- Jennifer Middleton, MD, MPH and Kenny Lin, MD, MPH
It's that time of year when we give thanks to our readers and highlight our most read posts of 2016. This list reflects the AFP Community Blog's growing audience; as compared to last year, when only one post was viewed more than 1000 times, this year five passed that mark.
1. Is Vitamin D supplementation good for anything? (January 12) - 2093 views
The next time a healthy adult of any age asks me if he or she should be taking a vitamin D supplement, I plan to answer: we don't know for sure, but probably not - and we don't need to know what your vitamin D level is, either.
2. 25 podcast episodes every family physician should listen to (July 18) - 1666 views
Podcasts, and their ability to make us engage with others’ stories, might be useful to physicians as they look for ways to take in new information, and above all, try to stay tuned in to the underlying messages their patients are sharing.
3. To rapid strep test or not to rapid strep test? (July 5) - 1416 views
Because the rapid strep test produces either a false positive or a false negative result a significant minority of the time, it is most useful in patients with an intermediate pre-test probability of having strep pharyngitis.
4. For acute low back pain, naproxen alone works best (February 22) - 1308 views
Prescribe naproxen alone for most patients with acute low back pain and no contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs); reserve cyclobenzaprine for patients who can't use NSAIDs; and prescribe oxycodone/acetaminophen only in patients who can't tolerate NSAIDs or cyclobenzaprine.
5. Which medications lower mortality in type 2 diabetes? (March 14) - 1284 views
Metformin has a proven mortality benefit for all patients with type 2 diabetes, even those on insulin. Metformin is so beneficial that clinicians should only consider discontinuing it if a patient's GFR is less than 44 mL/min, not just because the serum creatinine level is > 1.5 in men or >1.4 in women as previously recommended.
6. Hyaluronic acid injections don't help knee DJD (April 25) - 953 views
Unfortunately, the placebo effect with hyaluronic acid comes with cost and risk; injections can cost hundreds of dollars for one dose, and typical therapeutic regimens involve a series of 3-5 injections over several weeks.
7. New USPSTF and ACP guidelines on depression screening and treatment (February 8) - 847 views
A new clinical practice guideline reviewed the comparative effectiveness of treatment for major depressive disorder and recommended that "clinicians select between either cognitive behavioral therapy or second-generation antidepressants after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient."
8. What we say when we don't give an antibiotic matters (April 11) - 837 views
This study will change the way I speak with parents and adult patients about my decision not to prescribe antibiotics. I will make sure not to trivialize their concerns or refer to an illness as "just" a virus, and I will aim to use objective language to describe my rationale either way.
9. Myth-busting and fact-sharing about Family Medicine (February 1) - 792 views
Medical students, other specialists, and even the lay public often have questions about Family Medicine. Kozakowski et al answer these questions and many more in "Responses to Medical Students' Frequently Asked Questions About Family Medicine."
10. Have your female patients asked you about ROCA? (June 6) - 739 views
Offering a screening test directly to consumers prior to establishing its clinical utility is presumptuous at best and exploitative at worst; hopefully our patients will discuss the shortcomings of this test, and ovarian cancer screening in general, with us prior to spending $295 on it.
Wednesday, December 21, 2016
Thursday, December 15, 2016
How can medical educators support students' well-being?
- Kenny Lin, MD, MPH
Even twenty years later, I remember well the pervasive despair that engulfed me for much of my first two years of medical school. Even with a personal support system that included my family and several former college roommates and friends who lived in the same city, I struggled to find my bearings, academically and emotionally. Now that I spend much of my time teaching first-year medical students, I have wondered if the learning environment that I and other faculty provide contributes negatively or positively to their well-being.
A recent systematic review in JAMA examined the self-reported prevalence of depression, depressive symptoms, and suicidal ideation in medical students from 43 countries who were surveyed from 1982 to 2015. Longitudinal studies showed that students' mental health worsened significantly after starting medical school, with a median absolute increase in symptoms of 13.5%. On average, 27 percent of students reported depression or depressive symptoms, but only 16 percent of those students sought formal treatment. In contrast to my own experience, which was feeling much happier once I began third-year clerkships, there was no significant difference in depression prevalence between the preclinical and clinical years. Most alarmingly, 11 percent of students in these studies reported having suicidal thoughts during medical school.
A second systematic review examined associations between learning environment interventions and medical student well-being. The evidence base was limited: only 3 of 28 included studies were randomized trials, and most studies were conducted at a single site. Interventions that appeared to be effective in improving students' well-being included pass/fail grading systems, increased time with patients during the preclinical years, mental health programs, wellness programs including mind-body stress reduction skills, and formal advising/mentoring programs. In an accompanying editorial, Dr. Stuart Slavin observed that the educational culture of some medical schools is often an obstacle to implementing these kinds of reforms:
When signals of problems involving student mental health arise, the reaction in medical education has commonly been failure to recognize that the main problem is often with the environment, not the student. The response has often been limited, such as advising students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities. These approaches ... may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it.
To be sure, maximizing student well-being is not the only or even the most important goal of medical education. But just as it is possible to create positive practice environments that protect clinicians from burnout, educators can prepare students to practice medicine competently in learning environments that are least likely to harm their mental health.
Even twenty years later, I remember well the pervasive despair that engulfed me for much of my first two years of medical school. Even with a personal support system that included my family and several former college roommates and friends who lived in the same city, I struggled to find my bearings, academically and emotionally. Now that I spend much of my time teaching first-year medical students, I have wondered if the learning environment that I and other faculty provide contributes negatively or positively to their well-being.
A recent systematic review in JAMA examined the self-reported prevalence of depression, depressive symptoms, and suicidal ideation in medical students from 43 countries who were surveyed from 1982 to 2015. Longitudinal studies showed that students' mental health worsened significantly after starting medical school, with a median absolute increase in symptoms of 13.5%. On average, 27 percent of students reported depression or depressive symptoms, but only 16 percent of those students sought formal treatment. In contrast to my own experience, which was feeling much happier once I began third-year clerkships, there was no significant difference in depression prevalence between the preclinical and clinical years. Most alarmingly, 11 percent of students in these studies reported having suicidal thoughts during medical school.
A second systematic review examined associations between learning environment interventions and medical student well-being. The evidence base was limited: only 3 of 28 included studies were randomized trials, and most studies were conducted at a single site. Interventions that appeared to be effective in improving students' well-being included pass/fail grading systems, increased time with patients during the preclinical years, mental health programs, wellness programs including mind-body stress reduction skills, and formal advising/mentoring programs. In an accompanying editorial, Dr. Stuart Slavin observed that the educational culture of some medical schools is often an obstacle to implementing these kinds of reforms:
When signals of problems involving student mental health arise, the reaction in medical education has commonly been failure to recognize that the main problem is often with the environment, not the student. The response has often been limited, such as advising students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities. These approaches ... may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it.
To be sure, maximizing student well-being is not the only or even the most important goal of medical education. But just as it is possible to create positive practice environments that protect clinicians from burnout, educators can prepare students to practice medicine competently in learning environments that are least likely to harm their mental health.
Monday, December 5, 2016
Getting started with pet therapy
- Marselle Bredemeyer
The conclusion in AFP’s latest Curbside Consultation is unlikely to come as a surprise to anyone with a pet at home: animal companions do more than make us happy. They can be valuable for enhancing our health, too. The benefits of having a pet are strong enough that a recent article on pet-related infections is careful to dispel misconceptions about whether it is necessary to rehome an animal because of a zoonotic disease.
Asking about pets during an office visit can serve a larger purpose than preventing or treating a cause of infection, however. These conversations can help motivate patients who are striving to meet personal wellness goals, including quitting smoking. Such areas of overlap between animal and human health are common. In fact, worldwide, advocates for the One Health initiative increasingly encourage clinicians and veterinarians to recognize their interests in their patients as a shared project.
Pets’ positive impact on loneliness is one of many areas that researchers have looked into as they explore how to optimize health for humans and animals. Loneliness is especially prominent among older adults, with those older than age 80 years at the highest risk. The deleterious effects of prolonged feelings of social isolation have been well reported in the media, and include serious harms such as cognitive decline and even early mortality. Patients who are experiencing chronic loneliness may be reluctant to admit it, however. In these cases, a question about contact with animals becomes a potentially valuable way to explore patients’ day-to-day social interactions.
The conclusion in AFP’s latest Curbside Consultation is unlikely to come as a surprise to anyone with a pet at home: animal companions do more than make us happy. They can be valuable for enhancing our health, too. The benefits of having a pet are strong enough that a recent article on pet-related infections is careful to dispel misconceptions about whether it is necessary to rehome an animal because of a zoonotic disease.
Asking about pets during an office visit can serve a larger purpose than preventing or treating a cause of infection, however. These conversations can help motivate patients who are striving to meet personal wellness goals, including quitting smoking. Such areas of overlap between animal and human health are common. In fact, worldwide, advocates for the One Health initiative increasingly encourage clinicians and veterinarians to recognize their interests in their patients as a shared project.
Pets’ positive impact on loneliness is one of many areas that researchers have looked into as they explore how to optimize health for humans and animals. Loneliness is especially prominent among older adults, with those older than age 80 years at the highest risk. The deleterious effects of prolonged feelings of social isolation have been well reported in the media, and include serious harms such as cognitive decline and even early mortality. Patients who are experiencing chronic loneliness may be reluctant to admit it, however. In these cases, a question about contact with animals becomes a potentially valuable way to explore patients’ day-to-day social interactions.
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| Pablo, my bichon frise, poses with AFP's November 15 issue. |
What should physicians do if they suspect a patient is lonely and he or she doesn’t have a pet at home? This could identify patients who need help developing deeper social connections. Higher rates of loneliness among those who live by themselves and are without a pet could indicate a need to follow-up with the patient about how lack of contact with others might be affecting quality of life.
Patients who otherwise reply that they have interest in getting a pet but are not sure about caring for one in their older age will find reassurance from a physician useful. If there are no major contraindications to pet ownership, physicians can check that patients with limited access to transportation are aware of mobile veterinary and grooming services, and recommend contacting a local veterinarian’s office about free or low-cost animal care programs in the area. Additionally, many nonprofits are committed to helping older persons care for pets. Some U.S. shelters receive funding specifically for this purpose, and others are involved in foster networks that place animals with senior citizens while a permanent home is sought. Many of the nation’s Meals on Wheels programs will even deliver pet food to the people they serve if they have a pet at home.
Do you have a pet that’s improved your well-being as you’ve worked to improve your patients’? Listeners of AFP Podcast recently tweeted pictures of some of family medicine’s animal friends at the show’s Twitter account. With a dog of my own at home (see photo), I am always grateful that I can count on getting some “pet therapy” time at the end of every day, especially when there’s been a deadline.
Patients who otherwise reply that they have interest in getting a pet but are not sure about caring for one in their older age will find reassurance from a physician useful. If there are no major contraindications to pet ownership, physicians can check that patients with limited access to transportation are aware of mobile veterinary and grooming services, and recommend contacting a local veterinarian’s office about free or low-cost animal care programs in the area. Additionally, many nonprofits are committed to helping older persons care for pets. Some U.S. shelters receive funding specifically for this purpose, and others are involved in foster networks that place animals with senior citizens while a permanent home is sought. Many of the nation’s Meals on Wheels programs will even deliver pet food to the people they serve if they have a pet at home.
Do you have a pet that’s improved your well-being as you’ve worked to improve your patients’? Listeners of AFP Podcast recently tweeted pictures of some of family medicine’s animal friends at the show’s Twitter account. With a dog of my own at home (see photo), I am always grateful that I can count on getting some “pet therapy” time at the end of every day, especially when there’s been a deadline.
**
Marselle Bredemeyer is Associate Editor, AFP Online.
Tuesday, November 29, 2016
More guidance on statins for primary CVD prevention
- Kenny Lin, MD, MPH
Previous AFP Community Blog posts discussed the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline, provided additional perspectives on its 7.5% 10-year CVD event risk threshold for starting a statin, and noted that existing cardiovascular risk calculators tend to overestimate risk by significant margins. The ACC/AHA guideline has remained controversial in primary care. The American Academy of Family Physicians gave it a partial endorsement with qualifications (disclosure: I am a member of the AAFP Commission that made this recommendation), and a 2014 guideline from the U.S. Departments of Veterans Affairs and Defense recommended higher thresholds for considering (6%) or starting (12%) statins.
Two weeks ago, the U.S. Preventive Services Task Force weighed in with a new recommendation statement on the use of statins for primary prevention of cardiovascular events. The recommendations are similar to those from the ACC/AHA; the USPSTF recommends initiating low- to moderate-dose statins in adults aged 40 to 75 years with at least one CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater ("B" recommendation). They recommend shared decision making and selective statin prescribing for similar adults with a 7.5% to 10% CVD risk ("C" recommendation).
The USPSTF's higher risk thresholds for statin therapy compensate for uncertainty regarding the accuracy of CVD risk calculators, and the "C" recommendation recognizes that in persons at lower risk, the benefits of statins are less likely to outweigh the harms, which include liver enzyme abnormalities and muscle toxicity and a small increased risk of new-onset type 2 diabetes.
Although a prior USPSTF statement had recommended screening for lipid disorders in adults as early as 20 years of age, a new systematic review found no direct evidence on the benefits and harms of screening for or treatment of dyslipidemia in adults aged 21 to 39 years. So when should family physicians start checking cholesterol levels in asymptomatic adults, if statins don't become a treatment option until age 40? This is an area to exercise one's clinical judgment on a case-by-case basis, keeping in mind that healthy lifestyle counseling is more likely to be beneficial in adults with CVD risk factors than in adults without known risks.
Previous AFP Community Blog posts discussed the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline, provided additional perspectives on its 7.5% 10-year CVD event risk threshold for starting a statin, and noted that existing cardiovascular risk calculators tend to overestimate risk by significant margins. The ACC/AHA guideline has remained controversial in primary care. The American Academy of Family Physicians gave it a partial endorsement with qualifications (disclosure: I am a member of the AAFP Commission that made this recommendation), and a 2014 guideline from the U.S. Departments of Veterans Affairs and Defense recommended higher thresholds for considering (6%) or starting (12%) statins.
Two weeks ago, the U.S. Preventive Services Task Force weighed in with a new recommendation statement on the use of statins for primary prevention of cardiovascular events. The recommendations are similar to those from the ACC/AHA; the USPSTF recommends initiating low- to moderate-dose statins in adults aged 40 to 75 years with at least one CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater ("B" recommendation). They recommend shared decision making and selective statin prescribing for similar adults with a 7.5% to 10% CVD risk ("C" recommendation).
The USPSTF's higher risk thresholds for statin therapy compensate for uncertainty regarding the accuracy of CVD risk calculators, and the "C" recommendation recognizes that in persons at lower risk, the benefits of statins are less likely to outweigh the harms, which include liver enzyme abnormalities and muscle toxicity and a small increased risk of new-onset type 2 diabetes.
Although a prior USPSTF statement had recommended screening for lipid disorders in adults as early as 20 years of age, a new systematic review found no direct evidence on the benefits and harms of screening for or treatment of dyslipidemia in adults aged 21 to 39 years. So when should family physicians start checking cholesterol levels in asymptomatic adults, if statins don't become a treatment option until age 40? This is an area to exercise one's clinical judgment on a case-by-case basis, keeping in mind that healthy lifestyle counseling is more likely to be beneficial in adults with CVD risk factors than in adults without known risks.
Monday, November 21, 2016
Efforts underway to restrain rising prescription drug costs
- Mara Lambert
In a recent blog post, AAFP President-Elect Michael Munger, MD, addressed an all-too-familiar scenario physicians are encountering in their practices: when medications become too expensive, patients stop taking them. Over the past several years, Americans have faced exorbitant price increases on common treatments such as inhalers for asthma and insulin for diabetes. A Reuters report from this past April found that the prices of four of the top-10 most widely used drugs in the United States increased by more than 100% over the past five years, while six others rose by more than 50%. When steep price hikes for Daraprim and EpiPen made headlines during the past year, the public was justifiably concerned.
Pharmaceutical companies attribute price increases to the cost of researching, developing, and approving new drugs; however, there is a lack of transparency about how these prices are set. Medical societies and other organizations are now upping their efforts to remove the secrecy surrounding drug pricing with the ultimate goal of easing the burden on consumers.
In July, the American College of Physicians released a position paper that outlined various ways to reduce the increasing costs of prescription drugs. Then earlier this month, the American Medical Association announced the TruthinRx campaign to “uncover the truth behind prescription drug pricing.” The campaign’s mission is to improve transparency and restore affordability to medications by educating lawmakers and the public. Website visitors can send a pre-populated e-mail message to their senators and representatives asking them to support calls for increased transparency from pharmaceutical companies and health insurers.
In a similar vein, the Campaign for Sustainable Rx Pricing (CSRxP) is a nonpartisan coalition of physicians, employers, hospitals, nurses, patients, and payers striving to increase awareness of drug pricing and to promote transparency and competition. AAFP leadership met with CSRxP representatives in October to discuss their mutual concerns about drug costs.
The Fair Accountability and Innovative Research (FAIR) Drug Pricing Act (H.R. 6043) of 2016 and the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act (S. 3056) of 2016 are two current bills endorsed by CSRxP. The FAIR Act would require drug companies to disclose price increases greater than 10% and to provide supporting explanations for the increases, whereas the CREATES Act would close a loophole that prevents generic drug companies from accessing samples of branded drugs for research purposes, hence stifling competition.
These initiatives are a start. In the meantime, physicians should remain vigilant about asking patients whether they can afford their medications. In an AFP editorial from earlier this year, Steven R. Brown, MD, outlined five strategies for practicing high-value prescribing, including exercising skepticism and caution when prescribing new drugs, applying STEPS and knowing drug prices, prescribing generics and comparing value, restricting access to drug reps and office samples, and prescribing conservatively. Each of these actions can play a part in keeping costs down for patients and reducing health care spending at large.
In a recent blog post, AAFP President-Elect Michael Munger, MD, addressed an all-too-familiar scenario physicians are encountering in their practices: when medications become too expensive, patients stop taking them. Over the past several years, Americans have faced exorbitant price increases on common treatments such as inhalers for asthma and insulin for diabetes. A Reuters report from this past April found that the prices of four of the top-10 most widely used drugs in the United States increased by more than 100% over the past five years, while six others rose by more than 50%. When steep price hikes for Daraprim and EpiPen made headlines during the past year, the public was justifiably concerned.
Pharmaceutical companies attribute price increases to the cost of researching, developing, and approving new drugs; however, there is a lack of transparency about how these prices are set. Medical societies and other organizations are now upping their efforts to remove the secrecy surrounding drug pricing with the ultimate goal of easing the burden on consumers.
In July, the American College of Physicians released a position paper that outlined various ways to reduce the increasing costs of prescription drugs. Then earlier this month, the American Medical Association announced the TruthinRx campaign to “uncover the truth behind prescription drug pricing.” The campaign’s mission is to improve transparency and restore affordability to medications by educating lawmakers and the public. Website visitors can send a pre-populated e-mail message to their senators and representatives asking them to support calls for increased transparency from pharmaceutical companies and health insurers.
In a similar vein, the Campaign for Sustainable Rx Pricing (CSRxP) is a nonpartisan coalition of physicians, employers, hospitals, nurses, patients, and payers striving to increase awareness of drug pricing and to promote transparency and competition. AAFP leadership met with CSRxP representatives in October to discuss their mutual concerns about drug costs.
The Fair Accountability and Innovative Research (FAIR) Drug Pricing Act (H.R. 6043) of 2016 and the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act (S. 3056) of 2016 are two current bills endorsed by CSRxP. The FAIR Act would require drug companies to disclose price increases greater than 10% and to provide supporting explanations for the increases, whereas the CREATES Act would close a loophole that prevents generic drug companies from accessing samples of branded drugs for research purposes, hence stifling competition.
These initiatives are a start. In the meantime, physicians should remain vigilant about asking patients whether they can afford their medications. In an AFP editorial from earlier this year, Steven R. Brown, MD, outlined five strategies for practicing high-value prescribing, including exercising skepticism and caution when prescribing new drugs, applying STEPS and knowing drug prices, prescribing generics and comparing value, restricting access to drug reps and office samples, and prescribing conservatively. Each of these actions can play a part in keeping costs down for patients and reducing health care spending at large.
**
Mara Lambert is Senior Associate Editor of AFP.
Monday, November 14, 2016
Getting babies to sleep: strategies for fatigued parents
- Jennifer Middleton, MD, MPH
With a four-month-old of my own, I read the POEM on Getting an Infant to Sleep in the November 1 issue of AFP with more interest than I might have before becoming a parent. Prior studies have not found one sleep strategy to be superior to another. This latest study adds to the mix by finding that graduated extinction and sleep fading are not only effective but are well-tolerated by babies and parents alike.
Graduated extinction involves placing the infant down for bedtime while drowsy but still awake. Parents then wait a progressively increasing amount of time (2 minutes, then 4 minutes, then 6 minutes) before checking on the child. With sleep fading, parents progressively move bedtime later until the child falls asleep within 15 minutes of being laid down. The POEM study compared these two interventions in 6-month-olds with sleep difficulties to a control group and found that the time it took to fall asleep shortened with both methods. Infant and maternal stress also improved with both interventions. After 12 months, parent-child attachments were unaffected, and there was no change in the risk of emotional or behavioral problems.
An AFP article from 2015 includes graduated extinction among other recommended strategies from the American Academy of Sleep Medicine such as unmodified extinction ("cry it out") and scheduled awakenings (awakening babies 15 minutes prior to expected overnight awakenings). "Camping out" has also been shown to be equivalent to graduated extinction. With camping out, parents initially sit close by as the baby falls asleep and then gradually, over several nights, move further away from the crib until they are outside of the baby's room.
Once infants are old enough to consider implementing a sleep strategy (usually around 4-6 months of age), having several to suggest allows family physicians to work with parents to find an agreeable starting point. I especially appreciate being able to reassure families that, whatever they do, most babies will be sleeping through the night by 1 year of age. There's an AFP By Topic on Sleep Disorders in Children if you'd like to read more.
Monday, November 7, 2016
300 posts and still going strong
- Kenny Lin, MD, MPH
Today's post is the 300th for the AFP Community Blog, which I began writing in August 2010. Fellow medical editor Jennifer Middleton, MD, MPH because our second regular contributor in April 2013. In recognition of this milestone, I thought I would revisit some earlier wayposts - namely, our 100th, 150th, 200th, and 250th posts - and provide updates.
#100 - The spiritual assessment: unnecessary or essential? (9/20/12)
While one reader opined that spiritual concerns have "little to do with improving the health of our patients," another countered, "I do not think this article goes far enough in promoting this type of spiritual health assessment." ... Some readers expressed concerns that physicians might seek to impose their religious beliefs on vulnerable patients, while another suggested that "many physicians seem to have more fear of [discussing] spiritual issues than the patients do."
The debate continues about how best to incorporate the spiritual assessment into clinical practice. Earlier this year, the National Cancer Institute's Physician Data Query (PDQ) database published a comprehensive review of spirituality in cancer care that included a list of standardized assessment measures and suggested options for assisting patients with spiritual concerns.
#150 - Preventing recurrent kidney stones (11/4/13)
Researchers examined 28 studies regarding prevention of recurrent nephrolithiasis ... and found that water works fine for preventing the second episode after an initial event. But after the second episode, water by itself didn't do as well. Participants with multiple stone episodes who added a thiazide diuretic, a citrate, or allopurinol to their 2 liters of water a day, though, had fewer recurrences.
A 2016 study in a University of Minnesota–affiliated health system found that counseling and shared decision making were documented in less than half of outpatient visits for patients who underwent LDCT for lung cancer screening after publication of the USPSTF guidelines. Although we don't know if this experience is representative of national practice, it certainly isn't good news.
#250: SPRINT and lower systolic BP goals (11/23/15)
Aggressively adjusting medication doses based on what may be inaccurate office BP readings could potentially cause patients significant harm. Most of the time, the JNC 8 guidelines are likely to be more applicable to the patients in our offices than SPRINT's narrowly defined parameters.
No new hypertension guidelines have been issued since the publication of the SPRINT trial, but in August 2016, a majority of cardiologists at the European Society of Cardiology meeting gave a "thumbs down" to lowering blood pressure targets based on the trial's results. An article published in Circulation explained how the measurement technique used in SPRINT would have led to blood pressure readings 5-10 mm Hg lower than in clinical practice.
Today's post is the 300th for the AFP Community Blog, which I began writing in August 2010. Fellow medical editor Jennifer Middleton, MD, MPH because our second regular contributor in April 2013. In recognition of this milestone, I thought I would revisit some earlier wayposts - namely, our 100th, 150th, 200th, and 250th posts - and provide updates.
#100 - The spiritual assessment: unnecessary or essential? (9/20/12)
While one reader opined that spiritual concerns have "little to do with improving the health of our patients," another countered, "I do not think this article goes far enough in promoting this type of spiritual health assessment." ... Some readers expressed concerns that physicians might seek to impose their religious beliefs on vulnerable patients, while another suggested that "many physicians seem to have more fear of [discussing] spiritual issues than the patients do."
The debate continues about how best to incorporate the spiritual assessment into clinical practice. Earlier this year, the National Cancer Institute's Physician Data Query (PDQ) database published a comprehensive review of spirituality in cancer care that included a list of standardized assessment measures and suggested options for assisting patients with spiritual concerns.
#150 - Preventing recurrent kidney stones (11/4/13)
Researchers examined 28 studies regarding prevention of recurrent nephrolithiasis ... and found that water works fine for preventing the second episode after an initial event. But after the second episode, water by itself didn't do as well. Participants with multiple stone episodes who added a thiazide diuretic, a citrate, or allopurinol to their 2 liters of water a day, though, had fewer recurrences.
A related POEM in the January 15, 2015 issue of AFP discussed a randomized controlled trial that concluded that ultrasonography is the best initial imaging test for kidney stones in the emergency department (ED), reducing overall radiation exposure compared to initial computed tomography (CT) without differences in rates of return to the ED, pain scores, or complications.
#200 - Lung cancer screening (11/18/14)
Shared decision-making is increasingly recommended by screening guidelines, but I worry that these difficult discussions may not actually take place, even if family physicians are paid to initiate them with patients eligible for LDCT [low-dose computed tomography] screening. Will clinicians merely go through the motions and just order the test?
#200 - Lung cancer screening (11/18/14)
Shared decision-making is increasingly recommended by screening guidelines, but I worry that these difficult discussions may not actually take place, even if family physicians are paid to initiate them with patients eligible for LDCT [low-dose computed tomography] screening. Will clinicians merely go through the motions and just order the test?
A 2016 study in a University of Minnesota–affiliated health system found that counseling and shared decision making were documented in less than half of outpatient visits for patients who underwent LDCT for lung cancer screening after publication of the USPSTF guidelines. Although we don't know if this experience is representative of national practice, it certainly isn't good news.
#250: SPRINT and lower systolic BP goals (11/23/15)
Aggressively adjusting medication doses based on what may be inaccurate office BP readings could potentially cause patients significant harm. Most of the time, the JNC 8 guidelines are likely to be more applicable to the patients in our offices than SPRINT's narrowly defined parameters.
No new hypertension guidelines have been issued since the publication of the SPRINT trial, but in August 2016, a majority of cardiologists at the European Society of Cardiology meeting gave a "thumbs down" to lowering blood pressure targets based on the trial's results. An article published in Circulation explained how the measurement technique used in SPRINT would have led to blood pressure readings 5-10 mm Hg lower than in clinical practice.
Monday, October 31, 2016
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.
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.
Monday, October 24, 2016
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.
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.
Monday, October 17, 2016
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:
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:
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.
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.
Monday, October 10, 2016
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.
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.
Monday, October 3, 2016
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?
Thursday, September 22, 2016
Guest Post: Falls Prevention Awareness Day
- Stephen Hargarten, MD, MPH
Today is the 9th annual observation of Falls Prevention Awareness Day in the United States. Falls are the leading cause of both fatal and nonfatal injuries among older adults age 65 and over. The Centers for Disease Control and Prevention (CDC)’s latest Morbidity and Mortality Weekly Report (MMWR) article, Falls and Fall Injuries Among Adults Aged 65 Years and Over — United States, 2014 outlines the epidemiology of older adult falls, and how clinicians can use CDC’s evidence-based STEADI (Stopping Elderly Accidents, Deaths, & Injuries) initiative to help prevent them. STEADI provides tools for clinicians to use with older adult patients to screen for fall risk using three simple steps:
· Ask: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling?
· Review/Reassess/Discontinue any medications or combinations that can increase the risk of falling.
· Recommend at least 800 mg IU of vitamin D to improve bone, muscle, and nerve health in older adults.
Every hour of every day, in communities across the United States, a patient who either just fell or is a fall risk, is being evaluated by a family physician or emergency care clinician. It is critically important that clinicians in urgent and primary care settings ask, review, and recommend fall prevention strategies for older adults.
The new CDC article highlights that in 2014, over 27,000 older adults died because of falls, and 2.8 million people were treated in emergency departments (EDs) for falls-related injuries. In the same year, CDC discovered that one in four older adults reported falling, totaling almost 29 million falls, and seven million fall injuries.
Falls not only cause injuries and affect the independence of older adults—they also have an impact on the economy. The annual medical costs associated with older adult falls are estimated to be $31 billion per year. The article estimates that the older adult population will increase 55% by 2030. The incidence of falls among this growing population will continue to increase unless effective interventions like STEADI are implemented nationwide.
Older adult falls are preventable. For patients in the ED or inpatient setting, care givers need to constantly evaluate and reevaluate for fall risk. Hospital bed side rails always should be in place to avoid an unintended fall from the bed.
Clinicians can play a critical role by following STEADI’s comprehensive approach of: 1) Asking older adult patients about falls, 2) assessing gait and balance, 3) reviewing medications, 4) prescribing interventions such as strength and balance exercises, 4) and recommending least 800 mg IU of vitamin D every day to prevent falls among older adults. Because many patients do not discuss the problem with their doctor, clinicians must be vigilant about asking patients about their falls, screening for fall risk, and implementing STEADI into practice.
As we acknowledge Falls Prevention Awareness Day, I encourage you all to take a stand against falls by integrating into your daily practice: Ask, Review, and Recommend for older adults. It’s good medicine!
**
Dr. Hargarten is Chair of the CDC's National Center for Injury Prevention and Control, Board of Scientific Counselors, and Professor and Chair of the Department of Emergency Medicine and Associate Dean for the Global Health Program at the Medical College of Wisconsin.
· Ask: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling?
· Review/Reassess/Discontinue any medications or combinations that can increase the risk of falling.
· Recommend at least 800 mg IU of vitamin D to improve bone, muscle, and nerve health in older adults.
Every hour of every day, in communities across the United States, a patient who either just fell or is a fall risk, is being evaluated by a family physician or emergency care clinician. It is critically important that clinicians in urgent and primary care settings ask, review, and recommend fall prevention strategies for older adults.
The new CDC article highlights that in 2014, over 27,000 older adults died because of falls, and 2.8 million people were treated in emergency departments (EDs) for falls-related injuries. In the same year, CDC discovered that one in four older adults reported falling, totaling almost 29 million falls, and seven million fall injuries.
Falls not only cause injuries and affect the independence of older adults—they also have an impact on the economy. The annual medical costs associated with older adult falls are estimated to be $31 billion per year. The article estimates that the older adult population will increase 55% by 2030. The incidence of falls among this growing population will continue to increase unless effective interventions like STEADI are implemented nationwide.
Older adult falls are preventable. For patients in the ED or inpatient setting, care givers need to constantly evaluate and reevaluate for fall risk. Hospital bed side rails always should be in place to avoid an unintended fall from the bed.
Clinicians can play a critical role by following STEADI’s comprehensive approach of: 1) Asking older adult patients about falls, 2) assessing gait and balance, 3) reviewing medications, 4) prescribing interventions such as strength and balance exercises, 4) and recommending least 800 mg IU of vitamin D every day to prevent falls among older adults. Because many patients do not discuss the problem with their doctor, clinicians must be vigilant about asking patients about their falls, screening for fall risk, and implementing STEADI into practice.
As we acknowledge Falls Prevention Awareness Day, I encourage you all to take a stand against falls by integrating into your daily practice: Ask, Review, and Recommend for older adults. It’s good medicine!
**
Dr. Hargarten is Chair of the CDC's National Center for Injury Prevention and Control, Board of Scientific Counselors, and Professor and Chair of the Department of Emergency Medicine and Associate Dean for the Global Health Program at the Medical College of Wisconsin.
Monday, September 19, 2016
Should family doctors treat opioid addiction?
- Jennifer Middleton, MD, MPH
The physicians in the office where I practice recently received the opportunity to train for a Drug Abuse Treatment Act (DATA) waiver for buprenorphine prescribing. A lively discussion among us ensued, with a few of us willing to be trained but the rest uncomfortable with the idea. As I've discussed this issue with others, it seems that many family physicians have strong feelings about not prescribing buprenorphine. The common argument seems to be that these often complex patients should be left to addiction specialists to treat.
Barriers cited in the medical literature to physician prescribing of buprenorphine include a lack of resources, time, and institutional support but also "mistrust of people with addiction...and [a] difficult patient population." 40% of physicians in a 2013 survey believed that buprenorphine diversion contributes to accidental overdoses and is thus dangerous to prescribe.
In the September 1 issue of AFP, though, physicians from the Robert Graham Center argue that family physicians need to be more involved in treating opioid addiction with buprenorphine. They cite a 2014 Cochrane systematic review that demonstrated buprenorphine's efficacy in treating patients with opioid addiction, and they call for policy changes to encourage more family physicians to prescribe buprenorphine. A study in the Annals of Family Medicine found that most physicians with DATA waivers were concentrated in urban areas, leaving 30 million in the U.S. without access to buprenorphine treatment; this same study also found that only 3% of family physicians had DATA waivers as of 2012.
I wrote about current recommendations for opioid use and monitoring a few months ago, and certainly family physicians have an obligation to be responsible regarding opioid prescribing. We have an obligation as a specialty, however, to consider our response to opioid addiction as well. Just under 4000 physicians in the U.S. are board certified by the American Board of Addiction Medicine, which is far insufficient to meet the needs of the estimated 2 million individuals in the U.S. currently struggling with opioid addiction.
The medical literature to date provides little guidance regarding measures to increase buprenorphine prescribing. Providing training in treating addiction during residency increased psychiatry residents' use of buprenorphine in their practices after residency; training Family Medicine residents might be similarly effective. Institutional support and adequate local mental health resources are also likely key. The AAFP recently updated their position paper on chronic pain management and opioid misuse (including a section on buprenorphine use) which includes this call to action:
Are you currently prescribing buprenorphine, or are you considering obtaining a DATA waiver to do so?
The physicians in the office where I practice recently received the opportunity to train for a Drug Abuse Treatment Act (DATA) waiver for buprenorphine prescribing. A lively discussion among us ensued, with a few of us willing to be trained but the rest uncomfortable with the idea. As I've discussed this issue with others, it seems that many family physicians have strong feelings about not prescribing buprenorphine. The common argument seems to be that these often complex patients should be left to addiction specialists to treat.
Barriers cited in the medical literature to physician prescribing of buprenorphine include a lack of resources, time, and institutional support but also "mistrust of people with addiction...and [a] difficult patient population." 40% of physicians in a 2013 survey believed that buprenorphine diversion contributes to accidental overdoses and is thus dangerous to prescribe.
In the September 1 issue of AFP, though, physicians from the Robert Graham Center argue that family physicians need to be more involved in treating opioid addiction with buprenorphine. They cite a 2014 Cochrane systematic review that demonstrated buprenorphine's efficacy in treating patients with opioid addiction, and they call for policy changes to encourage more family physicians to prescribe buprenorphine. A study in the Annals of Family Medicine found that most physicians with DATA waivers were concentrated in urban areas, leaving 30 million in the U.S. without access to buprenorphine treatment; this same study also found that only 3% of family physicians had DATA waivers as of 2012.
I wrote about current recommendations for opioid use and monitoring a few months ago, and certainly family physicians have an obligation to be responsible regarding opioid prescribing. We have an obligation as a specialty, however, to consider our response to opioid addiction as well. Just under 4000 physicians in the U.S. are board certified by the American Board of Addiction Medicine, which is far insufficient to meet the needs of the estimated 2 million individuals in the U.S. currently struggling with opioid addiction.
The medical literature to date provides little guidance regarding measures to increase buprenorphine prescribing. Providing training in treating addiction during residency increased psychiatry residents' use of buprenorphine in their practices after residency; training Family Medicine residents might be similarly effective. Institutional support and adequate local mental health resources are also likely key. The AAFP recently updated their position paper on chronic pain management and opioid misuse (including a section on buprenorphine use) which includes this call to action:
[T]he AAFP challenges itself and its members at the physician, practice, community, education, and advocacy levels to address the needs of a population struggling with chronic pain and/or opioid dependence.You can read here about how to obtain a DATA waiver. This 2006 AFP article provides information about initiating and managing buprenorphine treatment, and there's also an AFP By Topic on Substance Abuse.
Are you currently prescribing buprenorphine, or are you considering obtaining a DATA waiver to do so?
Monday, September 12, 2016
New developments in the Zika epidemic
- John E. Delzell, Jr, MD, MSPH
In her AFP Community Blog post on February 29th, Dr. Jennifer Middleton provided a great overview of the health risks associated with the Zika virus and the recommendations from the Centers for Disease Control and Prevention (CDC). To a family doctor in South Florida, the risk of Zika seems very acute, so I have been thinking about it a lot this summer. Over the past month, 40 new patients have contracted Zika from local mosquitoes. The affected area includes the popular tourist destination, Miami Beach, and an area just north of downtown Miami. The CDC has taken the historic step of recommending against travel to these two areas. The recommendation states:
· Pregnant women should not travel to these areas.
· Pregnant women and their partners living in or traveling to these areas should follow steps to prevent mosquito bites.
· Women and men who live in or traveled to these areas and who have a pregnant sex partner should use condoms to prevent infection every time they have sex or not have sex during the pregnancy.
· Effective contraception to prevent pregnancy in women and their partners who want to delay or prevent pregnancy is a key prevention strategy for Zika.
· All pregnant women in the United States should be assessed for possible Zika virus exposure and signs or symptoms of Zika during each prenatal care visit.
· Pregnant women who live in or frequently travel to these areas should be tested in the first and second trimester of pregnancy.
· Women with Zika should wait at least 8 weeks after symptoms began before trying to get pregnant, and men with Zika should wait at least 6 months after symptoms began.
Aedes aegypti mosquitoes can transmit several emerging viral infections, including chikungunya, dengue, and Zika. The Aedes aegypti female mosquito can lay up to 1,000 eggs, and they love to live indoors. Since 2014, the chikungunya virus has begun to have local transmission from infected mosquitoes in Florida and Puerto Rico. Dengue fever had a resurgence in 2013 in Florida, and so far in 2016 there have been 40 travel related cases and one case of local transmission.
Why are we seeing and hearing about these new tropical diseases now? There are several reasons that South Florida (the three-county area of Miami-Dade, Broward, and Palm Beach counties plus the Everglades and the Keys) is at high risk. The climate is tropical with daily rain and average high temperatures in the 80s most of the year, making for an ideal breeding ground for mosquitoes. People come from all over the world to enjoy the beaches in Miami and Fort Lauderdale. Finally, South Florida includes large, diverse immigrant populations from affected countries such as Haiti, the Dominican Republic, Venezuela, Brazil, and Cuba.
So how are public health officials responding to the Zika virus? In downtown Miami, there has been an aggressive ground and aerial spraying campaign to control the mosquito population. This has caused some controversy in the Miami Beach area with protests and a delay in aerial spraying. In the Florida Keys, there is an unpopular proposal to release genetically modified mosquitoes that will produce sterile offspring and (hopefully) decrease the overall mosquito population. On August 5, the U.S. Food and Drug Administration approved these modifications as posing little to no risk of harm to humans, but the project has yet to begin.
Right now preventing Zika infection consists mostly of mosquito control and avoidance, but efforts to develop a vaccine have accelerated and may only be a year or two away, as reported in a fascinating story in the New Yorker. In the meantime, it is important for family physicians to stay up to date on the latest information about the Zika virus. The Featured Content section of the AFP homepage includes other useful resources on this evolving epidemic from the American Academy of Family Physicians, the CDC, and the World Health Organization.
**
Dr. Delzell (@Ed_in_Med) is Assistant Editor at AFP and Vice President and Designated Institutional Officer of Broward Health Medical Center in Fort Lauderdale, Florida.
In her AFP Community Blog post on February 29th, Dr. Jennifer Middleton provided a great overview of the health risks associated with the Zika virus and the recommendations from the Centers for Disease Control and Prevention (CDC). To a family doctor in South Florida, the risk of Zika seems very acute, so I have been thinking about it a lot this summer. Over the past month, 40 new patients have contracted Zika from local mosquitoes. The affected area includes the popular tourist destination, Miami Beach, and an area just north of downtown Miami. The CDC has taken the historic step of recommending against travel to these two areas. The recommendation states:
· Pregnant women should not travel to these areas.
· Pregnant women and their partners living in or traveling to these areas should follow steps to prevent mosquito bites.
· Women and men who live in or traveled to these areas and who have a pregnant sex partner should use condoms to prevent infection every time they have sex or not have sex during the pregnancy.
· Effective contraception to prevent pregnancy in women and their partners who want to delay or prevent pregnancy is a key prevention strategy for Zika.
· All pregnant women in the United States should be assessed for possible Zika virus exposure and signs or symptoms of Zika during each prenatal care visit.
· Pregnant women who live in or frequently travel to these areas should be tested in the first and second trimester of pregnancy.
· Women with Zika should wait at least 8 weeks after symptoms began before trying to get pregnant, and men with Zika should wait at least 6 months after symptoms began.
Aedes aegypti mosquitoes can transmit several emerging viral infections, including chikungunya, dengue, and Zika. The Aedes aegypti female mosquito can lay up to 1,000 eggs, and they love to live indoors. Since 2014, the chikungunya virus has begun to have local transmission from infected mosquitoes in Florida and Puerto Rico. Dengue fever had a resurgence in 2013 in Florida, and so far in 2016 there have been 40 travel related cases and one case of local transmission.
Why are we seeing and hearing about these new tropical diseases now? There are several reasons that South Florida (the three-county area of Miami-Dade, Broward, and Palm Beach counties plus the Everglades and the Keys) is at high risk. The climate is tropical with daily rain and average high temperatures in the 80s most of the year, making for an ideal breeding ground for mosquitoes. People come from all over the world to enjoy the beaches in Miami and Fort Lauderdale. Finally, South Florida includes large, diverse immigrant populations from affected countries such as Haiti, the Dominican Republic, Venezuela, Brazil, and Cuba.
So how are public health officials responding to the Zika virus? In downtown Miami, there has been an aggressive ground and aerial spraying campaign to control the mosquito population. This has caused some controversy in the Miami Beach area with protests and a delay in aerial spraying. In the Florida Keys, there is an unpopular proposal to release genetically modified mosquitoes that will produce sterile offspring and (hopefully) decrease the overall mosquito population. On August 5, the U.S. Food and Drug Administration approved these modifications as posing little to no risk of harm to humans, but the project has yet to begin.
Right now preventing Zika infection consists mostly of mosquito control and avoidance, but efforts to develop a vaccine have accelerated and may only be a year or two away, as reported in a fascinating story in the New Yorker. In the meantime, it is important for family physicians to stay up to date on the latest information about the Zika virus. The Featured Content section of the AFP homepage includes other useful resources on this evolving epidemic from the American Academy of Family Physicians, the CDC, and the World Health Organization.
**
Dr. Delzell (@Ed_in_Med) is Assistant Editor at AFP and Vice President and Designated Institutional Officer of Broward Health Medical Center in Fort Lauderdale, Florida.
Monday, September 5, 2016
Raynaud phenomenon: clinical pearls
- Kenny Lin, MD, MPH
Reversible pallor of the tips of the fingers and/or toes on exposure to cold or emotional stress, known as Raynaud phenomenon, is a common manifestation of systemic lupus erythematosus (SLE) highlighted in the August 15th issue of AFP. As discussed in an earlier Photo Quiz, the differential diagnosis may include acrocyanosis, acute peripheral arterial occlusion, and frostbite. Raynaud phenomenon can be primary (idiopathic) or secondary to / associated with systemic conditions, such as SLE or systemic sclerosis/scleroderma.
How can family physicians distinguish primary from secondary Raynaud phenomenon? According to a recent review in the New England Journal of Medicine, patients with primary Raynaud phenomenon typically have a younger age of onset and thumb sparing. Patients with an age of onset over 40 years and severe, frequent events are more likely to develop connective tissue disease. Although most patients with primary Raynaud phenomenon have a normal erythrocyte sedimentation rate (ESR), neither a normal ESR nor a negative antinuclear antibody titer are necessary to make the diagnosis.
If trigger avoidance does not adequately control symptoms, the BMJ Clinical Evidence Handbook and Cochrane for Clinicians concur that an effective drug treatment for primary Raynaud phenomenon is a calcium channel blocker, particularly nifedipine. Although calcium channel blockers (CCBs) reduce average frequency of attacks by 1-2 per week, they do not affect severity or physiologic measurements (e.g., finger systolic pressure or skin temperature), and can be associated with headache, flushing, tachycardia, or edema. Both BMJ and Cochrane conclude that there is a close trade-off between benefits and harms. In their Practice Pointers, Drs. Dean Seehusen and Joseph Huang recommend that "a frank discussion of the benefits and risks should take place before prescribing CCBs to patients with Raynaud phenomenon." Other less well-studied medications for Raynaud phenomenon include phosphodiesterase type 5 inhibitors, topical nitrates, fluoxetine, and losartan.
Reversible pallor of the tips of the fingers and/or toes on exposure to cold or emotional stress, known as Raynaud phenomenon, is a common manifestation of systemic lupus erythematosus (SLE) highlighted in the August 15th issue of AFP. As discussed in an earlier Photo Quiz, the differential diagnosis may include acrocyanosis, acute peripheral arterial occlusion, and frostbite. Raynaud phenomenon can be primary (idiopathic) or secondary to / associated with systemic conditions, such as SLE or systemic sclerosis/scleroderma.
 |
| Image from AFP's Photo Quiz. Get the AFP Photo Quiz app. |
How can family physicians distinguish primary from secondary Raynaud phenomenon? According to a recent review in the New England Journal of Medicine, patients with primary Raynaud phenomenon typically have a younger age of onset and thumb sparing. Patients with an age of onset over 40 years and severe, frequent events are more likely to develop connective tissue disease. Although most patients with primary Raynaud phenomenon have a normal erythrocyte sedimentation rate (ESR), neither a normal ESR nor a negative antinuclear antibody titer are necessary to make the diagnosis.
If trigger avoidance does not adequately control symptoms, the BMJ Clinical Evidence Handbook and Cochrane for Clinicians concur that an effective drug treatment for primary Raynaud phenomenon is a calcium channel blocker, particularly nifedipine. Although calcium channel blockers (CCBs) reduce average frequency of attacks by 1-2 per week, they do not affect severity or physiologic measurements (e.g., finger systolic pressure or skin temperature), and can be associated with headache, flushing, tachycardia, or edema. Both BMJ and Cochrane conclude that there is a close trade-off between benefits and harms. In their Practice Pointers, Drs. Dean Seehusen and Joseph Huang recommend that "a frank discussion of the benefits and risks should take place before prescribing CCBs to patients with Raynaud phenomenon." Other less well-studied medications for Raynaud phenomenon include phosphodiesterase type 5 inhibitors, topical nitrates, fluoxetine, and losartan.
Monday, August 29, 2016
Who isn't receiving colorectal cancer screening?
- Jennifer Middleton, MD, MPH
The U.S. Preventive Services Task Force recently updated its colorectal cancer screening recommendations, affirming its prior “A” grade for adults aged 50 to 75. While screening rates in the U.S. have increased over the past decade, there is still room for improvement, especially among
uninsured individuals, some minority populations, and immigrants. A
2010 systematic review found lower rates of colorectal cancer screening among Hispanic and Asian Americans, along with anyone born
outside of the United States. A more recent study found even lower rates among
Spanish-speaking Hispanics compared to English-speaking Hispanics. Differences in access to care only accounted for some of
these disparities.
Successful strategies that increase screening rates include providing fecal occult blood
tests in a manner that addresses language barriers, and providing culturally appropriate patient education materials and/or 1-on-1
contact with a nurse or health educator. Additionally, the state of Michigan
partnered with a large health insurer to mail reminder cards
about colorectal cancer screening, which increased uptake by 16%; in Wisconsin,
providing grants
for screening events in underserved communities also increased screening rates. Adding a
telephone call to a reminder letter increased screening rates in New York, but telephone calls by themselves did not. Ensuring adequate physician
access for minority and underserved populations also increases screening; one study found that the distribution and supply of family physicians and gastroenterologists correlates with better screening rates.
Although many practices track their overall colorectal cancer screening rates, this figure may mask variations by race, ethnicity, or foreign-born status. Recognizing screening disparities is an important first step. Trying one or more of the above interventions to improve screening rates in underserved populations with a Plan, Do, Study, Act (PDSA) cycle might then be a reasonable next course of action. There’s a recent AFP article on Colorectal Cancer Screening and Surveillance if you’d like a refresher on recommended screening methods.
Although many practices track their overall colorectal cancer screening rates, this figure may mask variations by race, ethnicity, or foreign-born status. Recognizing screening disparities is an important first step. Trying one or more of the above interventions to improve screening rates in underserved populations with a Plan, Do, Study, Act (PDSA) cycle might then be a reasonable next course of action. There’s a recent AFP article on Colorectal Cancer Screening and Surveillance if you’d like a refresher on recommended screening methods.
Monday, August 22, 2016
Overcoming obstacles to HPV vaccination
- Kenny Lin, MD, MPH
Human papillomavirus (HPV) vaccines, which prevent infection with HPV genotypes that cause cervical, anal, vaginal, and penile cancers, are hardly new. The quadrivalent and bivalent HPV vaccines were reviewed in AFP in 2007 and 2010, respectively, and a 9-valent vaccine was approved by the U.S. Food and Drug Administration in 2014. Although long-term studies have yet to demonstrate that HPV vaccines reduce cancer rates, a recent systematic review found that introduction of the quadrivalent vaccine in 9 countries (including the U.S.) was associated with a 90% reduction in infections from the targeted genotypes and similar reductions in genital warts and high-grade cervical abnormalities. Women who receive HPV vaccine are at considerably lower risk for undergoing colposcopy and associated invasive diagnostic or therapeutic procedures.
The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that all boys and girls receive the 3-dose HPV vaccine series at age 11 to 12. However, CDC data from 2014 show that only 40% of girls and 21% of boys had completed the series by age 17. In contrast, 80% of 13 to 17 year-olds had received meningococcal vaccine, and 88% had received TdaP (tetanus, diphtheria, and acellular pertussis) vaccine, which provide protection against serious, but comparably rare, infections. Earlier this year, all 69 National Cancer Institute-designated Cancer Centers released a consensus statement expressing concern about persistently low HPV vaccination rates in the U.S. compared to other countries, which they labeled a "serious public health threat."
A 2015 AFP editorial by Drs. Herbert Muncie, Jr. and Alan Lebato examined parental and physician impediments to HPV vaccination. Parents often express concerns about vaccine safety and worry that their children may be more likely to start having sex after receiving the vaccine. Family physicians can reassure parents on both of these questions:
Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010, although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache). Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier, nor is their risk of acquiring an STI increased.
In other cases, physicians have been the primary obstacles to vaccination: they are sometimes reluctant to bring up the topic of sex, they believe the vaccine is unnecessary because Pap smears will detect early cervical cancer, or they present the vaccine as "optional" or don't offer it at all. Drs. Muncie and Lebato suggested several effective strategies for improving HPV vaccination rates:
Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent. Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.
Human papillomavirus (HPV) vaccines, which prevent infection with HPV genotypes that cause cervical, anal, vaginal, and penile cancers, are hardly new. The quadrivalent and bivalent HPV vaccines were reviewed in AFP in 2007 and 2010, respectively, and a 9-valent vaccine was approved by the U.S. Food and Drug Administration in 2014. Although long-term studies have yet to demonstrate that HPV vaccines reduce cancer rates, a recent systematic review found that introduction of the quadrivalent vaccine in 9 countries (including the U.S.) was associated with a 90% reduction in infections from the targeted genotypes and similar reductions in genital warts and high-grade cervical abnormalities. Women who receive HPV vaccine are at considerably lower risk for undergoing colposcopy and associated invasive diagnostic or therapeutic procedures.
The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that all boys and girls receive the 3-dose HPV vaccine series at age 11 to 12. However, CDC data from 2014 show that only 40% of girls and 21% of boys had completed the series by age 17. In contrast, 80% of 13 to 17 year-olds had received meningococcal vaccine, and 88% had received TdaP (tetanus, diphtheria, and acellular pertussis) vaccine, which provide protection against serious, but comparably rare, infections. Earlier this year, all 69 National Cancer Institute-designated Cancer Centers released a consensus statement expressing concern about persistently low HPV vaccination rates in the U.S. compared to other countries, which they labeled a "serious public health threat."
A 2015 AFP editorial by Drs. Herbert Muncie, Jr. and Alan Lebato examined parental and physician impediments to HPV vaccination. Parents often express concerns about vaccine safety and worry that their children may be more likely to start having sex after receiving the vaccine. Family physicians can reassure parents on both of these questions:
Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010, although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache). Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier, nor is their risk of acquiring an STI increased.
In other cases, physicians have been the primary obstacles to vaccination: they are sometimes reluctant to bring up the topic of sex, they believe the vaccine is unnecessary because Pap smears will detect early cervical cancer, or they present the vaccine as "optional" or don't offer it at all. Drs. Muncie and Lebato suggested several effective strategies for improving HPV vaccination rates:
Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent. Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.
An editorial in AFP's July 15th issue by Drs. Jamie Loehr and Margot Savoy provided additional tips for physicians on addressing and overcoming vaccine hesitancy in general. More immunization resources, including the latest childhood and adult immunization schedules from the ACIP, are available in AFP's Immunizations Topic Collection.
Monday, August 15, 2016
Relieving chronic work-related pain and job insecurity
- Marselle Bredemeyer
A Curbside Consultation article in AFP’s July 15th issue highlights the difficulties that immigrants working in low-wage jobs experience when it comes to addressing workplace hazards without the support of advocates and health care professionals. This challenge is not unique to immigrants, although they are disproportionally affected; underreporting of workplace injuries is a widespread problem. The Occupational Safety and Health Act, which was passed in 1970, covers persons working in nearly all sectors and protects all employees regardless of immigration status.
The Occupational Safety and Health Administration (OSHA), formed to enforce elements of the labor act, has its weak points, however. In a response to recent requests that sought reduced production line speeds at poultry plants, an OSHA representative cited “limited resources” as one factor precluding the implementation of definitive rules from being considered. The expectation for employers is broad, in any sense—they have a “general duty” to ensure a safe workplace.
Where does this leave patients like the one in the Curbside Consultation article? Although workers can’t anticipate that there are explicit regulations applying to individual aspects of their job, such as the amount of weight they are permitted to lift, there are actions that can be taken—like those described in the article commentary—to prevent long-term injury from repetitive motion.
Unlike the legal right to work in a safe environment, immigration status has a huge bearing on a person’s access to health care. In the case scenario described in the journal feature, the patient’s Cuban origin ensured her Medicaid eligibility for a temporary time. Many immigrants who are legally present are ineligible for Medicaid for five years after arrival, however, and those who are undocumented cannot shop for private coverage on the Patient Protection and Affordable Care Act’s (ACA) exchanges. Refugees and asylees, along with other select groups, whether from Cuba or dozens of other countries, have immediate access to health care assistance for at least eight months.
There are still a number of questions that researchers need to tackle regarding occupational health among immigrants. How can employers reduce the undue risk of harm migrants face in the workplace? Why does this disparity exist? Fear of job loss is, unfortunately, all too often well founded. Family physicians who are aware of existing labor protections and legal and community resources can not only guide the treatment of occupational disorders, but also empower patients who choose to take steps to improve workplace safety. Without a physician to take a directed history in the first place, connections between acute and chronic illnesses and workplace conditions will remain in the dark.
A Curbside Consultation article in AFP’s July 15th issue highlights the difficulties that immigrants working in low-wage jobs experience when it comes to addressing workplace hazards without the support of advocates and health care professionals. This challenge is not unique to immigrants, although they are disproportionally affected; underreporting of workplace injuries is a widespread problem. The Occupational Safety and Health Act, which was passed in 1970, covers persons working in nearly all sectors and protects all employees regardless of immigration status.
The Occupational Safety and Health Administration (OSHA), formed to enforce elements of the labor act, has its weak points, however. In a response to recent requests that sought reduced production line speeds at poultry plants, an OSHA representative cited “limited resources” as one factor precluding the implementation of definitive rules from being considered. The expectation for employers is broad, in any sense—they have a “general duty” to ensure a safe workplace.
Where does this leave patients like the one in the Curbside Consultation article? Although workers can’t anticipate that there are explicit regulations applying to individual aspects of their job, such as the amount of weight they are permitted to lift, there are actions that can be taken—like those described in the article commentary—to prevent long-term injury from repetitive motion.
Unlike the legal right to work in a safe environment, immigration status has a huge bearing on a person’s access to health care. In the case scenario described in the journal feature, the patient’s Cuban origin ensured her Medicaid eligibility for a temporary time. Many immigrants who are legally present are ineligible for Medicaid for five years after arrival, however, and those who are undocumented cannot shop for private coverage on the Patient Protection and Affordable Care Act’s (ACA) exchanges. Refugees and asylees, along with other select groups, whether from Cuba or dozens of other countries, have immediate access to health care assistance for at least eight months.
There are still a number of questions that researchers need to tackle regarding occupational health among immigrants. How can employers reduce the undue risk of harm migrants face in the workplace? Why does this disparity exist? Fear of job loss is, unfortunately, all too often well founded. Family physicians who are aware of existing labor protections and legal and community resources can not only guide the treatment of occupational disorders, but also empower patients who choose to take steps to improve workplace safety. Without a physician to take a directed history in the first place, connections between acute and chronic illnesses and workplace conditions will remain in the dark.
Monday, August 8, 2016
Virtuous cycling: lower diabetes risk, but wear a helmet
- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH
I (Jennifer) live in a community with a wonderful bicycle path system,
and around this time of year it gets a lot of use. In a 2011 Letter to the Editor titled "The Virtuous Cycle," AFP Deputy Editor Mark Ebell, MD, MS encouraged readers to advocate in their communities for "safe, convenient, and enjoyable places to walk, run, and bike" rather than continuing to "harangue our patients about exercise and be frustrated when they do not listen to us."
Sensible advice, but do recreational and commuter cyclists have better health outcomes than non-cyclists, is it enough to cycle during only part of the year, and is it ever too late to get on the bike? A prospective cohort study of more than 50,000 Danish men and women recruited between the ages of 50 and 65 and followed for an average of 14 years recently provided answers to these questions. In a multivariable analysis, both seasonal and year-round cyclists had up to a 20 percent reduced relative risk for developing type 2 diabetes, even if they started cycling late in life.
The health benefits of cycling can be easily negated, though, by the risks of not wearing a helmet. Even though helmet-wearing cyclists are more likely to survive trauma than those not wearing helmets, and despite laws mandating helmets across the country, many bicycle riders continue to go bareheaded. A 1999 survey found the most common reasons for not wearing a helmet included "uncomfortable," "annoying," "it's hot," "don't need it," and "don't own one." This survey also found that peer and/or parent wearing of helmets increased the likelihood that children wore them too.
Sensible advice, but do recreational and commuter cyclists have better health outcomes than non-cyclists, is it enough to cycle during only part of the year, and is it ever too late to get on the bike? A prospective cohort study of more than 50,000 Danish men and women recruited between the ages of 50 and 65 and followed for an average of 14 years recently provided answers to these questions. In a multivariable analysis, both seasonal and year-round cyclists had up to a 20 percent reduced relative risk for developing type 2 diabetes, even if they started cycling late in life.
The health benefits of cycling can be easily negated, though, by the risks of not wearing a helmet. Even though helmet-wearing cyclists are more likely to survive trauma than those not wearing helmets, and despite laws mandating helmets across the country, many bicycle riders continue to go bareheaded. A 1999 survey found the most common reasons for not wearing a helmet included "uncomfortable," "annoying," "it's hot," "don't need it," and "don't own one." This survey also found that peer and/or parent wearing of helmets increased the likelihood that children wore them too.
A review of children's cycling accidents from the National Trauma Data Bank found that white children and/or children with
private insurance were much more likely to wear a helmet than African-American
children and/or children with Medicaid. Another study in Los Angeles County found lower helmet use among older children, non-white children, and children
from a low socioeconomic status. Programs that give away free helmets to children either in
schools or in physicians’ offices increase helmet use and may reduce health disparities. Although physician counseling also increases helmet wear in patients under age 18, in one survey less than
half of physicians providing care to this age group provided it.
Unfortunately, there haven't been any studies of
interventions to increase helmet wearing in adults.
The bottom line is that encouraging patients to start cycling for long-lasting health benefits should be accompanied by counseling on the importance of wearing helmets.
Monday, August 1, 2016
Guest Post: preventing sexual assualt
- Yalda Jabbarpour, MD
According to a 2010 article in AFP, sexual assault is associated with sexually transmitted infections (STIs), posttraumatic stress disorder, anxiety, depression, chronic pain syndromes, drug and alcohol abuse, irritable bowel syndrome, headaches, fibromyalgia and sexual dysfunction. Sexual assault is a true public health crisis. What can family physicians do to curb this epidemic?
Much of the literature on the physician’s role in sexual assaults deals with the aftermath: collection of the rape kit, post-exposure STI prophylaxis, identifying and treating long term physical and psychological sequelae. But I would argue that, as is the case in much of what we do, prevention is the key. I propose we start by defining the problem for our patients. In the Post/Kaiser poll, 46 percent of college-aged respondents said it’s unclear whether sexual activity that occurs when both people have not given clear agreement constitutes sexual assault. This means that we need to have open and honest conversations with adolescents and young adults about the need for both parties to give consent before having sex. Establishing rapport is key to broaching sensitive topics with adolescents, and to do this, it is important to ask adolescents specific questions about their practices rather than stating general facts.
Once we have defined the problem, we need to counsel patients on the risk factors associated with it and how to mitigate those. Race, ethnicity, social class, study habits or religious practices were not related to sexual assault in the Kaiser poll. However, women who said they sometimes or often drink more than they should are twice as likely to be victims of completed, attempted or suspected sexual assault compared with those who rarely or never do. Therefore, counseling men and women on responsible drinking strategies—such as using a buddy system, pouring their own drinks, and knowing their limits—is key.
Certainly, physicians alone cannot solve the issue of sexual assault, but we should consider addressing it in every preventive health discussion we have with college-aged students. When sharing her solidarity with other victims of sexual assault, the Stanford victim appropriately quoted Anne Lamott: “Lighthouses don’t go running all over an island looking for boats to save; they just stand there shining.” It may not be within our power, or our job description, to stamp out sexual assault, but physicians can serve as lighthouses, helping to illuminate for our patients a safe path through their college careers.
Much of the literature on the physician’s role in sexual assaults deals with the aftermath: collection of the rape kit, post-exposure STI prophylaxis, identifying and treating long term physical and psychological sequelae. But I would argue that, as is the case in much of what we do, prevention is the key. I propose we start by defining the problem for our patients. In the Post/Kaiser poll, 46 percent of college-aged respondents said it’s unclear whether sexual activity that occurs when both people have not given clear agreement constitutes sexual assault. This means that we need to have open and honest conversations with adolescents and young adults about the need for both parties to give consent before having sex. Establishing rapport is key to broaching sensitive topics with adolescents, and to do this, it is important to ask adolescents specific questions about their practices rather than stating general facts.
Once we have defined the problem, we need to counsel patients on the risk factors associated with it and how to mitigate those. Race, ethnicity, social class, study habits or religious practices were not related to sexual assault in the Kaiser poll. However, women who said they sometimes or often drink more than they should are twice as likely to be victims of completed, attempted or suspected sexual assault compared with those who rarely or never do. Therefore, counseling men and women on responsible drinking strategies—such as using a buddy system, pouring their own drinks, and knowing their limits—is key.
Certainly, physicians alone cannot solve the issue of sexual assault, but we should consider addressing it in every preventive health discussion we have with college-aged students. When sharing her solidarity with other victims of sexual assault, the Stanford victim appropriately quoted Anne Lamott: “Lighthouses don’t go running all over an island looking for boats to save; they just stand there shining.” It may not be within our power, or our job description, to stamp out sexual assault, but physicians can serve as lighthouses, helping to illuminate for our patients a safe path through their college careers.
**
Dr. Jabbarpour is the Robert L. Phillips, Jr. Health Policy Fellow at Georgetown University School of Medicine.
Monday, July 25, 2016
Stepping up counseling about sun safety
- Jennifer Middleton, MD, MPH
The U.S. Preventive Services Task Force (USPSTF) is
currently
updating its 2012 recommendations regarding counseling to prevent skin cancer,
and it couldn’t come at a better time, as the incidence of malignant melanoma
continues to rise. The USPSTF found previously that counseling
fair-skinned individuals aged 10-24 increases the use of sun-protective
behaviors, but this counseling isn’t happening frequently enough in primary care.
A 2004 study of family physicians found that only 60% were routinely
providing counseling about sun protection and skin cancer prevention; commonly
cited barriers to doing so included lack of time and limited information about
the effectiveness of counseling. A more comprehensive survey in
2014 found that family physicians provided sun safety counseling far less
frequently, and usually only in association with specific patient diagnoses
such as actinic keratosis or a history of other skin problems. In contrast to what the evidence supports, the age group most likely to receive counseling in this study was adults in their 70s; counseling at child and young adult visits was rare. Since only 30% of adults regularly
follow sun safety practices, and tanning in young adults remains highly prevalent, there are ample opportunities for family physicians to make a difference for our patients by providing
this counseling.
Other effective interventions may be worth incorporating into your practice as well. Mailing
personalized handouts about
skin cancer prevention increased sun safety behaviors (use of sunscreen, protective
clothing, hats, and sun avoidance) more than providing generic handouts in one
study. In another study, calculating
a melanoma risk score (SAMScore) and targeting counseling to patients at higher
risk decreased sunbathing. Counseling young adults about tanning should elicit the specific reasons why they tan; physicians can then target their messages, such as
discussing sunless tanning products, alternative methods to relax, or debunking
the myth that a tan protects against further skin damage.
Helping patients adopt healthier behaviors is an important part of the primary care clinician's role, and applying motivational interviewing techniques along with tailoring our counseling to each patient’s stage of change may be useful. Having a structured practice intervention to help patients adopt sun safety measures may also reduce the burden on individual clinicians.
Helping patients adopt healthier behaviors is an important part of the primary care clinician's role, and applying motivational interviewing techniques along with tailoring our counseling to each patient’s stage of change may be useful. Having a structured practice intervention to help patients adopt sun safety measures may also reduce the burden on individual clinicians.
Monday, July 18, 2016
25 podcast episodes every family physician should listen to
- Marselle Bredemeyer
As an associate editor in the AFP editorial offices in Leawood, KS, I work alongside our authors and other non-physician staff to help craft each issue of the journal. We use checklists, stylebooks, and calculators to prepare articles for press, guided by our readers and their needs throughout the process. More than merely gauging the readability of a sentence, this means visualizing the big picture: the information we provide being used at the point of care, as research material, or for continuing education. This picture comes together over time, by staying tuned in to comments we receive on the website, phone, through e-mail, and via social media (Twitter and Facebook), where I love to see replies and messages about the content I am sharing.
My sketch of the family medicine specialty has largely been shaped by these experiences, but the voice that sticks in my mind as I work comes from a podcast, an early episode of Slate’s “Working” that featured a family physician from Washington, D.C. Whether you’re new to podcasts or a long-time listener, the format’s storytelling power and lasting impact are what make it stand out.
As the number of podcasts continues to grow, so has an emphasis on the deep-listening strategies that can improve patient care in the office setting. Shared decision making is often a central part of care, from screening practices to end-of-life planning. Hearing what patients are saying and communicating with them in a way that meets their needs can transform their health, even at routine visits.
With that in mind, podcasts, and their ability to make us engage with others’ stories, might be useful to physicians as they look for ways to take in new information, and above all, try to stay tuned in to the underlying messages their patients are sharing. Want to start listening or add new favorites to your queue? With the help of AFP Podcast hosts Steve Brown, MD, Jake Anderson, DO, and Luke Peterson, DO, the four of us have come up with a family medicine podcast playlist that features a variety of shows talking about medicine, public health, and patient relationships. If the tweet might help medical students learn better note-taking, the podcast might help us all be better listeners.
What are you listening to? Share this post and add your own favorite episodes when you do!
AFP Podcast
Bonus Episode with J. Lloyd Michener, MD
Only Human
Doctor Stories: The Patient I’ll Never Forget
How to Stop an Outbreak
This American Life
Something Only I Can See
Embedded
The House
The Hospital
Questioning Medicine
The Dexa Scam
Sawbones: A Marital Tour of Misguided Medicine
Syphilis
Heroes of Patent Medicine
Invisibilia
The Secret History of Thoughts
The Problem with the Solution
Best Science Medicine
Televised Medical Talk Shows (paid subscription required; listen to new episodes for free on iTunes)
Radiolab
The Cathedral
Staph Retreat
Patient Zero: Updated
Elements
Birthstory
A Gobbet o’ Pus 810
Occam and Fallacies
99% Invisible
Fountain Drinks
Planet Money
The Experiment Experiment
Black Market Pharmacies
Your Organs Please
Clipping Coupons for Health Care
Freakonomics
How to Become Great at Just About Anything
How Many Doctors Does It Take to Start a Healthcare Revolution?
As an associate editor in the AFP editorial offices in Leawood, KS, I work alongside our authors and other non-physician staff to help craft each issue of the journal. We use checklists, stylebooks, and calculators to prepare articles for press, guided by our readers and their needs throughout the process. More than merely gauging the readability of a sentence, this means visualizing the big picture: the information we provide being used at the point of care, as research material, or for continuing education. This picture comes together over time, by staying tuned in to comments we receive on the website, phone, through e-mail, and via social media (Twitter and Facebook), where I love to see replies and messages about the content I am sharing.
My sketch of the family medicine specialty has largely been shaped by these experiences, but the voice that sticks in my mind as I work comes from a podcast, an early episode of Slate’s “Working” that featured a family physician from Washington, D.C. Whether you’re new to podcasts or a long-time listener, the format’s storytelling power and lasting impact are what make it stand out.
As the number of podcasts continues to grow, so has an emphasis on the deep-listening strategies that can improve patient care in the office setting. Shared decision making is often a central part of care, from screening practices to end-of-life planning. Hearing what patients are saying and communicating with them in a way that meets their needs can transform their health, even at routine visits.
With that in mind, podcasts, and their ability to make us engage with others’ stories, might be useful to physicians as they look for ways to take in new information, and above all, try to stay tuned in to the underlying messages their patients are sharing. Want to start listening or add new favorites to your queue? With the help of AFP Podcast hosts Steve Brown, MD, Jake Anderson, DO, and Luke Peterson, DO, the four of us have come up with a family medicine podcast playlist that features a variety of shows talking about medicine, public health, and patient relationships. If the tweet might help medical students learn better note-taking, the podcast might help us all be better listeners.
What are you listening to? Share this post and add your own favorite episodes when you do!
AFP Podcast
Bonus Episode with J. Lloyd Michener, MD
Only Human
Doctor Stories: The Patient I’ll Never Forget
How to Stop an Outbreak
This American Life
Something Only I Can See
Embedded
The House
The Hospital
Questioning Medicine
The Dexa Scam
Sawbones: A Marital Tour of Misguided Medicine
Syphilis
Heroes of Patent Medicine
Invisibilia
The Secret History of Thoughts
The Problem with the Solution
Best Science Medicine
Televised Medical Talk Shows (paid subscription required; listen to new episodes for free on iTunes)
Radiolab
The Cathedral
Staph Retreat
Patient Zero: Updated
Elements
Birthstory
A Gobbet o’ Pus 810
Occam and Fallacies
99% Invisible
Fountain Drinks
Planet Money
The Experiment Experiment
Black Market Pharmacies
Your Organs Please
Clipping Coupons for Health Care
Freakonomics
How to Become Great at Just About Anything
How Many Doctors Does It Take to Start a Healthcare Revolution?