Monday, May 21, 2018

Tips for caring for persons with developmental disabilities

- Jennifer Middleton, MD, MPH

Two articles in the current issue of AFP, along with other recent primary care literature, contain a wealth of practical tips and techniques for successfully - and respectfully - caring for persons with developmental disabilities.

"Adults with Developmental Disabilities: A Comprehensive Approach to Medical Care" provides an overview of office accessibility pointers, communication techniques, approaches to preventive care and acute illnesses, and end-of-life planning. It also includes a discussion on the medical versus neurodiversity models of diversity, asserting that accepting patients as they are is preferable to trying to "normalize" them:
The goal of health care for patients with developmental disabilities is to improve their well-being, function, and participation in family and community. It is not always necessary or desirable to try to change a person's traits and characteristics to make them appear or behave more normally. 
Along those lines, the patient in this issue's Close-up, "Persons with Disabilities: I'm the Expert About the Body," says, "[T]here are many things they cannot know about me just by observing the way I look or the way I communicate." Avoiding the temptation to make assumptions can go a long way toward communicating respect. This website, quoted within the feature article, includes brief video examples of engaging with patients with no or limited speaking ability. An AFP Curbside Consultation from 2017 reinforces the importance of grounding medical decision making within the patient's definition of quality of life - which may not always align with physicians' assumptions.

Improving our ability to care for persons with developmental disabilities is critically important to reducing health care disparities between them and the non-disabled population. A 2017 statewide study across Ohio found that, compared with persons with no disability, persons with a disability (and/or their supporters) were more likely to report their health status as being "fair" or "poor," had more hospital and Emergency Department (ED) visits, and had more problems "getting needed care." Disabled persons reported more frequent "delayed treatment[s]," problem[s] getting care," and "problem[s] seeing a specialist." A study from the United Kingdom examining hospital admissions found similarly: hospitalizations were double that of non-disabled persons, even after controlling for "higher levels of comorbidity." The authors of both studies call for further studies to explore solutions to minimize these disparities; improving communication between persons with developmental disabilities and physicians, as detailed in the AFP articles above, may be an important first step.

These AFP articles also include a collection of online toolkits and resources on "Supported Decision Making." You can read more in the AFP By Topic on Care of Special Populations. Since family physicians often care for supporters, too, the CDC has tips for caregivers of persons with a disability, and so does FamilyDoctor.org.

Monday, May 14, 2018

Few family physicians are delivering babies, and few women are having VBACs. What's stopping them?

- Kenny Lin, MD, MPH

In 2017, fewer than one in five members of the American Academy of Family Physicians (AAFP) reported providing obstetric care. In a previous Graham Center Policy One-Pager in AFP, Dr. Tyler Barreto and colleagues reported that between 2009 and 2016, the percentage of family physicians practicing high-volume obstetrics (more than 50 deliveries per year) fell from 2.1% to 1.1%. A subsequent study in Family Medicine by Dr. Sebastian Tong and colleagues found that 51% of recent family medicine residency graduates intended to provide prenatal care, and 23% intended to deliver babies; however, less than 10% were delivering after 1 to 10 years in practice.

In a recent policy brief in the Journal of the American Board of Family Medicine, Dr. Barreto and colleagues analyzed data from the 2016 Family Medicine National Graduate Survey to identify barriers faced by residency graduates who stated interest in delivering babies but did not do so in practice. Almost 60% of respondents cited the lack of opportunity to do deliveries in the practice they joined and lifestyle considerations as the most important factors. Fewer than 10% felt that inadequate training or reimbursement were major issues.

Although these recent studies did not specifically focus on family physicians who perform surgical deliveries, prior research has established that Cesarean delivery outcomes are comparable whether performed by family physicians or obstetrician-gynecologists. To support women who choose to attempt labor and vaginal birth after Cesarean delivery (VBAC), the AAFP published a 2015 guideline that was largely based on an Agency for Healthcare Research and Quality review of the benefits and harms of VBAC versus elective repeat Cesarean. I summarized the key findings of this review in AFP's "Tips From Other Journals":

The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). ... The evidence suggests that most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant.

As mentioned previously on the Community Blog, access to VBAC remains limited or nonexistent in many parts of the U.S., and debates continue about its safety for mothers and babies. This month in CMAJ, Dr. Carmen Young and colleagues analyzed a Canadian hospital database containing information on women with a single prior Cesarean between 2003 and 2015 and a second singleton birth at 37 to 43 weeks gestation. They found that rates of the composite outcomes "severe maternal morbidity and mortality" and "serious neonatal morbidity and mortality" were significantly higher after attempted VBAC compared to elective repeat Cesarean. However, absolute differences in these outcomes were low, with NNTs of 184 and 141, respectively.

This new study may give some hospitals and maternity care providers pause about continuing to support women who desire VBAC, and, together with the dwindling numbers of family physicians providing delivery services, could push the overall U.S. Cesarean rate of 32% higher in future years.

Monday, May 7, 2018

Supporting our patients' health outside of the office

- Jennifer Middleton, MD, MPH

Our patients' incomes, neighborhoods, and educational levels impact their health at least as much, if not more, than the interventions we discuss with them within our practice settings. Identifying patients who are struggling with housing, bills, child care, and/or safety might feel like a daunting task, though, and connecting them to helpful resources can feel overwhelming. A new toolkit released by the AAFP can make these tasks manageable; The EveryONE Project provides screening tools to help family physicians screen for social determinants of health (SDOH) and also connect patients to local resources.

The EveryONE Project website contains links to screen patients for SDOH challenges, a guide to patient resources, and planning tools for your office (or practice setting) to implement these changes. Each of these links provides more in-depth background material, a robust list of specific suggestions, and references to resources like Aunt Bertha, an online search engine that lists social services by zip code. These resources simplify connecting individual patients to local resources. (If you're interested in community planning tools, check out the CDC's Tools for Putting Social Determinants of Health into Action.)

A 2017 AFP editorial, "Acting on Social Determinants of Health: A Primer for Family Physicians," includes additional suggestions to implement SDOH interventions and also gives examples of how doing so can benefit patients:
Rather than simply recommending that a patient eat better and exercise more, care teams can connect patients to a local community garden, low-cost exercise resources (e.g., YMCA), or neighborhood walking groups. As another example, knowing that a patient lives in a neighborhood with old housing may prompt a physician to proactively screen for lead exposure based on elevated community risk. 
Perhaps a staff member in your office, or a visiting nursing or medical student, might compile a list of local resources where you practice, starting with tools like Aunt Bertha. Perhaps your practice might identify a champion to work through The EveryONE Project's assessment checklist. Or, perhaps your practice has a best practice to share with other Community Blog readers - please do so in the comment section below. The AFP By Topic on Health Maintenance and Counseling includes tools to deepen your understanding of your patients' unique situation via an in-depth family history and spiritual assessment as well.

If our goal is whole person health, then including SDOH assessment into our practices is essential. No advanced training in public health or social work is necessary to use these tools. As Sir Michael Marmot said, quoted in the The EveryONE Project Guide to Social Needs Screening Tool and Resources, "Why treat people and send them back to the conditions that made them sick in the first place?"

Monday, April 30, 2018

Top research studies of 2017 for primary care practice

- Kenny Lin, MD, MPH

In the most recent installment in an ongoing series in American Family Physician, Drs. Mark Ebell and Roland Grad summarized research studies of 2017 that were ranked highly for clinical relevance by members of the Canadian Medical Association who received daily summaries of studies that met POEMs (patient-oriented evidence that matters) criteria. This year's top 20 studies included potentially practice-changing research on cardiovascular disease and hypertension; infections; diabetes and thyroid disease; musculoskeletal conditions; screening; and practice guidelines from the American College of Physicians and the U.S. Preventive Services Task Force.

The April issue of Canadian Family Physician, the official journal of the College of Family Physicians of Canada, also featured an article on "Top studies relevant to primary care practice" authored by an independent group that selected and summarized 15 high-quality research studies published in 2017. Not surprisingly, some POEMs ended up on both lists:

1) Home glucose monitoring offers no benefit to patients not using insulin

2) Treatment of subclinical hypothyroidism ineffective in older adults

3) Pregabalin does not decrease the pain of sciatica

4) Steroid injections ineffective for knee osteoarthritis

The common theme running through these four studies is "less is more": commonly provided primary care interventions were found to have no net benefits when subjected to close scrutiny.

On the other hand, in a randomized trial that appeared on CFP's but not AFP 's list, adults and children with small, drained abscesses who received clindamycin or trimethoprim-sulfamethoxazole were more likely to achieve clinical cure at 10 days than those who received placebo, although the antibiotics also caused more adverse events, particularly diarrhea (number needed to harm = 9 to 11). As Dr. Jennifer Middleton explained on this blog last year, these findings challenge a previous Choosing Wisely recommendation from the American College of Emergency Physicians that states, "Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up." More can sometimes be, well, more.

Speaking of the Choosing Wisely campaign, Drs. Grad and Ebell will highlight more primary care-relevant research studies from 2017 consistent with the principles of the campaign in AFP later this year.

Monday, April 23, 2018

Caring for agitated patients...and ourselves

- Jennifer Middleton, MD, MPH

A patient of mine, who works in healthcare, was allegedly assaulted by a patient last week with injuries serious enough to warrant an Emergency Department visit. I suspect many healthcare workers can tell stories of times when they, or a colleague, felt unsafe with a patient. Nearly 70% of workplace assaults in the U.S. occur in healthcare or social services settings. A 2010 study of family physicians in Canada found that 39% reported at least one serious assault at some point during their career. Although thoughtful preparation can't provide a complete guarantee of safety, it can help to reduce the risk of serious injury at the hands of an agitated patient.

A recent AFP review of the American Psychiatric Association's (APA) Practice Guidelines on Psychiatric Evaluation in Adults includes taking a thorough mental health and social history, assessing for substance abuse, and assessing for risk of harm to self or others:
If the patient reports having aggressive ideas, the APA recommends that clinicians assess the patient's impulsivity, including anger management issues; determine the patient's access to firearms; identify specific persons toward whom homicidal or aggressive ideas or behaviors have been directed; and ask about the history of violent behaviors in the patient's biological relatives.
Patients can be agitated for reasons besides a mental health issue, according to a recent article in the Journal of Family Practice. Before determining whether a patient's agitation is due to a mental/behavioral health issue, metabolic/physiological cause, substance use, and/or perceptions of unfair treatment, though, we should employ the same de-escalation techniques: stay calm, be non-confrontational, assess the availability of help, and explore solutions. The article provides suggestions for maximizing safety with agitated patients in a variety of practice settings and also suggests the use of scales like the Agitated Behavior Scale to assess risk. It also includes a discussion on interventions to mitigate the development of post-traumatic stress disorder (PTSD) in healthcare workers including Critical Incident Stress Debriefing (CISD) and workplace support measures like Cleveland Clinic's "Code Lavender."

"What to Do When Emotions Run High" from the current issue of Family Practice Management centers on the importance of recognizing, and then addressing, patients' upset feelings before they escalate. The author encourages physicians to pay attention to nonverbal cues (such as "a blank stare or an angry tone") and respond to them by sharing your observation and making gentle inquiries ("'[I]t seems like something is really bothering you today,'" or "'I sense I may have done something to upset you, and if so I'd like for us to discuss it'"). Providing empathic statements can help to defuse tensions, and the author's advice to not "take it personally" reminds us that patients' upset feelings "are usually not about us."

Have you discussed workplace safety where you practice? What resources have you found helpful?

Monday, April 16, 2018

American Family Physician Podcast passes 1,000,000 downloads: why podcasts matter

- Steven R. Brown, MD, FAAFP

We released the first episode of the American Family Physician (AFP) Podcast in December 2015. AFP Podcast is a collaboration between American Family Physician, the most-read journal in primary care, and faculty and residents of the University of Arizona College of Medicine – Phoenix Family Medicine Residency.

Today the podcast passed a significant milestone: 1,000,000 episode downloads! We began counting downloads in May 2016, so this milestone was achieved in less than two years. The AFP Podcast audience continues to grow, and our listeners are now downloading episodes an average of over 45,000 times per month. A podcast with over 20,000 downloads per month, averaged over a year, is considered “high impact” for scholarly work. AFP Podcast is regularly a Top 10 medical podcast on iTunes, and has over 170 five star ratings on the platform. Listeners to the podcast are engaged. The credits at the end of each episode have been read by medical students, residents, and practicing physicians in 39 states and 4 countries. The @AFPPodcast Twitter account has over 1300 followers and an average of over 30,000 impressions per month.

Additionally, AFP Podcast has received a 2017 Gold EXCEL Award from Association Media & Publishing: Educational Podcast category.

Why podcasts matter

The role of podcasts in medical education is growing. With the emergence of new technology, changes in learning preferences, and resident work-hour restrictions, asynchronous methods of education are increasingly relevant. 89% of emergency medicine residents listen to podcasts regularly and 72% report podcasts change their clinical practice. 86% of these emergency residents report podcasts as their favorite form of medical education because of portability, ease of use, and ability to listen while doing sometime else.

We have received multiple comments from practicing family physicians that the AFP Podcast is useful as an American Board of Family Medicine preparation resource. Clerkship directors tell us they recommend AFP Podcast to students in required family medicine clerkships.

Podcasts are also a useful platform for exploring not just practice-changing clinical evidence, but the humanistic aspects of medical practice. The 2016 post “25 podcasts that every family physician should listen to” remains one of the most read articles on the AFP Community Blog. Recommendations from that post include podcasts related to public health, improving learning, patient stories, and medical economics.

The podcast Greyscale, produced by family physician Ben Davis, explores the physician – patient relationship and its impact on practice. Sawbones, hosted by family physician Sydnee McElroy and her husband Justin McElroy, discusses medical history and is regularly ranked as a Top 100 podcast in the iTunes “Comedy” category.

Podcasting quality

While many residents, medical students, and physicians are listening to medical podcasts, there is scant literature related to podcast quality. How do we know which podcasts should be recommended? How can the AFP Podcast be sure we are producing a quality product, worthy of family physicians and learners everywhere?

Two recent studies (published here and here) have examined medical education podcast quality. Both acknowledge that study of this topic is in its infancy. Key criteria for excellence include credibility (transparency, trustworthiness, avoidance of bias), content (professionalism, academic rigor), and design (aesthetics, interaction, functionality, ease of use).

Our editorial team will continue to strive to meet these metrics. Engagement from listeners is essential to these efforts. As we say on the credits at end of each episode: “Please send us your thoughts by emailing AFPPodcast@aafp.org or tweeting @AFPpodcast.” Engagement from listeners will help us improve AFP Podcast for the next million downloads and beyond.

**

Dr. Brown is an AFP Contributing Editor and Editor, AFP Podcast.

Monday, April 9, 2018

Increasing pneumococcal vaccination rates

- Jennifer Middleton, MD, MPH

A Medicine by the Numbers feature on Pneumococcal Vaccines in Chronic Obstructive Pulmonary Disease (COPD), in the current issue of AFP, gives pneumococcal vaccination in persons with COPD a "green" rating, indicating that the benefits outweigh potential harms. Despite these benefits, too few adults with COPD are receiving pneumococcal vaccination.

To clarify, adults with COPD aged less than 65 years should receive Pneumovax 23 (PPSV23); Prevnar 13 (PCV13) is only indicated for adults aged 18-64 with immunodeficiencies, certain hemoglobinopathies, and other specialized conditions (for a full list, check out this CDC Summary). All adults, regardless of co-morbid health conditions, should receive Prevnar 13 at age 65 followed by Pneumovax 23 at least one year later.

The article describes the evidence base demonstrating that, in persons with COPD, the number needed to treat (NNT) for pneumococcal vaccination is 21 to avoid an episode of community-acquired pneumonia and 8 to avoid an acute COPD exacerbation. (The authors reviewed studies that included adults both under and over age 65 to reach these conclusions.) While pneumococcal vaccination might not prevent mortality from COPD, patients are likely to be pleased with the benefit of avoiding pneumonia and/or exacerbations, especially given the lack of reported harms with this vaccine.

The CDC found that, in 2015, only 23% of adults eligible for pneumococcal vaccination had received one (the number eligible includes diagnoses other than COPD). Nonwhite adults and adults without health insurance reported lower vaccination rates. A study of vaccination attitudes and knowledge in Germany found that patient knowledge that pneumococcal vaccination was recommended correlated with increased rates of vaccination among eligible adults; interestingly, for influenza and tetanus vaccines, knowledge alone in this same study did not predict vaccination (though attitudes about each vaccine did).

Increasing awareness of the indications for pneumococcal vaccination is one step to increase vaccination rates; physician reminders, patient letters, and nurse-driven vaccination when used together were also effective at increasing rates in ambulatory specialty practices. In primary care practices, the 4 Pillars Toolkit has been effective; the 4 Pillars Toolkit includes online resources for increasing convenience, patient communication, systems of care, and practice motivation.

Pharmacist-driven interventions to increase influenza and pneumococcal vaccinations in patients with COPD have had mixed success. One study found pharmacist-initiated interventions did not increase pneumococcal vaccination rates for those with COPD or asthma in community settings. Inpatient pharmacist-led patient education, however, may increase pneumococcal vaccination. Employee health screenings that include a pharmacist review of vaccinations may also increase vaccination rates.

Ideal strategies are likely to differ by practice and locale; resources to guide your practice include the AFP By Topic on Immunizations (excluding Influenza) that includes this editorial on Navigating the Changes in Pneumococcal Vaccinations for Adults as well as this overview of the 2018 Advisory Committee on Immunization Practices (ACIP) Adult Immunization Recommendations. From Family Practice Management comes this article providing an overview of practice strategies to both increase vaccination rates and minimize lost costs from storing vaccines.

What strategies have worked to increase pneumococcal vaccination rates in your practice?

Tuesday, April 3, 2018

What's new in asthma treatment?

- Kenny Lin, MD, MPH

As part of the process of updating the 2007 National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines, the Agency for Healthcare Research and Quality (AHRQ) recently released two comparative effectiveness reviews. The first AHRQ review concluded that subcutaneous and sublingual immunotherapy for patients with environmental allergies both reduce the use of long-term controller medications for asthma, and that sublingual immunotherapy also improves asthma symptoms and quality of life. A previous article in American Family Physician discussed allergen immunotherapy for family physicians who wish to offer this treatment in their offices or to determine whether a patient would be a candidate for therapy for an allergist.

The second AHRQ review evaluated the effectiveness of inhaled corticosteroids, long-acting beta agonists (LABA), and long-acting muscarinic antagonists (LAMA) for asthma in different patient populations. In children younger than age five with recurrent wheezing, the authors found that intermittent inhaled corticosteroid use during upper respiratory tract infections decreases asthma exacerbations. Another section of the review, which was published as a research article in JAMA, found that in patients with uncontrolled, persistent asthma, adding LAMA to inhaled corticosteroids reduced exacerbations compared to adding placebo, but had similar benefits compared to adding LABA. Finally, a third section concluded that in patients age 12 years and older, the use of combined inhaled corticosteroids and LABA as controller and quick relief therapy was associated with a lower risk of asthma exacerbations than more traditional strategies involving a controller therapy plus a short-acting beta agonist as relief therapy.

It remains to be seen how this new evidence will be incorporated into the next version of the NAEPP guidelines, which have historically advocated a stepwise approach to management of persistent asthma until good control is achieved. A shortcoming of the AHRQ reviews is that they did not specifically examine harms of LABA, the subject of a Medicine By the Numbers in the March 1 issue of AFP. A Cochrane review examined 48 trials that compared step therapy with an inhaled LABA/steroid combination to a higher inhaled steroid dose in more than 33,000 patients with asthma. Although 1 in 73 patients in the LABA/steroid group avoided a mild asthma exacerbation, there was no benefit on hospitalizations, deaths, or severe exacerbations. Moreover, the authors concluded that 1 in 1,430 additional persons in the LABA/steroid group would experience an asthma-related death, leading them to conclude that combination LABA/steroid inhalers have no benefits. Given the close balance of benefits and harms and uncertainty surrounding these estimates, family physicians should practice shared decision-making with patients about the pros and cons of controller medication options.

Dr. Jennifer Middleton summarized some useful tools and apps for asthma management in a previous Community Blog post, and you can find more information on the diagnosis, prevention, and treatment of asthma in our AFP By Topic collection.

Monday, March 26, 2018

Which interventions benefit patients with dementia?

- Jennifer Middleton, MD, MPH

The prevalence of dementia continues to rise, and, according to "Evaluation of Suspected Dementia" in the latest issue of AFP, it's estimated that 14 million adults will be affected by 2050. This increasing prevalence brings increasing concern for many aging adults about developing dementia along with concern by families about how to support their loved ones. Several recent studies provide guidance; although information about diagnosing and caring for dementia patients is relatively robust, the evidence base is weaker regarding interventions that can slow cognitive decline.

Many patients and families worry about impending dementia when early signs of memory loss appear, but mild cognitive impairment (MCI) does not always lead to a dementia diagnosis. In a 2014 study, researchers followed 357 patients with MCI diagnoses over a 3 year period and found that only 22.4% of them progressed to a dementia diagnosis during this time. The majority of patients had stable symptoms that did not worsen.

For those patients who do receive dementia diagnoses, they and their caregivers may ask about interventions to decrease symptom progression. A recent series of systematic reviews explored several options. Despite earlier studies suggesting at least a small benefit from dementia medications, a 2018 systematic review examining the use of different medications (including dementia medications, antihypertensives, non-steroidal anti-inflammatory medications, aspirin, and statins) found that none delayed cognitive decline. Another systematic review examining the role of over-the-counter supplements found similarly; omega-3 fatty acids, various vitamins, soy, and gingko biloba all failed to demonstrate an effect. Turning to non-pharmacologic interventions, cognitive training increases cognitive abilities in normal adults, but studies have not, to date, supported a role in preventing or slowing dementia progression. Of all potential interventions, only physical activity has been found to slow cognitive decline, but the evidence behind this assertion is of low quality.

Although limited options are currently available to slow dementia's progress, several interventions do exist to help patients and families cope. Case managers can assist family physicians with meeting the most common needs of patients with dementia and their caregivers, early diagnosis and disease education, by providing education, connecting families to local resources, developing care plans, and coordinating social services. Caregivers who interacted with case managers reported increased confidence in caring for their family members. AAFP also has an online Cognitive Care Kit that includes cognitive evaluation tools, management resources, caregiver resources, and tools for discussing end of life planning. Shared group visits can offer patients and caregivers support and can increase practices' efficiency in caring for these often complex patients.

There's an AFP By Topic on Dementia if you'd like to read more; it includes these pro and con editorials regarding routine screening for cognitive impairment (about which the United States Preventive Services Task Force has issued an "I" statement). The AFP article on "Evaluation of Suspected Dementia" includes links to several assessment tools; I've added the Mini-Cog test and the Saint Louis University Mental Status Examination (SLUMS) to my AFP Favorites page for easy access at the point-of-care.

What resources and tools have you found useful in caring for patients with dementia?

Wednesday, March 21, 2018

For hypertension and diabetes, lower treatment targets not necessarily better

- Kenny Lin, MD, MPH

In a previous AFP Community Blog post, Dr. Jennifer Middleton analyzed the 2017 American College of Cardiology / American Heart Association clinical practice guideline on high blood pressure in adults, which proposed lowering the threshold for hypertension from 140/90 to 130/80 mm Hg. Later, the American Academy of Family Physicians and the American College of Physicians independently declined to endorse this guideline, citing concerns about its methodology (e.g., no quality assessment for included studies), management of intellectual conflicts of interest, and lack of information on harms of intensive drug therapy.

The March 15th issue of American Family Physician included a Practice Guideline summary and an editorial perspective on the ACC/AHA guideline by Dr. Michael LeFevre, a member of the panel that developed the JNC 8 guideline for hypertension in adults. In his editorial, Dr. LeFevre pointed out that the guideline's strengths include its emphasis on proper blood pressure measurement technique to avoid overtreating adults with normal out-of-office blood pressures. On the other hand, he argued that "it is an overreach" to classify everyone with a blood pressure above 130/80 as having uncontrolled hypertension. He predicted that since intensive behavioral counseling has only modest benefits in lowering blood pressure, many patients at low risk of cardiovascular disease will end up being treated with medication:

Much harm will come if this change [to the definition of hypertension] is widely accepted and implemented, particularly if quality measures that echo this definition are put into place. Harms from the consequences of poor measurement, overmedication, and arbitrary quality measures can easily offset the small reduction in CVD events found in trials of high-risk persons.

Blood pressure is not the only area of family medicine where there is ongoing debate about appropriate treatment thresholds. In a recent clinical guidance statement, the American College of Physicians recommended that clinicians "aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes," and "consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%." This statement elicited a critical response from the American Diabetes Association and endocrinology groups, who argued that lower blood glucose targets are sometimes appropriate to reduce the risk of microvascular and perhaps cardiovacular complications.

This debate between lower and higher A1c targets has been ongoing for years, as illustrated by a pair of Pro and Con editorials on this topic that appeared in AFP in 2012. On the whole, however, more relaxed glucose control can have substantial benefits, especially for older persons with type 2 diabetes, as Dr. Allen Shaughnessy and colleagues argued in 2015:

A large part of the acceptance that “lower is better” hinges on a false belief that a pathophysiologic approach to decision making is always correct. It seems logical that reducing blood glucose levels to nondiabetic normal, no matter the risk or cost, should result in improved patient outcomes. But it doesn't. Today, an older patient with type 2 diabetes is more likely to be hospitalized for severe hypoglycemia than for hyperglycemia.

Underlining this point, a vignette-based study in the March/April issue of Journal of the American Board of Family Medicine found that primary care clinicians (particularly internists and nurse practitioners) would often chose to intensify glycemic control in an older adult with a HbA1c level of 7.5% and multiple life-limiting comorbidities. As family physicians look for opportunities to improve care for patients with hypertension and diabetes, we should not miss opportunities to avoid harm. 

Monday, March 12, 2018

Breastfeeding + pacifiers = no problem

- Jennifer Middleton, MD, MPH

In the designated "Baby-Friendly" hospital where I round, the use of pacifiers is discouraged in breastfeeding infants in the newborn nursery. Advising breastfeeding mothers about the risks of pacifier use contributing to early weaning is common practice, despite conflicting studies regarding the validity of this risk. A Cochrane meta-analysis, reviewed in the March 1 issue of AFP, may put the controversy to rest, as the reviewers found that pacifier use did not interfere with the establishment or duration of breastfeeding.

The Cochrane reviewers identified two randomized controlled trials (RCTs) for their meta-analysis, both of which divided breastfeeding mothers of newborn infants into two groups: one where pacifiers were prohibited, and one where pacifiers were permitted. Researchers in both RCTs found no difference in breastfeeding rates at 3-4 months of life between these two groups. Arguments against pacifier use have cited previous observational studies finding that pacifier use correlates with diminished establishment of maternal milk supply; the permissive pacifier groups in both of these RCTs, however, included pacifier use even in the immediate newborn period.

As these RCTs only included outcomes on breastfeeding rates in the first months of life, the AFP reviewers rightly encourage future research focusing on pacifiers' possible effect on additional outcomes including maternal confidence and total duration of breastfeeding. These more robust outcomes may dispel any lingering concerns about pacifier use. Adding pacifiers back to the tools available for comforting newborns certainly may benefit both babies and parents; since nonnutritive sucking is a natural self-soothing reflex in newborns, I suspect many parents would concur with my own experience regarding a pacifier's utility in calming a fussy baby.

If you'd like to read more, there are recent AFP articles on "Strategies for Breastfeeding Success" and "Risks and Benefits of Pacifiers," an editorial on "The Maternal Health Benefits of Breastfeeding," and a patient information page on "Helpful Tips for Breastfeeding." (Although these earlier articles do not reflect the findings of this new meta-analysis regarding pacifier use, they still contain a wealth of useful information for supporting breastfeeding in your practice.) The AAFP has a position paper on breastfeeding which encourages breastfeeding education in medical schools and residencies, breastfeeding-friendly office practices, and community advocacy to support breastfeeding mothers. This Society of Teachers of Family Medicine blog post from 2013 puts a compelling personal spin on the challenges of returning to work while breastfeeding, including suggestions on supporting breastfeeding within our own profession of working mothers.

Monday, March 5, 2018

Public health and advocacy resources in American Family Physician

- Kenny Lin, MD, MPH

Shaping local and national policies to improve patients' health outcomes is an appropriate and important role for family physicians. For the past several years, I have taught public health and advocacy skills to medical students, and last month, I attended Academy Health's National Health Policy conference in Washington, DC, for the first time. Although the majority of participants were researchers or policy analysts, family physicians were well-represented as medical directors, public health and insurance officials, and leaders of privately funded community health improvement projects.

In a previous blog post, I discussed the concept of assessing social determinants of health through "community vital signs," geocoded and individually linked data derived from public data sources. Although American Family Physician focuses on health interventions that clinicians provide in offices, emergency rooms, hospitals, and long-term care facilities, it also publishes resources to help family physicians improve social determinants outside of health care settings. For example, a 2014 editorial examined the role of the family physician in preventing and managing adverse childhood experiences, and a review article in the February 1 issue discussed implications for physicians of childhood bullying.

Previous editorials and articles have addressed environmental health hazards such as lead, radonair pollution and climate change, and a 2011 Letter to the Editor urged family physicians to take action to affect the built environment of American communities by "working to ensure that our patients have safe, convenient, and enjoyable places to walk, run, and bike." Other public health issues where physician advocacy can make a positive difference include food insecurity, homelessness, and firearm safety.

Family physicians are often first responders to natural and unnatural disasters in their communities. From influenza pandemics to bioterrorism, preparedness and early recognition is essential to protecting our patients. A 2015 editorial argued that the rapid spread of infectious diseases and migration and displacement of diverse populations have made global health knowledge essential for every family physician, regardless of location: "As the recent Ebola epidemic demonstrated, the world is not only smaller than ever, but it is also more intricately connected. Exotic diseases once confined to the third or developing world are now everyone's concern. Global has truly become local." For example, clinicians are likely to encounter victims of sex trafficking and labor trafficking in their practices.

AFP's sister publication, FPM, also provides resources for primary care clinicians with community and public health roles, from launching a community-wide flu vaccination plan, to following the Grand Junction, Colorado example of improving health system cost and quality outcomes, to working with community-based senior organizations. Finally, family medicine advocates can stay abreast of national initiatives that will shape the specialty's future, such as direct primary care, the patient-centered medical home, and the Medicare Access and CHIP Reauthorization Act (MACRA).

Monday, February 26, 2018

Diagnosing concussion with a blood test?

- Jennifer Middleton, MD, MPH

The Food and Drug Administration (FDA) reported last week that it had approved a new blood test to help diagnose mild traumatic brain injury (mTBI or "concussion") called the Banyan Brain Trauma Indicator. The test measures two proteins, UCH-L1 and GFAP, that are released by the brain into the bloodstream within 12 hours of injury. The FDA press release includes discussion regarding this test's potential to reduce the number of CT scans patients with suspected mTBI receive. The study cited by the FDA to approve this test, however, has not yet been published for physicians to review.

A 2012 AFP article reviewing "Current Concepts in Concussion: Evaluation and Management" describes the difficulties in making a concussion diagnosis:
Concussion can be difficult to recognize, complicated by the lack of a universal definition. Additionally, there are no direct objective measures for diagnosis or recovery, no treatments with well-documented effectiveness, and limited empiric prospective data to guide return-to-play decisions.
The article reviews the high incidence of mTBI in the United States (estimated to be between 1.6-3.8 million injuries annually) and cites that over 1 million of these patients are evaluated in US emergency departments every year. Many of these patients get CT scans of their brain to rule out serious intracranial processes despite the existence of guidelines like the New Orleans criteria that discourage CT scans in patients without headache, vomiting, intoxication, amnesia, seizure, or visible trauma. Using serum biomakers to reduce the use of CT scans in suspect mTBI patients would save patients from unnecessary radiation exposure; this radiation exposure may increase risk for future cancers, especially in patients who receive multiple scans over their lifetimes. An AFP Journal Club article author from 2010 is quoted as saying, "After I have told a patient or parent that a head CT is the equivalent of 100 to 200 chest radiographs, you'd be surprised how many say they really don't need or want the test."

Prior studies regarding the utility of UCH-L1 and GFAP to diagnose concussion have had mixed findings. A previous study examining the use of these 2 proteins along with a 3rd not mentioned in the Banyan Brian Trauma Indicator found decent sensitivity for detecting mTBI but poor specificity; a positive test result was suggestive of mTBI, but a negative test result did not reliably rule it out. A systematic review of these biomarkers' utility from last year was less enthusiastic, finding "insufficient evidence" that these tests are "ready for clinical application."

While the FDA's desire to make this test available as quickly as possible is admirable, not sharing the data that led to its approval makes it challenging for physicians to use it. As with most medical diagnostic tests, the results of the Banyan Brain Trauma Indicator will not merely be "yes" or "no," and understanding the chances of a false positive (or negative) along with the positive (or negative) predictive value will be important for physicians to apply it thoughtfully. Hopefully more information will be forthcoming from the FDA soon, and hopefully, too, the study they cite will be available for our scrutiny as well. In the meantime, here are some mTBI resources from AFP for your review.

Monday, February 19, 2018

Enthusiasm should not outweigh evidence on vitamin D

- Kenny Lin, MD, MPJH

In 2005, Dr. Mark Ebell authored an AFP editorial on the rise and fall of vitamin E, subtitled "lessons in patient-oriented evidence." Observational studies associated lower vitamin E levels with coronary artery disease, leading many physicians to recommend that patients take vitamin E supplements for cardiovascular protection. 19 randomized, controlled trials later, the verdict was in: vitamin E supplementation actually increased all-cause deaths. Dr. Ebell viewed the "vitamin E saga" as an instructive cautionary tale:

It is important to remember that biochemical theory does not equal clinical benefit. Improvements in disease-oriented outcomes, such as free-radical activity, are no substitute for patient-oriented outcomes, such as all-cause mortality. Sometimes our enthusiasm for unproven treatments may harm our patients.


Physicians and patients, it turns out, were already turning to testing and treatment with another vitamin that was a marker of chronic health conditions in observational studies: vitamin D. Between 2000 and 2010, the volume of serum 25-hydroxyvitamin D levels in Medicare patients increased 83-fold, and by 2014, 4 out of 10 adults 70 years or older reported taking a daily vitamin D supplement of at least 1,000 IU, and nearly 7 percent of adults over 60 were taking more than 4,000 IUs daily, a level that the National Academy of Medicine considers to be potentially toxic.

Unfortunately, the vitamin D saga has much in common with the vitamin E saga. According to a review article in the February 15th issue of AFP by Drs. Michael LeFevre and Nicholas LeFevre, vitamin D supplementation in community-dwelling adults has not demonstrated any benefits for ischemic heart disease, cerebrovascular disease, or cancer in clinical trials. The U.S. Preventive Services Task Force and the American Academy of Family Physicians concluded that there is inadequate evidence that supplements improve psychosocial or physical functioning in persons with lower vitamin D levels.

In an accompanying editorial, I argued that the harms of routine screening and supplementation with vitamin D outweigh the benefits, especially when the costs of testing (more than $300 million annually in Medicare alone) are considered:

It is time for clinicians and patients to curb our enthusiasm for vitamin D screening and supplementation. Strategies to decrease unnecessary testing could include distributing the patient handout on vitamin D tests created by Consumer Reports for the Choosing Wisely campaign and implementing clinical decision support for ordering laboratory tests. ... Family physicians should also counsel patients on the recommended dietary allowance for vitamin D (600 IU per day in adults 70 years and younger, and 800 IU per day in adults older than 70 years), and discourage most patients from using supplements, especially in dosages near or above the tolerable upper limit of 4,000 IU per day.

Monday, February 12, 2018

Treating and preventing disease with dietary fiber

- Jennifer Middleton, MD, MPH

The current issue of AFP includes a review article on Hemorrhoids: Diagnosis and Treatment Options that discusses the roles fiber intake has both in contributing to hemorrhoids (when too low) and treating them (when appropriately increased). The authors recommend that patients with hemorrhoids increase their fiber intake to 25-35 grams per day and provide a link to a handout listing high fiber foods. As a high fiber diet can also help prevent and treat hyperlipidemia, constipation, and diverticulosis, family physicians should be proficient in discussing this important digestive component with patients.

Adequate daily fiber intake may protect against the development of hyperlipidemia. Children with chronic constipation consume less fiber than their peers with normal bowel patterns. Inadequate fiber intake is associated with the development of diverticulosis, which can put patients at risk for diverticulitis.

Increasing dietary fiber can modestly reduce LDL levels, improve constipation, and, along with exercise and weight loss if indicated, reduce the risk of recurrent diverticulitis. (Of note, a Cochrane meta-analysis found no role for using fiber supplementation to improve symptoms of irritable bowel syndrome.) Increasing fiber by increasing consumption of high-fiber whole foods, and not with fiber product supplementation, provides the most benefit.

Most Americans consume less than half of those recommended 25-35 grams of fiber daily, though many are trying to increase their consumption by choosing more fruits, vegetables, and whole grain products. Unfortunately, many products marketed as "whole grain" in the United States contain very little fiber. We should counsel patients to look beyond claims about whole grain content and examine food labels to choose products with a minimum of 3 grams of fiber per serving. Advising patients, also, to gradually increase their fiber intake may help them minimize the unpleasantness of bloating and excess flatulence that can accompany a rapid change in fiber consumption. Patients may find nutrition tracking apps such as My Diet Coach, reviewed in the current issue of Family Practice Management, to be useful in monitoring their daily fiber intake. Other apps such as (Fooducate and Shopwellcan help patients make more informed choices at the grocery store.

Providing specific advice in the context of motivational interviewing increases our patients' likelihood of success at making any behavioral modification stick; there's an AFP By Topic on Health Maintenance and Counseling as well as an AFP By Topic on Nutrition if you'd like to read more. What resources have you found useful to help patients increase their daily fiber intake?

Friday, February 2, 2018

The changing of the guard: from Dr. Siwek to Dr. Sexton

- Kenny Lin, MD, MPH

The February 1 issue of AFP marked the first time since 1988 that a family physician other than Dr. Jay Siwek was serving as the journal's editor-in-chief. Dr. Siwek, who bade farewell to readers in a poignant, memory-filled editorial in the January 15 issue, will stay on as editor emeritus. This month, Dr. Siwek introduced his successor, longtime associate editor Dr. Sumi Makkar Sexton. You can read about Dr. Sexton's extensive qualifications and experience in Dr. Siwek's latest piece, and learn about her plans for the future of AFP, which include making journal content more usable at the point of care, in her introductory editorial.

It has been my good fortune to know Jay and Sumi for the past 14 years, since I arrived at Georgetown University School of Medicine as AFP's medical editing fellow in the summer of 2004. Both played critical roles in my development as a family physician and medical editor, during and after my one-year fellowship. It was Jay, in his previous capacity as Chair of Georgetown's Department of Family Medicine, who hired me as a junior faculty member and supported each of my subsequent promotions to assistant, associate, and full professor. After I left the department for several years to work as a medical officer at the Agency for Healthcare Research and Quality and earn a master's degree in public health, it was Jay who convinced me to return and deploy my new skills to direct the department's health policy fellowship and eventually take on other leadership and teaching positions in population health.

On the other hand, it was Sumi, as the editor of Tips from Other Journals (an AFP department that ended in 2013) who continued to hone my writing and evidence-based medicine skills for years after my fellowship ended. Under her supervision, from 2005 to 2010 I wrote more than 60 summaries of primary care-relevant research studies for AFP. And after my first post-fellowship clinical position unexpectedly fell through, it was Sumi who hired me to see patients at her thriving practice, Premier Primary Care Physicians, which was an early adopter of innovations such as electronic medical records and advanced-access scheduling.

As AFP's new deputy editor, I have worked closely with Sumi and Jay for the past several months to support their changing of the guard at editor-in-chief, and I look forward to many more years of collaborating with them both. Moving on from Dr. Siwek to Dr. Sexton is an important transition, but the best-read journal in primary care won't miss a beat.

Monday, January 29, 2018

What's new in opioid prescribing, treatment, and education?

- Jennifer Middleton, MD, MPH

Coverage regarding the opioid epidemic shows no sign of slowing, and a flurry of articles this month -- 5 articles across 4 different Family Medicine journals -- bring several important insights and tools for family physicians to consider incorporating into their practices.

The first is an editorial published online in AFP this past week on "Treating Opioid Use Disorder as a Family Physician: Taking the Next Step." The editorial reviews 12 different models for providing buprenorphine-based medication assisted therapy (MAT) for opioid addiction in a primary care office, including outpatient models, inpatient models, and models that both do and don't incorporate behavioral counseling. Project ECHO is one model that may appeal to rural physicians, as it connects physicians interested in providing this treatment with experts via the internet. The editorial also includes a table with several valuable resources for physicians providing MAT, including the American Society of Addiction Medicine's website which has a wealth of resources for both physicians and patients.

A cross-sectional study regarding "Prescription Opioid Use and Satisfaction with Care Among Adults with Musculoskeletal Conditions" in the Annals of Family Medicine found greater satisfaction associated with prescription opioid use. The authors examined 6 years of data from the Medical Expenditure Panel Survey for adults with documented musculoskeletal diagnoses; patients receiving prescription opioid medications had higher patient satisfaction scores than those not receiving opioids (odds ratio = 1.32; 95% confidence interval, 1.18–1.49). The authors found that patients taking opioids reported more pain and greater disability, however, than those not taking opioids and cautioned that:
"The lack of an association between opioid prescribing and improvements in pain on a population health level has been highlighted by the Centers for Disease Control and Prevention, who report that since 1999, the quantity of prescription opioids sold in the United States has almost quadrupled, yet there has not been an overall change in the amount of pain that Americans actually report."
Two articles examining office-based strategies for managing patients on chronic opioids in the Journal of the American Board of Family Medicine each share interesting insights. "Structured Management of Chronic Nonmalignant Pain with Opioids in a Rural Primary Care Office" describes a rigorous office process required of all patients receiving chronic opioid prescriptions, including administration of several validated scales at each visit (Brief Pain Inventory Short Form, Zung depression scale, SOAPP-R diversion risk assessment tool, and the Roland disability rating scale for back pain), a standard patient handout describing opioid risks, and a standardized documentation template. This approach increased compliance with state and federal opioid prescribing regulations and also decreased the total number of opioid prescriptions written by their office. "Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety" found that adding a pharmacist previsit to appointments for chronic pain decreased overall opioid prescribing with no change in reported patient pain scores.

Finally, from the Society of Teachers of Family Medicine's Family Medicine journal comes "Teaching Chronic Pain in the Family Medicine Residency," a cross-sectional survey of Family Medicine residency program directors about their program's curricula regarding chronic pain. With a 53% response rate of program directors from across the United States, they found that an average of 33 hours (with a wide range of 2-180 hours across programs) of curricular time is devoted to teaching about chronic pain in Family Medicine residencies. The authors hypothesized that residency programs with directors who had negative attitudes about chronic pain and/or MAT would provide less education on these subjects, but this hypothesis was not borne out in their findings; the only predictor of higher curricular time, interestingly, was a strong belief in the benefit of nonopioid treatments for chronic pain. The wide range of curricular hours across the US suggests that residency programs have some work to do to validate and standardize effective teaching on this important subject.

Which of these ideas and/or tools will you consider incorporating into your own practice? Or, perhaps, you have a different model of success to share with AFP readers; we welcome your comments below.

Tuesday, January 23, 2018

Should your next prescription be a mobile app?

- Kenny Lin, MD, MPH

Earlier this month, a blog post from Dr. Jennifer Middleton highlighted recent content in AFP that can help family physicians support patients' resolutions to make healthy lifestyle changes. Increasingly, I also recommend that patients consider using smartphone apps to give them extra motivation and allow them to chart their progress toward personal goals. The latest in a series of articles on medical apps in FPM reviewed four mobile apps designed to encourage healthy habits, including healthy eating, physical fitness, substituting water for sugary drinks, and taking prescribed medications. Although the evidence that apps provide greater benefits than usual care remains limited (a randomized trial of a fitness app reviewed previously by FPM found no statistical differences in weight loss, blood pressure, or satisfaction), "digital therapy" is now being used to promote wellness and improve self-management of chronic conditions as diverse as substance use disorder and atrial fibrillation.

A draft technical brief issued by the Agency for Healthcare Research and Quality reviewed the evidence on health outcomes for 11 commercially available mobile apps for self-management of type 1 or type 2 diabetes. For five apps, studies demonstrated clinically significant improvements in hemoglobin A1c levels at 3 to 12 months. However, no studies showed improvements in quality of life, blood pressure, weight, or body mass index.

Regarding apps for clinicians, the U.S. Food and Drug Administration (FDA) clarified in a recent guidance document how it intends to treat digital decision support software going forward. Software that functions as a diagnostic device will be regulated, while digital tools that merely assist clinicians in making diagnoses will be excluded from regulation and "cleared" for use. On its website, the FDA provides a list of examples of mobile medical apps that it has cleared or approved to date.

Whether mobile apps will complement traditional prevention, diagnosis and treatment in primary care, or replace them, remains to be seen. Do you routinely prescribe apps to your patients, and do you expect to do so more often in the future?

Monday, January 15, 2018

Supporting family physicians who provide maternity care

- Jennifer Middleton, MD, MPH

An editorial on Immediate Postpartum LARC: An Underused Contraceptive Option in the current issue of AFP has generated a lot of interest. Several comments have been left online, and (as of this writing), all of them are quite positive. At a time when family physicians' interest in obstetrics (OB) continues to wane, these commenters exemplify the vibrant community of family physicians who do choose to provide OB care; as a specialty, we should support these physicians and the often underserved communities they care for.

Family physicians who attend deliveries are a critical component of improving the health of rural communities. Obstetrician/gynecologists (OB/GYNs) tend to cluster in metropolitan areas, with many rural counties in the United States reporting that family physicians are their only source for OB care. Supporting training opportunities in residency is critical to encouraging future family physicians to consider including OB in their practices; exposure to models of care like prenatal group visits and physician group coverage models may reduce concerns about the feasibility of doing so.

Even those of us who do not attend deliveries, however, have an obligation to advocate for those who do. Several of the comments left on the current AFP LARC editorial point to the need for state and national advocacy efforts to eliminate reimbursement barriers to providing this valuable service. This advocacy does not have to be time-consuming or burdensome; it's easy to send messages to your state AFP chapter and/or state legislators.

We also have an obligation to support preconception and prenatal care. All family physicians should discuss contraception and family planning with not only our expecting patients but all of our patients of child-bearing age. We should encourage folic acid supplementation for all women capable of pregnancy. We should discuss healthy birth spacing intervals at well child visits. There's an AFP By Topic on Family Planning and Contraception if you'd like to read more.

The comments regarding the LARC editorial enriched future readers' experience with their ideas and references. The ability to comment on articles online is one way you can directly engage with AFP; find us on Facebook and Twitter to join those conversations. Don't forget, too, about the opportunity to comment below here on the Community Blog every week.

Monday, January 8, 2018

The top ten AFP Community Blog posts of 2017

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

For the first time since we started putting together lists of the year's most-read posts, three guest posts made the 2017 list, including the top two. We welcome submissions of guest posts from readers on topics of interest to family physicians; please send inquiries and submissions to Kenneth.Lin@georgetown.edu.

1. Guest Post: I have a new patient (January 3) - 1952 page views

I realize, again, that sometimes we family physicians are called to comfort and not cure. I see how filling her remaining days by helping others continues to bring her a sense of purpose. I have learned a great deal from her in a short time and am grateful that I accepted a new patient.

2. Guest Post: On the front lines of the opioid epidemic (February 21) - 1843 page views

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus.

3. What's in a name? Obesity, ABCD, and prediabetes (January 10) - 1558 page views

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.


4. The 2017 ACC/AHA Clinical Practice Guideline for High Blood Pressure (November 27) - 1281 page views

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.

5. Strategies to limit antibiotic resistance and overuse (June 26) - 1170 page views

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more.

6. Safety net doesn't shield patients from low-value care (April 17) - 1147 page views

The study authors found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.


7. After emergency contraception: what next? (January 21) - 1011 page views

Discussions about EC should include options for initiating a regular form of contraception along with information about ulipristal's effectiveness and possible interactions. Providing this information to women will allow them to choose both an EC method and a regular contraceptive method that best fit their priorities and wishes.

8. Simplifying treatment of acute asthma (March 27) - 978 page views

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.


9. Guest post: innovating connections in family medicine (February 6) - 970 page views

While I delight in new technology that enhances our care for patients, some aspects of family medicine won’t change. Technology won’t change the reassuring words we can offer to a worried parent or acutely ill patient. It won’t alter the power of our receptive ears being present for a scared patient. And it definitely won’t replace the wisdom, laughs, perspectives, and connections we encounter with our patients each day.


10. Vaccines in the news: controversies & updated recommendations (February 15) - 970 page views

Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.

Tuesday, January 2, 2018

Supporting patients' New Year's resolutions

- Jennifer Middleton, MD, MPH

The beginning of a new calendar year often sparks plans to improve health behaviors. When patients share these goals with us, we have many tools and resources available to help them succeed.

A recent AFP article reviews evidence showing that weight loss may be more successful in patients who set simple dietary goals as opposed to attempting to follow a complex diet regimen. Setting permissive (eat more vegetables) instead of restrictive (eat less sweets) goals may also be more effective for meaningful weight loss. Increasing consumption of nutrient-dense foods (whole grains, vegetables, fruits) benefits all patients, and motivational interviewing by a physician can help patients lose an average of an additional 3.3 pounds. A comprehensive review of available medications for weight loss along with when to consider a referral to bariatric surgery can be found in this article and in the AFP By Topic on Obesity.

Another recent AFP article reminds us that many smokers want to quit and have failed quit attempts in the past. This article reviews the 5 A's framework (ask - advise - assess - assist - arrange) as well as the stages of change model to increase our counseling effectiveness. Just one minute spent in tobacco cessation counseling can increase quit rates. The article also reviews nicotine replacement therapies, which have been shown to increase the success of a quit attempt by 50-70%, and encourages use of dual therapy (for example, patch and gum) for those patients smoking more than 1 pack a day. Calling or contacting patients at least 4 times after their planned quit date increases quit rates; AAFP's Office Champions model is one way of involving the entire office in providing this follow-up and helping patients stay smoke-free for good. The AFP By Topic on Tobacco Abuse and Dependence provides many more helpful resources.

A final recent AFP article cites the disappointing statistic that most individuals do not report ever receiving counseling from their physicians regarding physical activity. Engaging in shared decision making with patients, writing an exercise prescription, and providing handouts with exercise instructions have all been shown to increase physical activity. Patients who feel that they don't have the time for prolonged periods of exercise may be glad to know that even 10-minute bursts of exercise can be beneficial. Patients intimidated by demanding exercise regimens may be relieved to learn that the overall time spent in exercising seems to be more important than overall intensity. Individuals should aim for no more than 2 days off between exercising to prevent losses in metabolic activity gains from a regular exercise program. The AFP By Topic on Health Maintenance and Counseling includes this recent review regarding the United States Preventive Services Task Force (USPSTF)'s report on the benefits of behavioral counseling interventions for physical activity.

Perhaps one of your new year's resolutions is to increase your office's capacity for supporting patients' behavior change efforts; this Family Practice Management article describing the AAFP's "AIM-HI" office intervention model might provide some inspiration. Or, perhaps your office has a successful model already in place that you might share with other AFP Community Blog readers in the comment space below.

Here's to a healthy 2018!