detection of a tumor that was destined to become large." This study also concluded that most of the reduction in breast cancer mortality over the past 40 years could be attributed to improved systemic therapy rather than earlier tumor detection. In an AFP editorial on counseling women about breast cancer screening, Dr. Mark Ebell and I discussed the benefits and harms of mammography in younger women and noted that for every additional breast cancer death prevented by starting at age 40, two women will be overdiagnosed with (and overtreated for) breast tumors that never would have become clinically apparent.

Putting Choosing Wisely into practice: how are we doing?

- Jennifer Middleton, MD, MPH

Changing long-standing habits can be challenging, but several well-established axioms in medicine have fallen in the last couple of years. How are we doing with changing our practice to eliminate these unhelpful and/or possibly harmful interventions?

AFP recently published the "Top POEMs of 2015 Consistent with the Principles of the Choosing Wisely Campaign" which includes the following evidence-based findings:

• Meniscectomy does not improve long-term outcomes for patients with meniscal tears.
• Pregabalin (Lyrica) is ineffective for spinal stenosis neuropathic pain.
• Platelet-rich plasma injections for knee degenerative joint disease are no better than hyaluronic acid (and hyaluronic acid probably isn't that effective to begin with).
• The benefits of beta-blockers in CAD are limited to the first 30 days after a myocardial infarction.
• Continuing dual antiplatelet therapy 1 year after drug-eluting stent placement confers no additional benefit and can cause serious bleeding.
• Bridging anticoagulation for patients with atrial fibrillation undergoing surgery doesn't prevent venous thromboembolism and increases the risk of bleeding and cardiovascular events.
• Vitamin D doesn't reduce falls in community-dwelling postmenopausal women.

Last fall, Dr. Lin commented on the early uptake of 7 of the Choosing Wisely recommendations; the study found decreased use of imaging in line with 2 recommendations, but, unfortunately, use of the other 5 "Things Providers and Patients Should Question" either did not change or increased.

More recent studies have examined physician behavior regarding several of the Choosing Wisely initiatives. The number of inappropriate DEXA scans ordered in women under age 65 in a large ambulatory care network in the DC area did not change with the Choosing Wisely recommendation to not "use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors." A broader study created a composite score of adherence to 11 Choosing Wisely recommendations and examined national patterns; the researchers found preoperative cardiac testing for low-risk procedures to be the most prevalent low-value service performed (46.5%), followed by prescribing antipsychotics to dementia patients (31.0%), prescribing opioids for migraines (23.6%), and early imaging of acute low back pain (22.5%). The study found wide geographic variation in adherence and also found that:

[T]otal Medicare spending per capita was associated with low-value care utilization, in addition to a higher ratio of specialist to primary care physicians, a higher proportion of minority beneficiaries and a higher proportion of residents with poor or fair health.

Primary care physicians have higher awareness of Choosing Wisely than do other specialties, but we have room for improvement in implementation. A national survey of 2000 primary care physicians' attitudes about Choosing Wisely found that "[t]he most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists." Awareness of Choosing Wisely is an important first step, but we still have work to do regarding how we put it into practice.

The Choosing Wisely campaign's mission to reduce unnecessary medical care aligns well with the Right Care Alliance's mission "to restore trust, balance, professional ethics and principles of justice and equality to healthcare in the United States." This week is Right Care Action Week, where "thousands will be participating in radical actions that reimagine health care as listening, hearing, sharing, partnering, caring... and sanity." Ensuring that the care we deliver is "effective, affordable, and needed," the Right Care Alliance provides many opportunities to get involved, both in small and big ways. You can start by signing up to learn more about them here.

How can family physicians avoid making diagnostic errors?

- Kenny Lin, MD, MPH

Due to our broad scope of practice, family physicians are likely the most vulnerable of all physicians (with the possible exception of emergency medicine physicians) to diagnostic errors. Patients of all ages and different co-morbidities come in with undifferentiated complaints that could be attributed to multiple organ systems. In an editorial in the September 15th issue of AFP, Drs. John Ely and Mark Graber reviewed underlying reasons for incorrect diagnoses:

Most diagnostic errors are caused by the physician's cognitive biases and failed heuristics (mental shortcuts), such as anchoring bias (overly relying on the initial information received or initial diagnosis considered), context errors, or premature closure of the diagnostic process. More than 40 of these biases have been described, but most lead to a single pathway in which the physician fails to generate an adequate differential diagnosis or to even consider the correct diagnosis as a possibility. The single most common reason for a diagnostic error is simply, “I just didn't think of it."

In a previous Curbside Consultation, Dr. Caroline Wellbery explored some of these cognitive biases in greater detail. For example, availability bias "refers to the ease with which a particular answer comes to mind," and can lead physicians toward making diagnoses based on other recent patients with similar presenting symptoms. Premature closure may occur when a framing/anchoring bias causes a physician to view the patient through a familiar lens and dismiss evidence that is not consistent with that frame. Similarly, confirmation bias may lead physicians to overemphasize test findings that support their preliminary diagnoses. Dr. Allan Detsky brought some of these dry concepts to life in a recent narrative in JAMA where he compared difficult diagnoses to the plastic snakes that he used to scare away ducks from the dock at his family's vacation home:

When faced with a difficult and ongoing diagnostic dilemma, refocus on the key assumptions that have driven the strategy to search for the "snakes." Start by dividing the findings into those that are based on facts and those that are based on inferences derived from those facts. Design an experiment to see if those inferences are indeed true, like holding the snakes under the water to see what they will look like on the bottom of the lake.

In their AFP editorial, Drs. Ely and Graber suggested three approaches to reduce diagnostic errors in primary care: 1) Involve the patient as a partner in the diagnostic process; 2) Get second opinions from colleagues or consultants who have not been previously involved in the patient's care; 3) Use a diagnostic checklist to make sure that all appropriate differential diagnoses have been considered. On a health system level, the National Academies of Medicine published a report on "Improving Diagnosis in Health Care" last year, and the Society to Improve Diagnosis in Medicine is leading a coalition of professional organizations, including the American Academy of Family Physicians, to devise and implement strategies to prevent diagnostic errors across all specialties and healthcare settings.

Including women’s partners in preconception care

- Jennifer Middleton, MD, MPH

The September 15 issue of AFP reviews the new AAFP position paper recommending the discussion of preconception care at every visit for women of reproductive age. Along with asking female patients about their reproductive plans, the authors encourage us to work with them to optimize their health in case of unplanned pregnancy. Appropriately, the paper includes an often forgotten individual in determining maternal and infant well-being: the father and/or pregnant woman’s partner. The health of these potential fathers, along with the lifestyle habits of both male and same-sex female partners, are also important determinants of pregnancy outcomes. 

It can be challenging to remember to include preconception care during already busy visits, but the biggest challenge may be just getting these partners to our offices in the first place. Men visit physicians far less often than women, even when visits for OB care are excluded. Low income and uninsured men are even less likely to see physicians, and men of all income and insurance statuses do not routinely receive much counseling about mental health, sexual health, or violence and safety when they do come into the office. Including mental health assessment and counseling is especially important given that fathers can also experience perinatal depression, which can have consequences for both their partners and their children. Even more than their older counterparts, male adolescents may find accessing care for their sexual health especially stressful and intimidating. Discomfort regarding care-seeking affects same-sex female partners as well. Lesbian women access health care far less frequently than heterosexual women despite having comparatively higher rates of chronic disease, tobacco use, and heavy drinking. Ensuring access to welcoming care is an important first step in providing preconception care for the partners of women of child-bearing age, be they male or female.

Making our offices safe places for everyone is, then, a critical first step. Once they are there, incorporating preconception care into our everyday practice will likely require a team approach. Pre-visit planning may be one way of systematizing this care. There’s a Family Practice Management Topic Collection on Care Team & Staffing if you’re interested in other possible approaches. You can also read more about common psychosocial issues in men here, and there's an AFP By Topic on the Care of Special Populations that includes a subsection on Gay, Lesbian, Bisexual, and Transgendered Persons.

How is your office addressing preconception care?