Simplifying treatment of acute asthma

- Jennifer Middleton, MD, MPH

A 2 day course of oral dexamethasone emerged as an alternative to a 5 day prednisone course for acute asthma treatment in adults a few years ago, and now a POEM (patient-oriented evidence that matters) reviewed in the current issue of AFP suggests that just one dose of dexamethasone might also be an option.

The study researchers enrolled 465 adults between the ages of 18-56 who were diagnosed with acute asthma in an emergency department (ED). The participants were randomized to either 60 mg of prednisone for 5 days or 12 mg of oral dexamethasone once (followed by four days of placebo). This study used a noninferiority design; the researchers wanted to see if both regimens were equally efficacious regarding the reduction of relapses requiring additional days of steroid treatment. 9.8% of the prednisone group had a relapse compared with 12.1% of the single dose dexamethasone group, which was a statistically significant difference. There was no difference in hospitalization rates or adverse treatment effects between the two groups. Although 5 days of prednisone was more effective at preventing relapse, the researchers felt that the difference between the two treatment arms was small enough, and the benefits of better compliance high enough (since the dexamethasone was given in the ED), to still make it a viable option.

Shorter courses of dexamethasone may also be an option for our patients under the age of 18 with acute asthma. A meta-analysis published last year found that short courses (1-2 days) of dexamethasone were equivalent to longer courses of oral prednisone or prednisolone for children presenting to the ED with acute asthma in preventing relapse. 1-2 day treatment courses are likely easier for children and parents to adhere to, and children may additionally find oral dexamethasone to be more palatable than oral prednisolone. Inhaled anticholinergics are also a useful adjunctive treatment for children with acute asthma (and possibly for adults with severe exacerbations) as reviewed in this 2011 AFP article on the Management of Acute Asthma Exacerbations. The article mentions a 2008 study that found 3 days of prednisone to be equivalent to 5 days for outpatient treatment of acute asthma.

A 2016 Cochrane review on corticosteroid options for acute asthma in adults and children found that existing evidence was insufficient to state whether one type of oral corticosteroid therapy - regardless of specific medication or treatment duration - was superior to another for outpatient treatment of acute asthma, calling for larger, more rigorous trials. It is reassuring, at least, that they did not find any "convincing evidence" that one type of treatment was worse than another regarding rates of relapse, hospitalization, and adverse drug effect. For the time being, we'll need to use patient-centered decision making to arrive at the best treatment plan for each patient with acute asthma, though it certainly seems reasonable to consider shorter durations of oral corticosteroids in uncomplicated pediatric and adult patients. There's an AFP By Topic on Asthma if you'd like to read more.

Having a reliable source for potential practice-changers, like this 1-dose dexamethasone study, can help busy family physicians stay up to date. At the bottom of this most recent AFP POEM are links to several such resources. There's an archive of AFP's published POEMs, complete with a tool to quickly search them by discipline, topic, and/or keyword. The AFP Podcast regularly reviews the POEMs published in AFP like the one above, often adding additional information, angles, and/or resources along the way. The POEM of the Week Podcast with AFP Editor Dr. Mark Ebell is another audio resource that provides concise, thoughtful reviews of studies relevant to primary care.

How do you decide which corticosteroid to prescribe - and for how long - in acute asthma treatment?

The influence of residency training on high-value care

- Kenny Lin, MD, MPH

The American Academy of Family Physicians last week celebrated the results of the 2017 Match, which saw a record 3,237 medical students and graduates fill first-year positions in family medicine residency programs. Although there is ample evidence that providing primary care improves population health, it is less clear how residency training specialty or location influences future health care quality and spending.

As Dr. Jennifer Middleton and I mentioned in prior posts, the AAFP was an early adopter of the American Board of Internal Medicine Foundation's Choosing Wisely campaign against questionable or unnecessary medical interventions, but so far, studies have shown limited effects of the campaign in primary care. Since an estimated 30 percent of health care spending is wasted on unnecessary services, and a recent case study in JAMA suggested that "excessive resource utilization" may be considered an adverse event, it is worth studying if residency training spending patterns persist in clinical practice.

In a research paper in this month's Annals of Family Medicine, Dr. Robert L. Phillips, Jr. and colleagues at the American Board of Family Medicine and the Robert Graham Center analyzed spending patterns of a nationally representative sample of 3,075 family physicians and general internists who graduated from residency between 1992 and 2010 and who cared for a total of more than 500,000 Medicare patients. The physicians' residency program locations were matched with Hospital Service Areas (HSAs) and categorized by spending per patient into low-, average-, and high-cost groups. The researchers found that the "imprint" of residency training spending patterns persisted regardless of where physicians ended up providing primary care:

Physicians trained in high-cost HSAs spent significantly more per patient than those trained in low-cost HSAs, no matter what the spending category of the practice HSA. Averaged across all practice HSAs, this difference was $1,644. ... This relationship held true for family physicians and general internists in our multivariable analysis; general internists, however, made up two-thirds of sample physicians trained in high-cost HSAs, and family physicians made up two-thirds of those trained in low-cost HSAs. [Residency] graduates were significantly more likely to be low-cost physicians if their sponsoring institution produced fewer total physicians, more rural physicians, or more primary care physicians.

The researchers found no relationship between spending patterns and diabetes quality measures, suggesting that lower spending did not lead to worse health outcomes. And it is important to note that family physicians who trained in high-cost HSAs were as likely to be big health care spenders as general internists from high-cost programs; in other words, there did not appear to be anything inherent in family medicine training that caused graduates to spend less. However, more general internists provided costlier care by virtue of having trained in high-cost areas - most likely, those with tertiary academic medical centers. I agree with Dr. Phillips and colleagues' conclusion that their study "supports efforts to test interventions in residency training that may bend imprinting toward teaching and modeling behaviors that improve value in health care." One intervention has borne fruit for the past 8 years in a row: attracting more medical students to the specialty of family medicine.

Supporting our LGBT adolescents

- Jennifer Middleton, MD

Well care at all stages of life is an important part of many family physicians' practices, but perhaps our visits with adolescents are among the most crucial. Discussing sexual health and risk behaviors in all adolescents can help teens avoid serious health sequelae. These discussions are especially critical for lesbian, gay, bisexual, and transgendered (LGBT) youth, as Drs. Knight and Jarrett remind us in the current issue of AFP.  In their article "Preventive Health Care for Women Who Have Sex with Women" (WSW), they assert that "sexual minority adolescents face unique developmental challenges." Providing a supportive environment for sexual minority youth to discuss their sexuality allows us to provide counseling and care regarding these health concerns.

Adopting gender-neutral language with all of our adolescent patients indicates our willingness to provide a safe space for LGBT youth to tell their story. Asking "Is there someone special in your life?" instead of "Do you have a boyfriend/girlfriend?", for example, avoids assumptions regarding sexual orientation. Confidentiality during adolescent visits is especially important to LGBT teens, who may not have disclosed their sexual identity to family and friends. Protecting confidentiality is appropriate unless the adolescent's safety is immediately at risk (such as disclosure of ongoing abuse or intent to commit suicide). Inquiring about bullying is also a must for LGBT adolescents, as they are at higher risk of peer violence compared to their heterosexual peers. Connecting adolescents, and their families, with organizations such as Parents, Friends, and Families of Lesbians and Gays (PFLAG) and the Gay, Lesbian, and Straight Education Network (GLSEN) may help sexual minority teens find support that may be lacking in school or other social environments.

Establishing rapport and a safe environment allows physicians the opportunity to screen for common adolescent risk-taking behaviors. Drs. Knight and Jarrett discuss the health concerns that are disproportionately increased in adolescent WSW, including eating disorders, depression, social anxiety disorders, sexually transmitted infections (STIs), and substance abuse. Asking specifically about each of these issues can help family physicians uncover risk behaviors and provide counseling and treatment. The authors provide helpful language and prompts for obtaining a sexual and social history in WSW (table 4) along with safer sex recommendations particular to WSW (table 6). You can review counseling recommendations for men who have sex with men (MSM) in this 2015 AFP article; highlights include ensuring that hepatitis and meningitis vaccinations are up to date for MSM who meet criteria and offering pre- and post-exposure prophylaxis when warranted to reduce the risk of human immunodeficiency virus (HIV) infection.

Having awareness of these recommendations and using these techniques as physicians is only a first step; our offices must also reflect our commitment to provide care for all. In an accompanying editorial to Drs. Knight and Jarrett's AFP article, Dr. Stumbar reminds us to "create an inclusive office environment that features photos of same-sex and opposite-sex couples, the rainbow flag, and office staff who are comfortable with nontraditional family structures."  The AFP By Topic on Care of Special Populations includes a subheading on Gay, Lesbian, Bisexual, and Transgendered Persons if you'd like to read more.

Prioritizing effective clinical preventive services: an update

- Kenny Lin, MD, MPH

In a widely cited 2003 study, Dr. Kimberly Yarnall and colleagues estimated that in order for a family physician to provide all U.S. Preventive Services Task Force-recommended services to a patient panel of 2500 with an age and sex distribution similar to that of the U.S. population, he or she would need to spend 7.4 hours per working day, leaving little time to address acute or chronic medical problems. Although the subsequent rise of the patient-centered medical home model has allowed physicians to share this work load with other primary care team members, it remains difficult to meet all preventive care needs. In 2006, the National Commission on Prevention Priorities (NCPP) ranked 25 preventive health services recommended by the USPSTF and the Advisory Commission on Immunization Practices (ACIP) based on clinically preventable burden (health impact) and cost-effectiveness. The three services that received the highest score were aspirin use to prevent cardiovascular disease (CVD), the childhood immunization series, and tobacco use screening and brief interventions in adults.

In the January/February Annals of Family Medicine, the NCPP published an updated ranking of effective clinical preventive services, using similar methods as in their 2006 study. The childhood immunization series and adult tobacco use screening and counseling remained the most highly prioritized services, joined by counseling to prevent initiation of tobacco use in children and adolescents, first recommended by the USPSTF in 2013. Although low-dose aspirin for primary prevention remained important, the more targeted 2016 USPSTF recommendation to discuss use with high-risk adults lowered the estimated population health impact of this service. In a recent editorial in AFP, former USPSTF member Douglas Owens explained the rationale for focusing on persons 50 to 59 years of age with a 10% or greater 10-year CVD risk:

The decision to initiate aspirin should be based on a discussion of potential benefits and harms. ... Persons who value avoiding long-term medication use may benefit less from taking aspirin. Cardiovascular risk is also important: the higher a person's risk of CVD, the more potential benefit aspirin provides. The most favorable balance of benefits and harms occurs in persons who are at substantially elevated CVD risk but are not predisposed to bleeding complications. Finally, although older age increases the risk of cardiovascular events, it also increases the risk of bleeding complications.

Dr. Jennifer Middleton discussed the nuances of this recommendation statement, including aspirin's benefits for reducing colorectal cancer risk, in a previous post on the AFP Community Blog.

Finally, clinicians should be aware that the Affordable Care Act (ACA) mandated that in addition to the USPSTF and ACIP, preventive services recommended by the Bright Futures guidelines and the Women's Preventive Services Initiative be fully covered by private insurance plans without cost-sharing. The methods of these groups differ significantly, and unlike the NCPP, none of them review cost-effectiveness. Although political uncertainty surrounding possible repeal of the ACA makes it unlikely that this process will change in the near future, a 2016 editorial in JAMA Internal Medicine proposed improving the consistency of the groups' evidence review methodologies and forming a separate advisory committee "to integrate economic considerations into the final selection of free preventive services." Or, perhaps the NCPP itself could take on that role?