Taking stock of a new guideline for hypertension in children

- Kenny Lin, MD, MPH

Last week, the American Academy of Pediatrics (AAP) published a new practice guideline on screening, evaluation and management of high blood pressure in children and adolescents, updating a 2004 guideline from the National Heart, Lung, and Blood Institute. The new guideline includes 30 evidence-informed "key action statements" and 27 other recommendations based on consensus opinion. The AAP recommends that blood pressure be measured annually in every child starting at 3 years of age, and at every health care encounter in children with obesity, renal disease, diabetes, aortic arch obstruction or coarctation, or who are taking medications known to increase blood pressure. Notably, the guideline's blood pressure tables lower previous thresholds for abnormal blood pressure in children by several mmHg because they are based on normal weight children only.

The American Academy of Family Physicians (AAFP) currently supports the U.S. Preventive Services Task Force's (USPSTF) 2013 statement that "current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood." According to the USPSTF, the accuracy and reliability of blood pressure screening protocols in children has not been well studied; a sizable percentage of persons with high blood pressure in childhood will have normal blood pressure as adults; and there is inadequate evidence that lifestyle modification or pharmacotherapy results in sustained blood pressure decreases in children or prevents cardiovascular events. Also, abnormal blood pressure thresholds in the AAP guideline are based on a normal population distribution (with 3 different readings >95th percentile defined as hypertensive) rather than on patient-oriented evidence of improved outcomes, as in the JNC-8 guidelines for hypertension management in adults.

How can family physicians know if a new guideline is trustworthy and applicable to their patients? In a 2009 AFP article, Dr. David Slawson and I proposed several attributes of good practice guidelines:

• Comprehensive, systematic evidence search with end date noted
• Evidence linked directly to recommendations via strength of recommendation grading system
• Recommendations based on patient-oriented rather than disease-oriented outcomes
• Transparent guideline development process
• Potential conflicts of interest identified and addressed
• Prospectively validated (i.e., guideline use has been shown to improve patient-oriented outcomes)
• Recommendations offer flexibility in various clinical situations

Subsequently, the Institute of Medicine (IOM; now the National Academy of Medicine) published a report, "Clinical Practice Guidelines We Can Trust," that recommended many similar criteria. The IOM report informed the American Academy of Family Physicians' current processes for developing and endorsing clinical practice guidelines from other organizations. The AAP guideline will undergo a structured quality assessment by AAFP staff and members of the Commission on the Health of the Public and Science, who will recommend to the Board of Directors if the guideline should be fully endorsed, receive an Affirmation of Value, or not endorsed. So stay tuned for more news and analysis of this guideline in future issues of AFP.

STEADI-ing our older patients against falls

- Jennifer Middleton, MD, MPH

Falls can feel like an inevitable part of aging, but with just a little effort and teamwork we can help keep our older patients safe. The current issue of AFP reviews several evidence-based resources at our disposal in a feature article and an accompanying editorial, including the Centers for Disease Control's (CDC) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program.

The authors of the feature article, Preventing Falls in Older Persons, review the prevalence and risk factors for falls in the United States along with relevant Choosing Wisely recommendations. They provide an algorithm from the STEADI toolkit to identify patients at risk for falls using a patient checklist and the Timed Up and Go (TUG) test. Incorporating these 2 screening instruments into the Welcome to Medicare Visit fulfills the requirement to review functional ability and level of safety. Recommending physical therapy, reviewing medications, and ensuring home safety, visual correction, and appropriate footwear have been found to benefit patients at moderate to high risk of falling. Prescribing vitamin D is also recommended for some older adults, though Dr. Lin has written previously on the blog about the limited benefit of vitamin D supplementation for community-dwelling elders.

The accompanying editorial discussing the STEADI initiative reviews the costs for caring for older adults after a fall ($31 billion a year from Medicare alone) along with the development and components of the STEADI initiative: screen, assess, and intervene. A 2016 Community Blog guest post by Dr. Stephen Hargarten of the CDC reviewed each of these STEADI components. Plans to integrate STEADI screens and interventions in electronic health records (EHR) should assist physicians with incorporating falls assessment into our everyday workflow; while waiting for these build updates to arrive, creating a macro or template of the STEADI checklist within your own EHR might be useful.

Besides the printed materials available at the CDC's STEADI website, a quick search of your smartphone's app store will turn up an app or two for administering the TUG test; although I could not find any that were rigorously evaluated, the test is simple enough that a quick practice run using the app should demonstrate its utility. Family Practice Management has a topic collection on Medicare Annual Wellness Visits with tools for incorporating fall prevention into your practice, and there's an AFP By Topic on Geriatric Care that includes articles on gait and balance disorders as well as writing exercise prescriptions. Your office team might want to measure its progress with implementing these changes with a plan-do-study-act (PDSA) cycle, and the Institute for Healthcare Improvement has a video reviewing PDSA cycles along with a worksheet for charting the outcomes of your chosen intervention. You can obtain continuing medical education (CME) credit by completing the CDC's STEADI online course and/or by completing a Knowledge Self-Assessment (KSA) for the American Board of Family Medicine on Care of Vulnerable Elders.

Which of these resources have you and your office team found useful for helping reduce your elderly patients' fall risk? Which new resource are you eager to investigate?

Procedures and prevention: the challenges of Choosing Wisely

- Kenny Lin, MD, MPH

A 55 year-old woman with chronic low back pain and symptomatic knee osteoarthritis asks your opinion about lumbar fusion surgery and some arthritis walking shoes she saw advertised on television. She is prescribed long-acting oxycodone and physical therapy for back pain, and her orthopedist recently began a series of hyaluronic acid injections for her knees. She is up-to-date on cervical and breast cancer screening, but also desires screening for ovarian cancer.

Next, you see this patient's husband, a 60 year-old man with stable coronary artery disease. He was recently hospitalized for an episode of chest pain, and although tests did not show a myocardial infarction, a cardiac catheterization found an 80% stenosis in the left anterior descending artery. He already takes a baby aspirin daily, but his cardiologist has advised adding clopidogrel and having a coronary stent placed. Last year, he quit smoking after going through a pack of cigarettes a day for 40 years, and he is interested in screening for lung cancer. Also, since his brother was diagnosed with colorectal cancer at age 50, he has undergone screening colonoscopies at ages 40, 45, 50, and 55. These have all been normal, and he wonders if it is necessary for him to continue having them every 5 years.

Although both of these patients are fictitious, they represent common clinical scenarios in family medicine that contain enormous potential for overdiagnosis and overtreatment. In the August 15 issue of American Family Physician, Drs. Roland Grad and Mark Ebell present this year's edition of the "Top POEMs Consistent with the Principles of the Choosing Wisely Campaign," which includes the following suggested clinical actions:

• In patients with chronic low back pain, do not recommend lumbar fusion over physical therapy for pain or disability.
• In patients with chronic noncancer pain, try to avoid the use of long-acting opioids because they are associated with a significantly increased risk of premature mortality.
• In patients with knee degenerative joint disease, do not recommend hyaluronic acid injections because they are only minimally better than sham injections in improving pain and function.
• In patients with documented knee OA, do not recommend specifically designed walking shoes because they are no more effective than typical walking shoes at relieving pain and improving function.
• In patients with chronic stable angina and at least 70% stenosis of one coronary artery, do not recommend PCI with optimal medical therapy over optimal medical therapy alone.
• In patients with, or at risk of, coronary artery disease, do not add clopidogrel (Plavix) to aspirin because it does not change the overall risk of death.

As with last year's Top POEMs list, questioning unnecessary procedures or non-beneficial treatments is an effective way to protect patients from harm. But it's important to take a critical approach to preventive care as well to avoid overscreening. For example, as Dr. Jennifer Middleton noted in a previous blog post, one high-profile screening test for ovarian cancer still has big gaps in the evidence regarding its effect on mortality. Drs. Grad and Ebell advise against screening for ovarian cancer and carefully weighing the risks and benefits of lung and colorectal cancer screening:

• In women at average risk, do not recommend screening for ovarian cancer because they are unlikely to experience any mortality benefit.
• In all patients deciding to screen for lung cancer with low-dose CT, discuss the significant risks of harm (3% mortality from invasive procedures after screening) compared with the large number needed to screen to prevent one death from lung cancer (308; 95% confidence interval, 201 to 787).
• In patients who have one first-degree relative with colorectal cancer, but have not developed the cancer by 55 years of age, advise them that their risk is similar to the risk of colorectal cancer in the general population.

It is challenging, and sometimes uncomfortable, to question long-accepted practices that feel like "old friends," AFP assistant medical editor Allen Shaughnessy wrote in a 2016 editorial. He suggested that clinicians keep in mind that the purpose of these evidence-based recommendations, and all of those from the Choosing Wisely campaign, is to improve care and reduce harm:

Every aspect of patient care—every word we say, every test or exam we perform, every treatment or procedure we employ—carries with it the possibility of harm as well as the opportunity for benefit. Although eliminating overuse is often perceived as a way of cutting medical costs, it is really about decreasing wasteful, unnecessary testing and treatment that offer only the potential of harm without the corresponding possibility of benefit. Sometimes, we need to leave our old friends behind.