In defense of forbidden words and evidence-based medicine

- Kenny Lin, MD, MPH

I was a federal employee in the Department of Health and Human Services (HHS) during the George W. Bush and Obama administrations. Although the current era of "fake news" and "alternative facts" lay in the future, some subjects were inherently more sensitive than others, depending on which party controlled Congress and the White House. For example, breast cancer screening with mammography made political waves when the U.S. Preventive Services Task Force released updated recommendations in 2009 (while Congress was debating the Affordable Care Act) and again in 2015 (as the House of Representatives repeatedly voted to repeal it).

Over the weekend, the Washington Post, STAT, and multiple other news outlets reported that the Centers for Disease Control and Prevention (CDC) and another unidentified HHS agency were recently provided with a list of seven "words to avoid" when writing budget proposals. These banned or forbidden words are: "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." Although CDC director Dr. Brenda Fitzgerald e-mailed agency staff and tweeted yesterday that "there are no banned words at CDC," neither she nor an HHS agency spokesperson denied the reports.

The unprecedented news created a firestorm on Twitter and elicited an immediate response from Dr. Michael Munger, President of the American Academy of Family Physicians (AAFP), who said in a statement:

The American Academy of Family Physicians, which represents 129,000 family physicians and medical students, is both surprised and concerned by the Administration’s clear disregard for the importance of science and evidence-based medicine. ... This action is an obvious attempt to politicize the most fundamental tenets of medicine and research, which will have a chilling effect on the CDC’s ability to rely on science to justify the work it does to protect public health.

American Family Physician is editorially independent from the AAFP, but the journal's editors stand with the organization in urging the Administration to "fully assess the broader implications of this purely political maneuver and reconsider its recent directive to the CDC." Further, we condemn censorship of science and public health in any form and will not allow it to infiltrate our content, which includes and will continue to include all of the seven forbidden words. Finally, we consider evidence-based medicine to be the essential foundation for ethical patient care, by distinguishing effective health care from tests and treatments that are unnecessary and harmful.

What's new with flu?

- Jennifer Middleton, MD, MPH

We're starting to see our first few cases of influenza where I practice, and the Centers for Disease Control and Prevention (CDC) confirms that the 2017-18 influenza season is off and running in the United States. The predominant activity thus far has been influenza A(H3N2), which is included in all formulations of the influenza vaccine available in the US. Less than 40% of eligible children and adults in the US have received this year's vaccine, but it's not too late to increase our practices' vaccination rates. Here are some simple tips and tools to help do so from the primary care literature.

The Annals of Family Medicine's latest issue includes a randomized controlled trial using text messages to encourage influenza vaccination that had modest success in an Australian multi-center trial. The researchers chose to focus on high-risk populations within these 10 practices including the elderly, young children, pregnant women, individuals with co-morbid health conditions, and certain ethnic minorities. An average of 29 patients (or parents) received text messages for every patient who was vaccinated, costing the practices $3.48 per additional vaccinated patient (at $0.12/text message). That "number needed to text" (my wording) may seem unimpressive, but the cost and time investment that resulted in those vaccinations was modest. The greatest increase in vaccination rates was in children under the age of 5.

An article from Family Practice Management reviews five simple steps to improving vaccination rates: find a champion, use standing orders, optimize your documentation, provide regular reminders to providers, and give ongoing feedback. The authors describe a template for their vaccination standing order, tips for documenting vaccines received elsewhere and vaccine refusals, the use of electronic health record (EHR) and visual reminder systems, and tracking vaccination numbers with simple office metrics. They review the evidence base behind each of these five steps and provide specifics regarding how to implement each one.

A recent AFP Practice Guideline reviews the CDC's Advisory Committee on Immunization Practices' (ACIP) recommendations for the current season. It includes descriptions of the currently available vaccination products and also provides guidance regarding vaccinating persons with a history of Guillain-Barre syndrome (only in individuals at high risk of complications from influenza) or egg allergy (closely monitor persons with a history of anaphylactic egg allergy immediately after vaccination).

The AFP By Topic on Influenza provides many more resources, including patient information handouts and tips for conversing with vaccine-adverse individuals. The CDC's weekly FluView report is another useful tool that I recently added to my AFP Favorites page.

What strategies has your practice used to encourage influenza vaccination?

A simple test to rule out pathologic heart murmurs in kids

- Kenny Lin, MD, MPH

It happens all the time to family physicians at well-child visits: we listen to the heart, hear a murmur that wasn't documented as being there before, and wonder if it's necessary to obtain an echocardiogram and/or refer the child to a cardiologist. A previous review in American Family Physician by Drs. Jennifer Frank and Kathryn Jacobe listed several "red flags" that make a pathologic murmur more likely:

- Holosystolic or diastolic murmur
- Grade 3 or higher murmur
- Harsh quality
- Abnormal S2
- Maximum murmur intensity at the upper left sternal border
- A systolic click
- Increased intensity when the patient stands

The authors also recommended referral to a pediatric cardiologist if historical findings suggest structural heart disease, if cardiac symptoms are present, or if the family physician is unable to identify a specific innocent (physiologic) murmur. Even though innocent murmurs share several characteristics, some of these are subjective or difficult to distinguish, and the fear of missing a heart disease diagnosis may still lead to unnecessary referrals.

In an important study published in the November/December issue of Annals of Family Medicine, Dr. Bruno Lefort and colleagues prospectively evaluated 194 consecutive children aged 2 or older referred for heart murmur evaluations at 2 French medical centers to test the hypothesis that a simple, objective clinical test could exclude serious cardiac disease. 100 children had a murmur that was present when supine but completely disappeared when they stood up, per the pediatric cardiologists' examinations. Of these children, only two had an abnormal echocardiogram result, and only one required further evaluation and treatment for a non-trivial problem (an atrial septal defect that required percutaneous closure). The authors calculated that the complete disappearance of the heart murmur on standing had a positive predictive value of 98%, specificity of 93%, and sensitivity of 60% for innocent murmurs in children. This clinical standing test had superior predictive value compared to traditionally taught clinical features of physiologic murmurs, such as change in murmur intensity, location, or timing.

The investigators concluded that the complete disappearance of the murmur on standing may be a valuable test to rule out pathologic heart murmurs in children and prevent unnecessary imaging and referrals. They recommended that a larger study confirm the value of this test and its reproducibility between pediatric cardiologists and primary care physicians (whose assessments were not evaluated in this study).

The 2017 ACC/AHA Clinical Practice Guideline for High Blood Pressure

- Jennifer Middleton, MD, MPH

The 2017 Clinical Practice Guideline for High Blood Pressure was released 2 weeks ago by the American College of Cardiology (ACC), the American Heart Association (AHA), and 9 other professional societies. The AAFP was not one of these societies and has not yet endorsed the guideline. The nearly 200 page document is quite comprehensive, including a new classification scheme and updated treatment recommendations for patients with a range of co-morbidities. Given the size and scope of this Clinical Practice Guideline (CPG), it's unsurprising that some of its recommendations are being met with enthusiasm and others, perhaps, less so.

The 2017 CPG redefines normal versus abnormal blood pressure using both systolic and diastolic measurements. They define normal BP as a systolic of <120 mmHg and a diastolic of <80 mmHg, elevated BP as a systolic of 120-129 mmHg and a diastolic of <80 mmHg, stage 1 hypertension as a systolic of 130-139 mmHg or a diastolic of 80-89 mmHg, and stage 2 hypertension as a systolic of > 139 mmHg or a diastolic of > 89 mmHg. To make these diagnoses, the authors stress the importance of both accurate in-office BP measurements and ambulatory BP monitoring.

These definitions will significantly increase the number of persons in the United States with a diagnosis of elevated BP and hypertension. The authors justify this increase by citing meta-analyses showing progressively increasing hazard ratios for cardiovascular disease (CVD) risk beginning at a systolic of 120 mmHg or greater and/or a diastolic of 80 mmHg or greater; given the relatively small numbers of individuals who experience CVD complications at lower BPs, however, the absolute CVD risk increase in this population is modest.

The authors appropriately stress the use of nonpharmacological interventions including weight loss, increased physical activity, a healthy diet, and limited alcohol use, and they cite literature showing the efficacy of each of these interventions. These nonpharmacological interventions are the mainstay of treatment for elevated BP as well as stage 1 hypertension in individuals not at increased risk of CVD. They advise initiating pharmacologic treatment for stage 1 hypertension for individuals with diabetes, chronic kidney disease, established CVD, and/or whose 10-year ASCVD risk is calculated to be equal or greater to 10%; this group also includes persons over the age of 65. All individuals with stage 2 hypertension (>140/90 mmHg) should employ nonpharmacological and pharmacologic interventions, which is unchanged from previous guidelines.

The choice of a systolic of 130 mmHg to define hypertension is not without controversy. A commentary on the new guidelines points out that:

The use of a risk-based approach as well as more aggressive BP targets reflect a strong influence in these guidelines from the SPRINT trial....while SPRINT treated patients to an SBP goal of less than 120 mmHg, because repeated BP measurements in SPRINT are likely lower than what is seen in clinical practice, the guideline recommends a target of less than 130 mmHg, not 120 mmHg.

Similarly, "[t]he selection of a 10% ASCVD risk threshold appears also to have been a compromise, being higher than the threshold used to classify high risk in the lipid guidelines (7.5%) and different from that used in SPRINT (15% Framingham risk)." SPRINT's influence is significant, given its shortcomings, and these compromises feel more expert opinion-based than evidence-based. It should be noted that SPRINT's principal investigator is also one of the co-chairs of this CPG, though, according to the manuscript, he excused himself from acting as chair during the group's discussions about SPRINT. Another commentary notes the lack of data "regarding the balance of harms and benefits of treatment" in patients with this new definition of stage 1 hypertension. Several meta-analyses, including one developed for this guideline, have shown reduced CVD events in patients treated to a systolic BP target of 130 but not reduced mortality.

It's difficult to argue with this CPG's emphasis on nonpharmacologic treatment, ambulatory BP monitoring, team-based care, integration of QI efforts, and population health advocacy. Its new BP diagnosis definitions and treatment goals, however, may be more open to discussion, especially as no primary care societies were involved in their development. As Dr. Lin discussed last week on the blog, you can count on AFP to provide ongoing commentary on this and other new guidelines as they emerge.

Medicine moves fast. AFP is keeping up.

- Kenny Lin, MD, MPH

Two decades ago, an article in American Family Physician would appear once in print and thereafter only be accessible in the stacks of medical libraries (or family physicians' homes). Content represented the best science available at the time of publication, but there was no way to incorporate subsequent medical developments or new information, no matter how critical. Then, after archived issues of AFP went online in 1998, we began taking a series of small steps aimed at directing readers to the most current and relevant information on the website, including the AFP By Topic collections, adding links from older review articles to updated reviews on the same topic, and creating search tools for patient handouts and algorithms.

To keep up with the pace of medicine, we have begun selectively updating articles online with information of high public health importance. For example, during its October 25-26 meeting, the Advisory Committee on Immunization Practices (ACIP) voted to recommend preferential use of the recombinant subunit herpes zoster vaccine (Shingrix) over the herpes zoster live (Zostavax) vaccine for adults age 50 and older. The U.S. Food and Drug Administration had approved the Shingrix vaccine on October 23. Coincidentally, the November 15 issue that had just gone to press contained an article on prevention and management of herpes zoster and postherpetic neuralgia. It was too late to stop the presses, but not too late to incorporate the new ACIP recommendation into the online version of the article, along with an editor's note alerting readers about the new information.

In a different situation, after the Centers for Disease Control and Prevention (CDC) published updated guidance about caring for pregnant women with possible Zika virus exposure and diagnosis, evaluation, and management of infants with possible congential Zika virus infection, we decided to add an editor's note to our April 15 article on common questions and answers about Zika virus to direct readers to the most current CDC guidance. In this case, anticipating that public health recommendations will continue to evolve rapidly, we did not revise the online text of the article but instead pointed readers to the CDC website for future updates.

Finally, we will continue to create new collections of articles on related topics. The most recent AFP By Topic collection on Oral and Dental Conditions includes special bonus content on medical aspects of oral health that was produced in a collaboration between American Family Physician and the Academy of General Dentistry. Are there any topic collections that we don't have yet that you would find useful for your practice?

Caring for patients with asthma: tools & apps

- Jennifer Middleton, MD, MPH

A recent AFP article on "Chronic Cough: Evaluation and Management" states that the prevalence of asthma in patients with chronic cough is between 24-29%. Asthma in adults can be a tricky diagnosis to make and manage, but several tools and apps can help family physicians provide excellent care to these patients.

In-office spirometry can help make the diagnosis of asthma in an adult patient with chronic cough; an obstructive pattern with an FEV1 or FVC that improves with bronchodilator challenge is highly suggestive of asthma and should then prompt an assessment of asthma severity to guide treatment. The Choosing Wisely campaign encourages physicians to "not diagnose or manage asthma without spirometry." If you'd like a refresher on interpreting spirometry, this 2014 AFP article on "A Stepwise Approach to the Interpretation of Pulmonary Function Tests" provides a helpful overview.

If your office doesn't have spirometry, however, a simple peak flow meter can still be useful in making an asthma diagnosis. A patient with as-yet-undiagnosed asthma won't know their personal best peak flow value, but apps like Calculate by QxMD or MDCalc can estimate a personal best based on your patient's age, height, and gender. If a patient with chronic cough produces a peak flow less than 80% of that predicted value, empiric treatment for asthma is reasonable pending formal outpatient pulmonary function testing.

Managing an asthma diagnosis can feel overwhelming to patients, especially given the complexities inherent in managing and monitoring symptoms. Helping patients learn how to use their medications correctly is a critical early step. A sizable proportion of asthma patients do not use their metered dose inhalers (MDIs) correctly; providing written patient education material can help, but demonstrating how to use an MDI in the office improves patients' technique even more. Monitoring symptoms and peak flow readings is also important, since teaching patients how to monitor and interpret their peak flows can reduce urgent treatment visits for asthma.

Available online tools to help physicians monitor their asthma patient population include the Interactive Asthma Action Plan available from the Agency for Healthcare Research and Quality and the Association of Clinicians for the Underserved's Asthma Clinical Support Tool. Family Practice Management has a Disease Management Toolbox for Asthma which includes flow sheets and patient self-assessment surveys. There's an AFP By Topic on Asthma highlighting AFP's best content on diagnosis and treatment along with patient education materials. Using the search box on the Community Blog (upper right hand corner of this page) will display recent posts describing new studies about asthma management and treatment. Any of these resources might be useful links to add to your AFP Favorites page.

What resources do you find helpful to diagnose and care for patients with asthma?

Do statins benefit patients at low risk of cardiovascular disease?

- Kenny Lin, MD, MPH

There has been no shortage of recent guidance on statin use for the primary prevention of cardiovascular disease (CVD). The American College of Cardiology / American Heart Association and the U.S. Preventive Services Task Force (USPSTF) disagree about the appropriate 10-year CVD event risk threshold at which clinicians should recommend statins - 7.5% and 10%, respectively - but both agree that the benefits significantly outweigh the harms. So what should clinicians make of the Medicine By the Numbers in the Nov. 1 issue of AFP, which gave a Red (no benefits) rating to statins in persons at low (less than 20% 10-year) risk of cardiovascular disease?

Dr. John Abramson calculated the numbers needed to treat (NNT) to benefit and harm based on data from the 2012 Cholesterol Treatment Trialists (CTT) meta-analysis and the USPSTF's 2016 systematic review. Excluding patients with existing cardiovascular disease or a greater than 20% 10-year CVD event risk, the results showed no statistically significant mortality benefit, but 1 in 217 persons avoided a nonfatal myocardial infarction and 1 in 313 avoided a nonfatal stroke. On the harms side of the scale, 1 in 21 persons experienced pain from muscle damage, and 1 in 204 developed diabetes mellitus as a result of taking statins. Dr. Abramson acknowledged that his conclusion of "no benefit" relied on value judgments about the importance of these harms compared with cardiovascular events prevented:

In summary, studies have found no significant overall mortality benefit with statin therapy in low-risk patients, as well as no reduction in the risk of serious illness overall and very small benefits for nonfatal heart attack and stroke. Statins also appear to cause diabetes. Although this is uncommon, diabetes may occur more often than the prevention of a heart attack or stroke in patients taking statins. ... With no mortality benefit, no reduction in serious illness, an approximately 1% chance of avoiding a nonfatal heart attack or stroke, a similar or greater chance of developing diabetes, and a one in 21 chance of muscle damage, it seems wiser to focus on lifestyle changes (such as adopting a Mediterranean diet, exercising, and not smoking) instead of cholesterol drugs in low-risk patients.

These findings are broadly consistent with a 2011 Cochrane for Clinicians that noted that because "most trials included large numbers of persons with known CVD, ... clear evidence of the effectiveness of statins to prevent a first cardiovascular event is lacking." Other Cochrane reviews have found that statins reduce all-cause mortality in patients with non-dialysis chronic kidney disease, but do not prevent dementia or cognitive decline. A previous AFP article summarized considerations for safe use of statins, which should be part of shared decision making discussions with patients when the benefits and harms are so closely balanced.

Is short-term hormone replacement therapy reasonable?

- Jennifer Middleton, MD

A recent follow-up study of the Women's Health Initiative (WHI) trial is bringing hormone replacement therapy (HRT) back into the news. The WHI aimed to demonstrate that HRT improved cardiovascular outcomes in women, but instead they found not only an increased risk of coronary artery disease (CAD) and stroke but also breast cancer and venous thromboembolism (VTE) in participants taking HRT compared to those who were not taking HRT. The WHI intervention trial was stopped due to these findings, but researchers continued following these women for the next several years. They found that all-cause mortality did not differ between groups who had and had not been taking HRT when the intervention was halted.

When the WHI intervention was halted, women with a uterus who were taking estrogen and progesterone (and their corresponding control group taking placebo) had been enrolled for a median of 5.6 years, and women without a uterus taking estrogen only (and their corresponding control group taking placebo) had been enrolled for a median of 7.2 years. Following all of these women for a median of 18 years after the intervention groups stopped taking their HRT,* the hazard ratio (HR) for all-cause mortality in the estrogen and progesterone group compared to placebo was 1.02 (95% confidence interval 0.96-1.08); for the estrogen only group compared to placebo, the HR was 1.00 (95% confidence interval 0.88-1.01). HRs for deaths due to cardiovascular disease and cancer were similarly non-significant.

Breast cancer, CAD, stroke, and VTE are all serious conditions that certainly give me pause before prescribing HRT, and I have done so for only a small number of women. That small number of women, however, have disabling symptoms from menopause, and they have been willing to accept the risk of those complications in exchange for the ability to function during the day and sleep restfully at night. It is somewhat reassuring to know that, while their risk of these complications is significant, their overall mortality risk appears to be unchanged compared to women not taking HRT.

Using HRT to prevent chronic conditions still has a D grade from the United States Preventive Services Task Force (USPSTF), and this new study won't have me rushing to prescribe HRT to women with mild to moderate menopausal symptoms. There are several safer alternatives to ameliorate hot flashes and vaginal dryness as described in this 2016 AFP article on "Hormone Therapy and Other Treatments of Menopause." If you'd like to read more, there's also an AFP By Topic on Menopause.

*Less than 4% of enrolled women reported taking HRT at some point after the WHI intervention was halted in 2002.

Can social media misuse be a downer?

- Kenny Lin, MD, MPH

As previous AFP Community Blog posts have mentioned, social media use provides several professional benefits for family physicians: it can promote one's practice and engage patients, increase the dissemination of insightful or practice changing conference findings, and amplify the voice of our specialty to advocate on public health concerns. Similarly, patients can also benefit from social media's networking and community-enhancing functions. However, social media's potential downsides include cyberbullying, which targets persons of all ages but may be particularly damaging to children, and problematic internet use / Internet gaming disorder. The American Academy of Pediatrics issued a policy statement last year on office counseling for families and children five to 18 years of age on media use.

A Curbside Consultation in the October 15 issue of AFP explored the relationship between social media and mood disorders. For some persons, particularly in the millenial age group, social media misuse can cause or contribute to the anxiety-related condition "fear of missing out" (FOMO), wrote Drs. Kaitlyn Watson and David Slawson:

Viewing social media intensifies feelings of irritability, anxiety, and inadequacy. Additionally, the drive to stay in the loop can contribute to a cycle of unhealthy social media use. The more time individuals spend on social media, the more likely they are to feel that they are missing out on something, which many will then try to alleviate through more social media activity. Higher FOMO scores, as measured by a validated 10-question scale, are significantly associated with lower feelings of competence, autonomy, and connectedness with others compared with persons who do not worry about being left out.

For patients whose social media misuse is causing adverse emotional or physical symptoms, physicians can recommend any of several free or low-cost apps that help users "unplug" by limiting total social media time per day or restricting use of certain sites (e.g., Facebook, Snapchat) to specific time windows. Other suggested interventions include "changing notification settings to daily or weekly instead of instantly, developing offline relationships, committing to daily personal improvement practices (e.g., yoga, meditation, exercise), and cutting back on the number of social media formats on which the same person is followed." Finally, cognitive behavioral therapy and mindfulness exercises may also be helpful.

What has been your experience with managing symptoms of depression or anxiety linked to patients' social media use?

Interview with AFP's incoming editor-in-chief

- Jennifer Middleton, MD, MPH

On February 1, 2018, AFP will have its first new editor-in-chief in 29 years. In an interview this past week, Dr. Sumi Sexton shared some of her ideas with me about the journal's online presence (hyperlinks below are my additions):

How do AFP's online platforms (Facebook, Twitter, Community Blog, podcast, website) fit into your overall goals for the journal going forward?

I'd like to engage readers through the various platforms to generate discussion ranging from comments on various articles or AFP features to feedback on what we can do to improve.  We don't always have room to include everything we want on a topic in print, so it is nice to be able to include some of these online. I love the concept of Twitter chats, and how the most recent one on antibiotic prescribing incorporated an AFP editorial, a Cochrane for Clinicians, an AHRQ review, and was mentioned on the Community Blog. I look forward to seeing more of that.

AFP's Facebook page, Twitter feed, podcast, and Community Blog offer several different ways for readers to connect with us online, but the number of readers who engage with us on those platforms is a relatively small proportion of total AFP subscribers. How might AFP encourage more readers to connect with these platforms?

I intend to brainstorm with the AFP team on how we can enhance an article on a clinical topic through these platforms. For example, the "Diabetes Self-Management" article in the September 15 issue could be enhanced by a more personal story akin to Diary from a Week in Practice which I used to edit and dearly miss. Another example would be to provide information to family docs on what their colleagues are doing; in the September 1 issue, for example, the article on "Aseptic and Bacterial Meningitis" mentions the meningococcal type B vaccines. How many of our readers are giving this vaccine and why or why not?

In your recent AAFP news interview, you mentioned wanting to speak with readers "in person and online to see how we can better meet their needs." How do you envision connecting with readers online? What information would you like to learn from them?

It would be interesting to see responses from readers to online polling for certain features like editorials (for example, Controversies in Family Medicine) or articles on more controversial topics (like the article and editorial on "Testosterone Therapy" in the October 1 issue). While it may take a little time to post a comment, it is easy to click on a link to answer a quick yes or no on Twitter or Facebook. In addition to knowing what our readers think about medical topics, I'd like to know how they like to receive information. How could AFP be more accessible at the point of care? Is there anything we can do to make CME through the journal easier for them?

AFP's online presence will certainly continue to grow under Dr. Sexton's leadership, and we'll keep you updated about new tools and ways to connect. In the meantime, what additions would you like to see in AFP's online content? 

Key updates in preventive services from the USPSTF

Kenny Lin, MD, MPH

In the third installment of a series that began in 2015 and continued with last year's one-page Preventive Health Care schedule, American Family Physician recently published "USPSTF Recommendations: New and Updated in 2016," authored by Deputy Editor and former U.S. Preventive Services Task Force (USPSTF) member Mark Ebell, MD, MS. Dr. Ebell's editorial summarized 15 recommendations released by the USPSTF in 2016 and provided more details about several key updates.

1) Colorectal cancer screening: "the USPSTF now recommends that physicians offer any one of seven options for colorectal cancer screening:

- Annual fecal immunochemical testing (FIT);
- Colonoscopy every 10 years;
- FIT plus fecal DNA (Cologuard) every one to three years;
- Computed tomographic colonography every five years;
- The combination of flexible sigmoidoscopy and FIT;
- Flexible sigmoidoscopy alone every five years; or
- Annual guaiac-based fecal occult blood testing."

The recommended duration of routine screening remains from ages 50-75, with selective screening advised for adults aged 76-85 years, based on the patient's overall health, prior screening history, and personal preferences.

2) Aspirin for primary prevention of cardiovascular (CV) disease and colorectal cancer: "the USPSTF now recommends aspirin use only in adults 50 to 69 years of age who have a 10-year risk of a CV event of at least 10%, are willing to take aspirin for at least 10 years, and are not at increased risk of bleeding."

3) Statins for prevention of CV disease: "Like the [2013 ACC/AHA guidelines], the USPSTF recommendations for statin use base the decision on the patient's 10-year CV risk and do not identify specific low-density lipoprotein targets. They differ from the ACC/AHA guidelines in that they give a B rating for a low- or moderate-dose statin for patients with a 10-year CV risk event of 10% or greater, but a C rating for those with a 7.5% to 10% risk."

4) Depression screening in adults: "The recommendation ... now explicitly includes pregnant and postpartum women. The Edinburgh Postnatal Depression Scale is the recommended screening tool."

5) Screening for autism spectrum disorder (ASD): "Although there have been several small clinical trials showing the benefit of treatment in children with ASD, all trials were conducted in children who were identified by parents or caregivers and who have relatively severe symptoms. The USPSTF [insufficient evidence] recommendation covers screening in asymptomatic children whose parents and teachers have not identified any concerns."

For a complete list of Task Force recommendations on clinical preventive services, family physicians can consult the USPSTF's website or the Agency for Healthcare Research and Quality's Electronic Preventive Services Selector (ePSS) tool. For easy reference, AFP and the American Academy of Family Physicians have also collected USPSTF recommendations for children, adolescents/young adults (ages 11-26), and adults (ages 18 and older).

Learning about our patients via their pets

- Jennifer Middleton, MD, MPH

A Close-up on Pet Therapy in the October 1 issue of AFP shares one patient's benefit from caring for her dog through the challenges of an abusive relationship and subsequent homelessness. The patient's family physician helped her find low-cost veterinary care and allowed the dog to accompany the patient to visits; the patient's appreciation of these acts is clear in her narrative. Asking about pets as part of the social history can not only provide family physicians with important information about our patients' personal health but may also help us develop meaningful wellness strategies with patients that incorporate their pets.

Pet ownership correlates with several health benefits; pets can provide meaningful social support, encourage regular physical activity, and possibly even improve cardiovascular health. Pets may help children develop compassion and enjoy a higher quality of life. Similar to the Close-up mentioned above, the homeless youth who own pets report that they help them to not only feel safe but also help to attenuate loneliness.

Knowing about our patients' pets may help us understand their health better, but we can also incorporate our patients' pets into treatment plans for mental health conditions and cardiovascular disease. Regular time with pets can increase anxious individuals' willingness to engage with themselves and others in treatment. Creating an exercise routine that involves a pet may appeal to some patients. Discussing the risk to pets of second-hand tobacco smoke may motivate some patients to quit.

We can also work with our veterinary colleagues to ensure that pet ownership is healthy for pets and humans alike. This 2016 AFP editorial about the One Health initiative describes this partnership between veterinary and human medicine to reduce the prevalence of zoonotic infections such as rabies, ringworm, and toxoplasmosis. Here's a link to AFP articles that include the keyword Animal-Related Diseases if you'd like to read more.

Encouraging our patients who don't have pets to consider obtaining one, however, may be ill-advised; it's likely beyond our scope to investigate whether patients have the resources and ability to care adequately for a pet. If we feel interacting with animals might benefit a patient without a pet, we could suggest opportunities to interact with animals such as volunteering at a shelter or caring for a friend or family member's pet. Animal-assisted therapy may also be available in your community; this Curbside Consultation from 2016 describes animal-assisted therapy and its benefits in more detail.

What have you learned about your patients by asking about their pets? Have you incorporated patients' pets into their wellness strategies?

Medication-assisted treatment for opioid addiction: the family physician's role

- Kenny Lin, MD, MPH

Millions of Americans suffer from a potentially fatal disease that has become so common over the past decade that it has lowered the average life expectancy and has particularly devastated vulnerable populations, such as adults with mental health disorders. Although effective medications exist to treat this national health emergency, only a small fraction of family physicians can prescribe them, and even certified physicians face numerous obstacles to providing treatment where their services were most needed. Instead, most efforts have focused on disseminating guidelines to prevent this condition, mostly by reducing known risk factors. Unfortunately, most of what we know about prevention is only supported by low-quality evidence on patient outcomes.

I am writing, of course, about the epidemic of opioid use disorder and overdoses. In an editorial in the Sept. 15 issue of AFP, Dr. Jennifer Middleton argued that while reducing the risk of addiction through the selective and responsible prescribing of opioid medications for pain is important, it is not sufficient to turn the tide. Observing that there is a critical shortage of substance abuse subspecialists, she encouraged family physicians to obtain a Drug Abuse Treatment Act of 2000 (DATA 2000) waiver to prescribe buprenorphine:

Family physicians ... are already adept at combining behavioral interventions with medication management for chronic diseases such as diabetes, cardiovascular disease, and chronic obstructive pulmonary disease; addiction treatment requires a similar combination of lifestyle coaching and prescription oversight. ... 

Buprenorphine is no more complex or difficult to manage than many other treatments routinely used in primary care. Additionally, our specialty has historically embraced the needs of populations labeled as difficult or challenging, such as homeless persons, refugees, and those with developmental disabilities or mental illness. Patients who are struggling with addiction are no less deserving of our attention.

Whether or not medication-assisted treatment (MAT) for opioid use disorder should become part of every family physician's scope of practice is a subject of intense debate, most recently in a pair of Point/Counterpoint editorials in the Annals of Family Medicine. Echoing Dr. Middleton, Dr. David Loxtercamp wrote about his "conversion experience" - the 19 year-old patient with whom he realized that he needed to be able to prescribe MAT to provide adequate care to her and so many others like her. "I am still involved [in MAT]," he wrote, "because I am a doctor and this is the epidemic of our time, a social tsunami that can be traced to my prescription - and yours. ... Addiction is a chronic disease that is decimating our communities. We need no other reason to embrace its treatment within every primary care practice."

Taking the opposite view that not every family physician can "be at the front lines" of the fight against the opioid epidemic, Dr. Richard Hill outlined several other factors that weigh against most family physicians prescribing MAT: specialized treatment required, comorbid psychiatric illness, methods shortcomings of emerging models of care, and the risk that taking on this additional responsibility would create more job dissatisfaction and burnout. "Even if further research establishes an 'optimal' model of care for use in primary care," he asserted, "the nature of the disease [opioid use disorder] itself will place undue clinical burden on an already overextended clinical workforce. Perhaps future efforts and funding should be directed toward the development of readily accessible referral networks of mental health/addiction centers, both public and private."

Both sides of the debate make compelling points. What do you think the family physician's role should be in MAT for opioid addiction?

Prompting physicians and patients increases colorectal cancer screening

- Jennifer Middleton, MD, MPH

Despite multiple available options for colorectal cancer screening, a significant portion of adults aged 50-74 in the United States do not get screened as frequently as recommended by the United States Preventive Services Task Force (USPSTF). A pair of studies this past week describe moderately successful outreach strategies to patients and physicians, respectively, to boost rates.

The first study randomized nearly 6000 US adults aged 50-64 who were not up to date on their colon cancer screening into 3 groups: a colonoscopy outreach group, a fecal immunochemical test (FIT) outreach group, and a usual care group. Participants in the colonoscopy outreach group received mailings encouraging them to call to schedule a colonoscopy; if they didn't within 2 weeks, research staff called them. Participants in the FIT outreach group received mailings with a FIT kit and accompanying instructions. 38.4% of the colonoscopy outreach group and 28.0% of the FIT outreach group completed screening compared to only 10.7% of the usual care group. In the discussion section, the authors note some disappointment that "screening process completion for both outreach groups remained below 40%, highlighting the potential for further improvement."

The second study randomized nearly 1500 general practitioners in France into 3 groups: physicians in the first group received a personalized letter listing all of their patients who were not up to date on colorectal cancer screening, physicians in the second group received a letter describing their region's overall screening rate, and physicians in the third group received no communication at all. The researchers found a small increase in colorectal cancer screening rates in the physician group that received personalized letters (24.8% versus 21.7% for the regional screening information group versus 20.6% for the usual care group) that was statistically significant compared to the other 2 groups. In the discussion section, these authors note that this increase was "modest" and that they, similar to the study described above, also expected a higher screening rate than their results found.

Dr. Lin has written previously on the blog about the various methods available to screen for colorectal cancer in the US and the USPSTF's lack of guidance regarding which method to choose. The USPSTF states that, in addition to colonoscopy and FIT, fecal DNA testing and CT colonography are also options, and the task force encourages physicians to choose the test "that would most likely result in completion." You can read more about these methods in this 2015 AFP article and in the AFP By Topic on Colorectal Cancer.

I'd like to see a study that combines outreach efforts to physicians and patients; it would be interesting to see if the effect is additive in terms of increasing rates. In the meantime, perhaps your own office might create or review a registry of patients not up to date on their colorectal cancer screening, while also providing physicians with a list of these patients. Perhaps you might implement a standard script to discuss colorectal cancer screening with patients at appointments. Or, perhaps you might hire or train an existing staff member to serve as a care coordinator to manage these lists and reach out to patients.

With so many methods to choose from, which one will your office try next to improve colorectal cancer screening rates?

Blood pressure goals in patients with CKD: how low should we go?

- Kenny Lin, MD, MPH

In 2013, the Eighth Joint National Committee (JNC 8) recommended that adults with hypertension and chronic kidney disease (CKD) be treated to a blood pressure (BP) goal of lower than 140/90, after finding no evidence that treating to lower BP goals showed the progression of CKD. At the same time, the American College of Physicians published a guideline on screening, monitoring, and treatment of Stage 1 to 3 CKD that suggested pharmacologic therapy with an ACE inhibitor or angiotensin II receptor blocker, but noted "no difference in end-stage renal disease or mortality between strict blood pressure control (128 to 133/75 to 81 mm Hg) and standard control (134 to 141/81 to 87 mm Hg)."

Less than two years later, however, findings from the Systolic Blood Pressure Intervention Trial (SPRINT) suggested that some older adults at high risk of cardiovascular disease, including those with CKD, may experience additional benefits if treated to a systolic BP goal of 120. After reviewing SPRINT and other recent studies, the American Academy of Family Physicians and the American College of Physicians decided in a new guideline for adults aged 60 years or older to stick with a systolic BP goal of 140 for adults at high cardiovascular risk.

Two systematic reviews and meta-analyses published recently in JAMA Internal Medicine ensure that debate about BP goals for adults with CKD will continue. The first study, by Dr. Wan-Chuan Tsai and colleagues, identified 9 randomized trials (n=8127) that compared intensive BP control (less than 130/80 mm Hg) with standard BP control (less than 140/90 mm Hg) in nondiabetic patients with chronic kidney disease. They found no significant differences between the groups in annual rate of change in glomerular filtration rate (GFR), doubling of serum creatinine level, a composite renal outcome, or all-cause mortality over a median follow-up of 3.3 years.

The second study, by Dr. Rakesh Malhotra and colleagues, extracted data from 18 randomized trials that included 15,924 participants with CKD to determine if more intensive (mean systolic BP 132 mm Hg) compared with less intensive (mean systolic BP 140 mm Hg) control reduced mortality risk in persons with CKD stages 3 to 5. The authors found that more intensive BP control was associated with a statistically significant 14% lower relative risk of all-cause mortality.

An accompanying editorial by Dr. Csaba Kovesdy did a good job of putting these findings into perspective. Dr. Kovesdy pointed out that the benefits of a systolic BP goal of 120 for persons with CKD remain uncertain, and that the meta-analysis could have low external validity because trials had much lower absolute mortality rates than those in observational cohorts of adults with CKD. Finally, he observed that any incremental mortality benefit from intensive BP control is small in comparison to that already achieved by standard BP control:

We must remember that the highest risks of hypertension occur in those with extremely elevated BP levels, and the benefits accrued with treating systolic BP to levels below about 140 mm Hg are much smaller. ... More intensive vs less intensive BP lowering resulted in a [number needed to treat] to prevent 1 death of 167 based on the absolute risk reduction estimated in the meta-analysis by Malhotra et al and an NNT to prevent 1 composite renal failure event of 250 based on the results of another meta-analysis. These diminishing absolute benefits have to be weighed against the increased likelihood of adverse effects and the higher costs associated with more intensive BP lowering.

Bottom line: if family physicians choose to devote more resources to patients with CKD or other cardiovascular risk factors who might benefit from lower-than-usual BP goals, they should not lose focus on improving care for the 46% of U.S. adults with hypertension whose BPs are not adequately controlled by any standard.

Using clinical risk scores wisely

- Jennifer Middleton, MD, MPH

Physicians have several clinical calculator apps to choose from, but guidance about choosing the right score and interpreting its results isn't always as readily available. Busy family physicians looking to enhance their use of clinical risk scores will find several discussed among the articles in the current issue of AFP; understanding the nuances of each may help physicians choose the best ones to "favorite" in their calculator app of choice.

A practice guideline on "Newly Detected Atrial Fibrillation" and an editorial on the "Differences Between the AAFP Atrial Fibrillation Guideline and the AHA/ACC/HRS Guideline" both include a discussion on risk scores to predict stroke and bleeding risk in these patients. Using the CHA2DS2-VASc score increases the number of persons recommended to receive anticoagulation compared to the CHADS2 score, but the authors of both articles argue that these risk scores' ability to predict stroke risk is identical. Interestingly, neither of the clinical calculator apps that I have on my smartphone include the CHA2DS2-VASc score. The practice guideline does describe the HAS-BLED score's ability to predict bleeding risk as "slightly better" than other bleeding risk scores for patients on anticoagulation.

"Pleuritic Chest Pain: Sorting Through the Differential Diagnosis" discusses the importance of ruling out pulmonary embolism (PE), the most common life-threatening cause of pleuritic chest pain. The authors advocate for using a validated risk score in patients presenting with pleuritic chest pain to guide decisions about testing for PE; one of the reference articles describes several available validated risk scores but lists the Wells rule as "widely validated and commonly used;" regardless of the score used, a negative D-dimer test in a patient with a low pre-test probability score usually negates the need for further testing.

Similarly, "Exercise Stress Testing: Indications and Common Questions" discusses the use of the Diamond and Forrester score to calculate the pre-test probability of coronary artery disease (CAD) in patients with chest pain. Exercise stress testing provides the highest diagnostic utility in patients with an intermediate pre-test probability for CAD; low risk patients with negative cardiac enzymes typically require no further testing, and high risk patients should receive prompt intervention.

The AFP By Topic on Point-of-Care Guides provides not only numerous risk scores to use with patients but also an evidence-based summary of how to use them each in practice. You can bookmark this department collection and also save your most-used clinical calculator websites under your AAFP "Favorites" tab for easy future reference.

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.

Asking patients about herbal dietary supplements

- Jennifer Middleton, MD, MPH

The world of herbal dietary supplements can feel murky to physicians, as many supplements have limited rigorous data to back their efficacy and safety. Despite physicians' common reservations, though, an estimated 40.6 million US adults used these supplements in 2012. The authors of a current AFP article on Common Herbal Dietary Supplement-Drug Interactions cite studies showing that only 1 in 3 patients taking a supplement have informed their physician. If we are to help patients navigate the world of supplements safely, we first must know what they are taking.

Several studies have attempted to categorize which patients are more and less likely to discuss their supplement use with physicians. Women are more likely to inform their physicians of supplement use than men, and adults aged 45-64 are more likely to inform than adults aged 18-24. Asian Americans and Hispanic Americans are less likely to inform their physicians than other US ethnic groups. Patients who believe that supplements are safer than conventional medicine and/or not do consider them "medications"  are unlikely to report their use as well. Unfortunately, patients are often unaware of the risks that may exist with supplements.

Knowledge of herbal dietary supplements among physicians is varied, as are attitudes about their use. Physicians with negative views are more likely to advise patients against supplement use. Unfortunately, this advice can discourage patients from further disclosing supplement use at future visits. Physicians may also hesitate to broach the subject with patients because of their own limited knowledge, and, in general, physicians are willing to learn more about supplements and other complimentary medicine therapies given the opportunity.

Several potential solutions exist. Raising awareness of the prevalence of supplement use, and many patients' reticence to discuss it, is a necessary first step. Improving our knowledge of common therapies' safety and efficacy is another; the AFP article mentioned above includes a table (Table 3) with several useful resources, and there's also an AFP By Topic on Complimentary and Alternative Medicine. Since less than half of physicians ask patients about their supplement use, simply asking our patients at every visit is also important as most patients prefer for their physician to ask rather than bring up supplement use themselves. Demonstrating a nonjudgmental attitude may encourage patients to give us honest responses. Communication and cultural competence training may also help physicians more deeply understand and discuss varied health traditions with patients.

How do you discuss supplement use with patients? Are there resources that you have found especially useful?

How family physicians can push back against overpriced drugs

- Kenny Lin, MD, MPH

Sometimes missed in the headlines about the stratospheric costs of new specialty drugs is the contribution of price hikes for older, established drugs, including generics, to prescription spending increases. In an editorial in the July 1 issue of AFP, Dr. Allen Shaughnessy described several situations that drug manufacturers exploit to raise prices excessively (also known as price gouging):

- Limited to no alternatives
- Older products with few producers
- Same product, different use
- Single producer, no generic available
- Evergreening (minor changes to gain patent exclusivity)
- Pay for delay (paying generics manufacturers not to sell a generic version of an off-patent drug)

In the United States, Dr. Shaughnessy observed, "The biggest driver of the cost hike is, simply put, that pharmaceutical companies can charge whatever they want. Drugs cost what the market will bear. Many medications could be a lot less expensive, but because an insurance company, the government, or a patient is willing to pay the asking price, there is no push to lower the costs."

Price gouging has become such a problem for patients and insurers that the Maryland General Assembly recently passed legislation to discourage price gouging on essential off-patent or generic drugs. As explained by Drs. Jeremy Greene and William Padula in the New England Journal of Medicine:

The law authorizes Maryland’s attorney general to prosecute firms that engage in price increases in noncompetitive off-patent–drug markets that are dramatic enough to “shock the conscience” of any reasonable consumer. ... To establish that a manufacturer or distributor engaged in price gouging, the attorney general will need to show that the price increases are not only unjustified but also legally unconscionable. ... A relationship between buyer and seller is deemed unconscionable if it is based on terms so egregiously unjust and so clearly tilted toward the party with superior bargaining power that no reasonable person would freely agree to them. This standard includes cases in which the seller vastly inflates the price of goods.

The scope of the Maryland law is limited. It restricts action to off-patent drugs that are being produced by three or fewer manufacturers, and requires that manufacturers be given an opportunity to justify a price increase before legal proceedings are initiated. It is too early to know if the law will be effective against price gouging, or if it will be copied by other states that are also struggling to contain prescription drug cost increases in their Medicaid programs.

In the meantime, what can family physicians do to help patients lower their medication costs? In a 2016 editorial on the why and how of high-value prescribing, Dr. Steven Brown recommended five sound strategies: be a healthy skeptic, and be cautious when prescribing new drugs; apply STEPS and know drug prices; use generic medications and compare value; restrict access to pharmaceutical representatives and office samples; and prescribe conservatively.

Counseling families about social media

- Jennifer Middleton, MD, MPH

Counseling at well child visits about media use can easily fall by the wayside with so many other important topics to discuss. Our office's electronic health record (EHR) has several template options to choose from for well child exams that each include age-appropriate anticipatory guidance topics, but none of them, at any age, include media use. Adding that prompt may become imperative, especially given the American Academy of Pediatrics' (AAP) Use of Media by School-Aged Children and Adolescents guideline. A recent AFP issue reviewed this new guideline and reminds us of the importance of making time to discuss media use with families.

The AAP encourages physicians to screen for problems related to media use, such as sexting, cyberbullying, problematic internet use, and Internet gaming disorder, in children and adolescents. A recent survey of Texas high schoolers found that 28% of adolescents had texted a naked picture of themselves ("sexting"); in this study, teen girls who sexted were at higher risk of engaging in high risk sexual behavior. The authors of this study suggest asking all teens if they have ever sent, received, or been asked to text a naked picture and also note that the majority of teens are quite uncomfortable with participating in sexting.

The AFP review of this guideline notes that cyberbullying can bring "social, academic, and health concerns" for both the victim and the bully. Several validated scales for screening both bullying victims and perpetrators can be found in this CDC document; although none explicitly mention social media use, several questions are vague enough to potentially include cyberbullying.

Validated scales do exist for screening for problematic internet use and Internet gaming disorder. The 18-item Problematic and Risky Internet Use Screening Scale (PRIUSS) can help identify adolescents and adults with problematic internet use. Many adolescents and young adults with problematic internet use also have depression, social anxiety, and/or attention deficit disorder, so a positive PRIUSS should prompt exploration of these other possible diagnoses. The Internet Gaming Disorder Test (IGDT-10) is a 10 question screen for Internet gaming disorder.

Besides screening for these 4 conditions, the AAP encourages physicians to discuss boundary setting regarding places and times where media use is and is not appropriate. Parents should role model appropriate media use, such as keeping electronic devices (including televisions) outside of the bedroom. Parents also should discuss online safety with their children, though some parents feel unprepared to do so; the AAP has a list of tips for parents here. There's also an AFP By Topic on Health Maintenance and Counseling that includes additional resources for well child (and adult) visits.

No data yet exists showing that screening for these conditions positively influences any patient-centered outcomes, but their associations with mental illness and risky behaviors is convincing enough for me to incorporate them into my well child visits. I'm going to get started by asking our EHR leadership to add "media use" to our anticipatory guidance templates. What step will you take to facilitate conversations about media use with families?

Self-monitoring doesn't improve control of type 2 diabetes

- Kenny Lin, MD, MPH

"Have you been checking your sugars?" I routinely ask this question at office visits involving a patient with type 2 diabetes, whether the patient is recently diagnosed or has been living with the disease for many years. However, the necessity of blood glucose self-monitoring in patients with type 2 diabetes not using insulin has been in doubt for several years.

A 2012 Cochrane for Clinicians published in AFP concluded that "self-monitoring of blood glucose does not improve health-related quality of life, general well-being, or patient satisfaction" (patient-oriented outcomes) and did not even result in lower hemoglobin A1C levels (a disease-oriented outcome) after 12 months. In their article "Top 20 Research Studies of 2012 for Primary Care Physicians," Drs. Mark Ebell and Roland Grad discussed a meta-analysis of individual patient data from 6 randomized trials that found self-monitoring improved A1C levels by a modest 0.25 percentage points after 6 and 12 months of use, with no differences observed in subgroups. Based on these findings, the Society of General Internal Medicine recommended against daily home glucose testing in patients not using insulin as part of the Choosing Wisely campaign.

Still, the relatively small number of participants in trials of glucose self-monitoring, and the persistent belief that it could be useful for some patients (e.g., recent type 2 diabetes diagnosis, medication nonadherence, changes in diet or exercise regimen), meant that many physicians have continued to encourage self-monitoring in clinical practice. In a 2016 consensus statement, the American College of Endocrinology stated that in patients with type 2 diabetes and low risk of hypoglycemia, "initial periodic structured glucose monitoring (e.g., at meals and bedtime) may be useful in helping patients understand effectiveness of medical nutrition therapy / lifestyle therapy."

In a recently published pragmatic trial conducted in 15 primary care practices in North Carolina, Dr. Laura Young and colleagues enrolled 450 patients with type 2 non-insulin-treated diabetes with A1C levels between 6.5% and 9.5% and randomized them to no self-monitoring, once-daily self-monitoring, or once-daily self-monitoring with automated, tailored patient feedback delivered via the glucose meter. Notably, about one-third of participants were using sulfonylureas at baseline. After 12 months, there were no significant differences in A1C levels, health-related quality of life, hypoglycemia frequency, health care utilization, or insulin initiation. This study provided further evidence that although glucose self-monitoring may make intuitive sense, it improves neither disease-oriented nor patient-oriented health outcomes in patients with type 2 diabetes not using insulin.

Adding an antibiotic to uncomplicated I&Ds may improve outcomes

- Jennifer Middleton, MD, MPH

Adding an oral antibiotic after incision and drainage of an uncomplicated skin abscess has been found, to date, to not improve clinical outcomes. The American College of Emergency Physicians (ACEP) even has a Choosing Wisely recommendation to this effect. A study published last week, however, found differently: adding an antibiotic after incision and drainage (I&D) of small skin abscesses resulted in better clinical healing.

The study authors prospectively enrolled 505 adults and 281 children at several sites across the United States who presented to urgent care clinics, Emergency Departments (EDs), and outpatient care sites with small skin abscesses (no greater than 5 cm in diameter for adults, no larger than 3 cm for children under 1 year of age, no larger than 4 cm for children aged 1-8 years) and randomized them to receive, after incision and drainage, either 10 days of clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX), or placebo. 81.7% and 83.1% of the participants who received clindamycin or TMP/SMX, respectively, had a clinical cure 10 days after completing antibiotics, compared with only 68.9% of participants who received a placebo (95% confidence intervals 78.3-87.9, 76.8-86.7, and 62.9-74.9, respectively). When analyzed separately, the researchers found that clindamycin was more effective in the pediatric participants compared to TMP/SMX, while the difference between cure rates for adults for these 2 antibiotics was not significant.

New infections in the 30 days following treatment were more common in the placebo group than either antibiotic group; clindamycin was more effective than TMP/SMX in preventing recurrent infection, especially in pediatric participants. Adverse events were more common in the clindamycin group, though, and most commonly consisted of diarrhea and nausea; these were described as "mild or moderate and resolved without sequelae." 1 hypersensitivity reaction to TMP/SMX was described.

This study's findings contradict common practice and the ACEP's Choosing Wisely recommendation. A closer look at the references cited in the ACEP's Choosing Wisely recommendation, however, demonstrate that the evidence to date regarding treatment of uncomplicated skin abscesses has been a bit meager. They include a smaller randomized control trial (RCT) from 2010 that found placebo equivalent to TMP/SMX in 161 pediatric patients treated in EDs for uncomplicated abscesses; an RCT from 1985 that enrolled 50 adults and found no difference in clinical improvement between those treated with cephradine (a first-generation cephalosporin) and placebo; and, a 2011 cross-sectional study that examined differences in antibiotic prescribing habits across 3 separate pediatric EDs but did not examine clinical outcomes.

Additionally, the Infectious Diseases Society of America's 2014 Practice Guideline for the Diagnosis and Management of Skin and Soft Tissue Infections includes a "strong" recommendation against using antibiotics in uncomplicated skin abscesses but describes the quality of the evidence supporting this recommendation as "low." The more robust design of this new study, with its large number of participants and breath of geographic sites, makes its findings difficult to dismiss. It also builds on a 2016 RCT which found that, in care sites with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA), adding TMP/SMX to incision and drainage improved clinical cure rates in adults and teens with uncomplicated skin abscesses compared to placebo.

Given all of the attention on inappropriate antibiotic use these last few weeks on the blog, it's admittedly a bit tough to digest a study that suggests adding antibiotic treatment to a condition that didn't previously warrant it. It will be interesting to see if other researchers attempt to replicate this result or, perhaps, perform a systematic review of all of the data on this topic.

Will this study change how you care for patients after incision and drainage of an uncomplicated skin abscess?