Monday, December 10, 2018

Creating a welcoming office for LGBTQ patients

- Jennifer Middleton, MD, MPH

The current issue of AFP highlights "Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know" along with an accompanying editorial describing "The Responsibilities of Family Physicians to Our Transgender Patients." Both articles discuss the importance of tangibly demonstrating openness to transgender and gender-diverse persons by displaying "transgender-affirming materials," training staff regarding inclusive language and behavior, and adopting intake forms to offer more than just binary descriptors of "male" or "female." Several additional resources are available to family physicians to ensure that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals feel comfortable accessing healthcare in our offices.

The American Medical Association's Population Care website includes a page on creating an LGBT-friendly practice. The AMA emphasizes providing visual clues that your office is LGBTQ-friendly such as brochures, posters, and a nondiscrimination statement. There's a link to a podcast with more suggestions and information about listing your practice in the Gay and Lesbian Medical Association (GLMA) Provider Directory.

The United States Department of Health and Human Services' Adolescent Health website includes a section on Ensuring Inclusivity of of LGBTQ Youth. Their resources focus on inclusivity regarding contraception access and teen pregnancy prevention efforts. One handout stresses that "sexual identity is separate from sexual behavior" and cites data that LGBTQ teens are at higher risk of pregnancy than their heterosexual, cisgender peers.

Your office might also consider participating in a "Safe Zone" training session, described in more detail at the Safe Zone Project's website. LGBTQ individuals may seek out signs such as a "Safe Zone" emblem as a visual clue that they are in an accepting and affirming healthcare site.

We cannot deliver the best care to our communities if some members of our communities feel unsafe entering our offices. Educating ourselves - and our residents - is essential. The AAFP has a curriculum guide for family medicine residencies on Lesbian, Gay, Bisexual, and Transgender Health, citing data that the majority of family medicine residents rate their training on LGBTQ health as "fair or poor."  The AFP By Topic on Care of Special Populations also includes a subheading on Gay, Lesbian, Bisexual, and Transgendered Persons if you'd like to read more as well.

Tuesday, December 4, 2018

Improving care transitions for formerly incarcerated patients

- Kenny Lin, MD, MPH

A young man with schizophrenia, opioid use disorder (OUD) and chronic hepatitis C infection recently completed a 5-year prison sentence and was discharged back into the community. While he was incarcerated, he received antipsychotic medications and periodic laboratory monitoring of his liver disease; medication-assisted treatment for OUD was unavailable. At the time of his release, he was given a 30-day supply of pills and told to follow up with a primary care physician. The next few weeks will be a critical time for this patient's health, according to an article on care of incarcerated patients in the November 15th issue of American Family Physician:

Most inmates are discharged from correctional facilities without a supply of medications or referrals to primary care, mental health services, or substance abuse treatment. Lack of care coordination directly affects the health of former inmates. In the two weeks following release, former inmates are 129 times more likely to die of a drug overdose and 12 times more likely to die of any cause than members of the general public.

Former inmates face two significant obstacles to accessing primary care: affording care, and the reluctance of some clinicians to accept formerly incarcerated patients. Before 2014, an estimated 80 percent of incarcerated persons lacked health insurance or the financial resources to pay for basic health care. Even after the expansion of Medicaid to single and childless adults earning up to 138% of the federal poverty level in 36 states and the District of Columbia, many patients continue to slip through the cracks. A 2016 article in Kaiser Health News recounted the case of Ernest, a man with severe mental illness who served prison time in Indiana for killing his 2 year-old daughter during a psychotic delusion. Even though Indiana had expanded Medicaid by the time of Ernest's release and set up a system to enroll all eligible prisoners, records show that he was forced to enroll in the program on his own, wasting valuable time and delaying his transition of care:

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled. “Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Having health insurance does not necessarily mean that a patient will be able to access care, as illustrated in a recent Canadian study published in the Annals of Family Medicine. Researchers posing as prospective patients telephoned all family physicians listed as accepting new patients in British Columbia. The only difference between the patient roles was that one set mentioned that he or she had been released from prison a few months before. Among the 250 family physicians who answered the phone and were still providing primary care, control patients were twice as likely to be offered an appointment compared to persons recently released from prison (absolute risk difference = 41.8%).

In 2017, the American Academy of Family Physicians published a position paper on Incarceration and Health that suggested "family physicians can promote the health of individuals during the transition from correctional facilities to the community by supporting reentry processes that begin prior to release; collaborations between prison and community health services; integrated models of care; and linkages to housing, employment, and mental health support." To that, I would add that we should not discriminate against patients with a history of incarceration.

Monday, November 26, 2018

The 2018 ACC/AHA cholesterol guidelines: updates for family physicians

- Jennifer Middleton, MD, MPH

The American College of Cardiology (ACC) and American Heart Association (AHA), along with several other specialty organizations, have released a new "Guideline on the Management of Blood Cholesterol." Of note, this multi-specialty collaboration did not include primary care organizations like the American Academy of Family Physicians (AAFP) or the American College of Physicians (ACP); family physicians will find many similarities between this guideline and the 2013 ACC/AHA cholesterol guidelines, but a few changes may further complicate risk assessment and treatment discussions.

There is no change regarding the ACC/AHA's emphasis on lifestyle change as the basis for ASCVD prevention. There are also no changes to the treatment of two patient populations: individuals with clinical atherosclerotic cardiovascular disease (ASCVD) and individuals with serum low density lipoprotein cholesterol (LDL-C) levels greater than 190 mg/dL. For both groups, risk calculation with the ASCVD risk score is unnecessary; prescribe high-intensity (or maximally tolerated) statin therapy.

Recommendations regarding the use of statin medication for the primary prevention of ASCVD in persons with diabetes mellitus (DM) have been slightly revised. Moderate-intensity statin therapy is still recommended, as a starting point, for all patients with DM between the ages of 40-75 years. Previously, an ASCVD risk score greater than or equal to 7.5% was an indication for high-intensity statin therapy in this population; the 2018 guideline expands this recommendation to also include patients with one or more "diabetes-specific risk enhancers" (long duration of DM, albuminuria, eGFR < 60 mL/min, retinopathy, neuropathy, ankle-brachial index < 0.9) regardless of ASCVD risk score.

Perhaps the most complex changes center around those individuals aged 40-75 years who do not have DM and do not have clinical ASCVD. The 2013 guideline stratified these individuals into 2 risk categories, but the 2018 guideline now has 4:

  • Low risk: ASCVD risk score < 5%
  • Borderline risk: ASCVD score 5-7.4%
  • Intermediate risk: ASCVD score 7.5-19.9%
  • High risk: ASCVD score > 20%

Per this new guideline, low risk persons should focus on a healthy lifestyle. Borderline risk persons with one or more "risk enhancers" (see list below*) may consider moderate-intensity statin therapy after risks/benefits discussion with their physician. Intermediate risk persons should initiate moderate-intensity statin therapy if one or more risk enhancers* are present. High risk persons should initiate high-intensity statin therapy.

The 2018 ACC/AHA guideline also emphasizes following patients' LDL-C levels to both confirm adherence to therapy and to maximize benefit. They recommend that moderate-intensity statin therapy should lower LDL-C by 30-49%, and high-intensity statin therapy should lower LDL-C by at least 50%. The sources cited by the guideline to support these recommendations are expert opinion, however, and not randomized controlled trials (RCTs). It remains to be seen if primary care organizations such as the AAFP and ACP will endorse all or some of this guideline, especially this change regarding lipid monitoring.

The 2016 United States Preventive Services Task Force (USPSTF) recommendations regarding statins are similar regarding the benefit of primary prevention of those persons at highest risk (ASCVD risk score > 20%). The task force was less convinced regarding statins' primary prevention benefits among those at lower risk, giving a "B" grade for adults aged 40-75 years with an ASCVD risk score > or equal to 10% and at least one risk factor and a "C" grade for similarly aged adults with an ASCVD risk score between 7.5-9.9% and at least one risk factor. Statin therapy for primary prevention in persons > 75 years of age received an "I" grade, which is reasonably consistent with the 2018 ACC/AHA guideline's statement that "[f]or patients > 75 years of age, RCT evidence for statin therapy is not strong." The USPSTF also pointed out that most of the trials evaluating statins' efficacy in primary prevention enrolled participants based on the presence of risk factors, not based on the results of risk assessment tools.

The 2018 ACC/AHA cholesterol guideline contains much more content including a discussion regarding the use of statins in patients younger than 40 and also recommendations about appropriate candidates for coronary artery calcium scoring. The entire guideline has been published online ahead of print here. This "top 10 points" summary of the guideline may also be of interest. There's an AFP By Topic on Hyperlipidemia if you'd like to read more, which includes this Medicine by the Numbers article on "Statins in Persons at Low Risk of Cardiovascular Disease."

ACC/AHA's ASCVD "risk enhancers" include: family history of premature ASCVD, persistently elevated LDL-C > 160 mg/dL, chronic kidney disease, metabolic syndrome, women with history of pre-eclampsia or premature menopause, history of inflammatory diseases (for example, rheumatoid arthritis, psoriasis, HIV), ethnicity, persistently elevated triglycerides > 175 mg/dL. 

Tuesday, November 20, 2018

Safe outpatient management of low-risk patients with acute pulmonary embolism

- Kenny Lin, MD, MPH

I've practiced family medicine long enough to remember when treatment of any patient with acute deep venous thrombosis (DVT) required hospitalization for several days administering intravenous unfractionated heparin and oral warfarin while waiting for the patient's international normalized ratio (INR) to reach a therapeutic level. Thanks to the development of low molecular-weight heparins and direct-acting oral anticoagulants (DOAC), outpatient treatment of uncomplicated DVT is now the norm. But patients with newly diagnosed pulmonary embolism (PE) are still typically hospitalized, since they often have hemodynamic instability or other potentially life-threatening conditions.

According to a 2017 article in American Family Physician, the American College of Chest Physicians suggests considering outpatient treatment of acute PE "if the risk of nonadherence is low and the patient is clinically stable; has no contraindications to anticoagulation, such as recent bleeding, severe renal or liver disease, or platelet count of less than 70; and feels capable of managing the disease at home." A recent Point-of-Care Guide reviewed clinical decision tools that predict mortality in patients with newly diagnosed PE. The simplified Pulmonary Embolism Severity Index (sPESI) stratifies patients into low and high risk categories. Low risk patients have a 30-day mortality rate of 1%, while high risk patients have a 9% mortality rate.

A prospective cohort study published in CHEST earlier this year enrolled 200 consecutive adults with newly diagnosed PE and a low risk of mortality using the related Pulmonary Embolism Severity Index (PESI). Participants were observed in the emergency department (ED) for 12 to 24 hours, then treated with anticoagulant medications in the outpatient setting (173 patients were treated with DOACs). After 90 days, no patients had died or suffered a recurrent venous thromboembolism (VTE). One patient had a major bleed after a traumatic thigh injury that required a blood transfusion and surgery.

A pragmatic controlled trial in Annals of Internal Medicine evaluated the effect of implementing an electronic clinical decision support system (CDSS) that included the PESI tool and an educational intervention on decision making for patients with acute PE in the 21 community EDs of Kaiser Permanente Northern California. 10 EDs received access to the CDSS and in-person education and feedback from an onsite emergency physician-researcher ("study champion"); the other 11 EDs served as control sites. The primary outcome was discharge to home from the ED or an ED-based outpatient observation unit. At the intervention sites, home discharge increased from 17.4% to 28%, while there were no changes in discharge practices at control sites. The intervention was not associated with increases in 30-day major adverse events (recurrent VTE, major hemorrhage, or all-cause mortality).

One day, one of my trainees will be able to write, "I've practiced family medicine long enough to remember when even low-risk patients with acute PE required hospitalization ..."

Monday, November 12, 2018

Putting the "family" in family physicians' care of children with type 2 diabetes

- Jennifer Middleton, MD, MPH

The current issue of AFP includes a review on Type 2 Diabetes Mellitus in Children, reviewing current guidelines for screening, diagnosis, and treatment. Children with type 2 diabetes mellitus (DM2) have optimal success with their treatment regimens when their families are engaged in their care. This engagement is crucial to success with both lifestyle and pharmacologic treatments.

Improving nutrition and exercise can lower A1Cs and improve clinical outcomes in children with DM2. Physicians can guide these changes by providing dietician referrals, exercise prescriptions, and screen time limits. Just as children and adolescents with DM2 tend to be obese, their families also tend to have similarly elevated body mass indices along with "high fat intake, minimal physical activity, and a high incidence of binge eating." Encouraging the entire family to work together to improve their nutrition and exercise improves the pediatric diabetic patient's chance of success with these changes. 

Sometimes, though, engaging children and families in the office alone is insufficient. Interdisciplinary interventions, such as multi-systemic therapy led by a trained family therapist, lowers A1Cs, reduces hospitalizations, and reduces costs in children with type 1 diabetes mellitus; though these interventions have not been systematically studied in children with DM2, it seems reasonable to assume that they would be similarly effective. Interestingly, parents often under-estimate their children's health-related quality of life; it may be that these interdisciplinary interventions help younger diabetic patients better understand the severity of their disease and, consequently, increase their adherence.

Unfortunately, children initially prescribed only lifestyle change after a DM2 diagnosis rarely succeed at sustained blood sugar improvement; lifestyle measures alone only effect meaningful change in hemoglobin A1C values in 10% of pediatric DM2 patients. As such, the American Academy of Pediatrics recommends that all children be started on metformin, in addition to lifestyle counseling, at the time of diagnosis. Pairing medication taking with daily family routines significantly increases medication adherence, as does multi-systemic therapy as outlined above. Encouraging parents to adopt a more permissive parenting style may be another technique to increase adherence to both lifestyle and medication recommendations; "[y]outh with T2DM who perceive more autonomy (less parental control) in day-to-day and diabetes tasks are more likely to adhere to medication regimens." 

Working collaboratively with families and other disciplines are strengths of our specialty and can greatly benefit our younger patients with DM2. You can read more about DM2 in the AFP By Topic on Diabetes: Type 2, which includes both further reading for physicians and patient resources.

Tuesday, November 6, 2018

For mild hypertension in low-risk adults, harms of drug therapy outweigh benefits

- Kenny Lin, MD, MPH

Prior to publication of the controversial 2017 ACC/AHA clinical practice guideline, stage 1 or "mild" hypertension was defined as a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg. Although guidelines have recommended that persons with mild hypertension receive anti-hypertensive drug therapy if lifestyle modification does not lower blood pressure below 140/90, a Cochrane review found that such therapy did not reduce cardiovascular disease (CVD) events, stroke, or mortality compared to placebo. A 2015 meta-analysis that included high-risk persons (patients with diabetes and/or who had received prior antihypertensive treatment) suggested that drug therapy for mild hypertension may prevent CVD events, but others have argued that this analysis mixed apples with oranges and did not establish benefits for adults at low CVD risk.

A retrospective cohort study recently published in JAMA Internal Medicine sought to clarify the benefits and harms of drug therapy in low-risk adults with mild hypertension using data from 40,000 patients in an electronic health records database in the United Kingdom. The authors compared the outcomes of persons aged 18 to 74 with mild hypertension who were prescribed anti-hypertensive medications within 12 months of diagnosis to those in similar untreated persons. Persons with a history of CVD, left ventricular hypertrophy, atrial fibrillation, diabetes, chronic kidney disease, or a family history of premature heart disease were excluded from the study.

After a median follow-up duration of 5.8 years, there were no differences between the groups in all-cause mortality, stroke, myocardial infarction, acute coronary syndrome, or heart failure. However, the treated group had an increased risk of hypotension (number needed to harm = 41 at 10 years), syncope (NNH = 35), electrolyte abnormalities (NNH = 111), and acute kidney injury (NNH = 91).

Although ideally the findings from this observational study should be confirmed in a randomized, controlled trial, it is unlikely that a trial will ever be performed due to the large number of participants that would be needed in order to provide enough statistical power to detect a difference in mortality or rare CVD events in this population. In the meantime, the best available evidence suggests that the harms of drug therapy outweigh benefits for low-risk adults with a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg (recently redefined by the ACC/AHA as stage 2 hypertension). In these patients, family physicians and other primary care clinicians should emphasize nonpharmacologic management strategies such as a diet with a high intake of vegetables, fruits, and whole grains; moderating excessive sodium intake and alcohol consumption; and at least 150 minutes per week of moderate-intensity aerobic physical activity.

Monday, October 29, 2018

Acute Flaccid Myelitis: what family physicians should know

- Jennifer Middleton, MD, MPH

Although still quite rare, occurrences of acute flaccid myelitis (AFM), a polio-like condition that results in sudden limb weakness, have been increasing in the United States (US). Most of the affected individuals are children, and a definitive cause is not yet known. Family physicians can aid the Centers for Disease Control and Prevention (CDC)'s investigation by recognizing AFM's presentation and reporting suspected cases to their local health departments.

AFM is not a new condition, but its prevalence in the United States has been increasing, with 386 confirmed cases across 34 states since August of 2014. AFM's prevalence has been higher in the summer months during this time, but cases have been reported year-round. Patients present with sudden loss of strength in one or more limbs, with associated loss of muscle tone and reflexes. Some patients may also have facial drooping or speech changes. Urinary retention has occasionally been noted, and, rarely, some patients even experience respiratory failure. MRI of the spine reveals a gray matter lesion, and cerebrospinal fluid (CSF) typically shows excess white blood cells.

Often, a viral syndrome precedes these neurologic symptoms, but CDC researchers have yet to identify a clear etiology, viral or otherwise. Testing of affected individuals for poliovirus has consistently been negative. The increase in AFM cases does coincide with increased enterovirus D68 activity in the US, but testing in AFM patients has been inconsistent re: accompanying enterovirus infection. With no clearly identified cause, the CDC advises general prevention strategies such as hand washing and mosquito bite avoidance. Treatment for AFM is supportive, with the involvement of neurologists, physical therapists, and occupational therapists.

Physicians should promptly report any patient who presents with sudden flaccid limb weakness, regardless of lab or imaging findings; gathering information from affected individuals will be critical to identifying AFM's etiology. Family physicians can report cases by contacting their local health department and completing this patient summary form, available on the CDC website. For patients with muscle weakness that don't fit the clinical picture of AFM, this AFP article on "Evaluation of the Patient with Muscle Weakness" may be helpful. Since West Nile virus can also cause AFM, this 2016 AFP article on "Emerging Vector-Borne Diseases" may also be of interest.

Monday, October 22, 2018

PSA screening: USPSTF recommendations changed, but the evidence did not

- Kenny Lin, MD, MPH

Comparing the 2018 U.S. Preventive Services Task Force (USPSTF) recommendation statement on prostate cancer screening in the October 15th issue of AFP with its previous recommendation, the first question family physicians ought to ask is: what new evidence compelled the USPSTF to move from recommending against PSA screening in all men to determining that there was a small net benefit for screening in some men? Did another major randomized trial show a reduction in all-cause or prostate cancer-specific mortality in men invited to screening? Did other systematic reviewers re-analyze the evidence and find a mortality benefit where none previously existed? Have urologists or radiation oncologists developed new treatments for localized prostate cancer that no longer cause erectile dysfunction, urinary incontinence, or infections?

No, no, and no.

One of the Top 20 Research Studies of 2017 for Primary Care Physicians, the only U.S. trial of PSA-based screening for prostate cancer, reported that after a median followup of 15 years, there were still no differences in mortality between the two groups. In 2018, a large U.K. randomized trial of a single PSA screening also reported no effect on prostate cancer mortality after a median followup of 10 years. In both trials, more prostate cancers were diagnosed in the groups assigned to routine screening, but treating these cancers did not lead to improved health outcomes.

Last month, the authors of a 2010 Cochrane review of PSA screening (previously summarized in AFP's Cochrane for Clinicians) published an updated meta-analysis in the BMJ that incorporated the U.K. trial findings and extended followup of the U.S. and European screening trials and concluded that "at best, screening for prostate cancer leads to a small reduction in disease-specific mortality over 10 years but does not affect overall mortality." They also estimated that "for every 1000 men screened, approximately 1, 3, and 25 more men would be hospitalized for sepsis, require pads for urinary incontinence, and report erectile dysfunction, respectively." Another U.K. trial comparing active surveillance for localized prostate cancer with immediate surgery or radiation therapy found higher rates of clinical progression in the active surveillance group, but no differences in health-related quality of life or mortality.

Representing the views of American Academy of Family Physicians (AAFP), Drs. James Stevermer and Kenneth Fink explained in an editorial why "the AAFP believes that the net benefit [of PSA screening] does not justify routine screening or routinely offering shared decision making." The AAFP took the unusual step of declining to endorse the USPSTF recommendation statement and instead writing its own clinical preventive services recommendation that emphasizes the harms of routine screening. Men who bring up the topic of PSA screening should engage in shared decision-making with their physicians about the benefits and harms of screening and express a clear preference to be screened before undergoing the test.

Monday, October 15, 2018

Influenza vaccine in pregnancy decreases hospitalizations

- Jennifer Middleton, MD, MPH

According to the Centers for Disease Control and Prevention (CDC), pregnant women with influenza infection are more likely to be hospitalized than non-pregnant women of the same age. It seems intuitive that influenza vaccination would help reduce these hospitalizations, but data demonstrating as such has only been published in the last week. A large multi-center retrospective study found that influenza vaccination reduces influenza-related hospitalizations among pregnant women by 40%.

Organizations from several countries, including the CDC, comprise the Pregnancy Influenza Vaccine Effectiveness Network (PREVENT), who conducted this retrospective study that reviewed over 19,000 hospitalization records from Australia, Canada, Israel, and the western United States (US). A significant limitation to the study is that, overall, only 6% of pregnant women admitted for flu-like illness had documented influenza virus testing; among these women, 13% with confirmed influenza had been vaccinated, compared with 22% with confirmed influenza who had not been vaccinated. The authors note that vaccine uptake was low across all studied countries, with the US having the highest vaccination rates at just 50%. (The authors' findings correlate with CDC data from the 2016-17 influenza season, when 53.6% of pregnant US women were vaccinated.)

Given the many documented benefits of influenza vaccine in pregnancy, we need to improve vaccination rates. Safety concerns, especially in pregnancy, continue to be a major barrier to vaccination. The CDC has a website devoted to allaying these safety concerns that cites multiple studies demonstrating the vaccine's safety and efficacy in pregnancy. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) both also strongly recommend influenza vaccination in pregnancy; ACOG has an online fact sheet for patients as does AAFP's familydoctor.org.

Studies also cite low rates of physician recommendation as a factor in suboptimal influenza vaccination rates in pregnant women, even though physician recommendation to vaccinate correlates with higher vaccination rates. Even though many family physicians do not provide direct obstetric care, we can still work with our pregnant patients to encourage influenza vaccination. FPM has a resource describing "How to Talk to Reluctant Patients About the Flu Shot," and the latest issue of AFP includes the CDC's Advisory Committee on Immunization Practices (ACIP) update for 2018-2019. There's also an AFP By Topic on Influenza with more references and patient handouts.

Monday, October 8, 2018

Rise in congenital syphilis highlights pregnancy screening gaps

- Kenny Lin, MD, MPH

Last month, the Centers for Disease Control and Prevention (CDC) announced that the number of reported cases of congenital syphilis in the U.S. rose from 362 in 2013 to 918 in 2017, paralleling increases in syphilis infections in reproductive-age women during this time period. From 2016 to 2017, congenital syphilis cases rose from 16 to 23 per 100,000 live births. Although two-thirds of affected infants have no symptoms at birth, congenital syphilis is associated with increased neonatal mortality and a variety of early (through 48 months of age) and late complications, detailed in a previous AFP article.

The first line of prevention against congenital syphilis is screening for syphilis in all pregnant women at the first prenatal visit, a well-established standard of care that the U.S. Preventive Services Task Force (USPSTF) recently reaffirmed. Although some cases occur in infants whose mothers receive no prenatal care, about one-third of women who delivered a baby with congenital syphilis in 2016 were screened during their pregnancies.

The CDC, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists all recommend repeat syphilis screening in women at high risk for syphilis at around 28 weeks of gestation and at time of delivery. Women at high risk include those living in higher-prevalence communities or geographic areas; those living with HIV infection; those with a history of incarceration or commercial sex work; and those exposed to a sexual partner with confirmed syphilis infection. Early penicillin treatment of infected pregnant women reduces the risk of congenital syphilis.

The USPSTF has also previously recommended screening nonpregnant adults and adolescents at increased risk for syphilis infection. Higher risk groups in nonpregnant adults are similar to those in pregnant women, but also include men who have sex with men (MSM), particularly men aged 20 to 29 years, whose prevalence of primary or secondary syphilis is nearly 3 times higher than that of the general U.S. male population. Finally, the USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults at increased risk for sexually transmitted infections.

Monday, October 1, 2018

Exercise for chronic back pain: tips for success

- Jennifer Middleton, MD, MPH

The article on "Mechanical Low Back Pain" in the current issue of AFP provides an overview of diagnosis and treatment for the 1 in 5 adults who suffer from low back pain. The article reminds us that NSAIDs alone work just as well as opioids, muscle relaxers, and/or oral corticosteroids. Non-pharmacologic pain relief is emphasized, with some evidence of benefit found with physical therapy, osteopathic manipulative treatment, and exercise. Patients want more than just exercise advice, though; they also want to have their experiences with both pain and exercise considered to develop personalized recommendations.

Patients want physicians to listen to their prior experiences with back pain and exercise, taking their perceived fitness ability into account when recommending exercise. They prefer plans that consider their exercise likes and dislikes. Patients also want an exercise plan that they feel they can be successful with, partially because they fear judgment from their physician if they don't improve. Validating patients' experiences with their pain, eliciting their exercise preferences, and having resources to discuss with patients may increase the likelihood of their success with a new exercise regimen.

Engaging regularly in exercise is challenging for many people, let alone someone with chronic low back pain. Simply counseling patients regarding physical activity is a critical first step, one that many patients don't ever recall hearing from their physician. Working with patients to create a tailored exercise prescription may help. Several fitness apps, as recently reviewed in FPM, also provide a wide range of motivational methods, from raising money for charity to running from simulated zombie chases.

AFP has additional resources you may find useful, including the AFP By Topic on Health Maintenance and Counseling along with patient education at familydoctor.org, where "sports and exercise at every age" is the site's current monthly focus.

Monday, September 24, 2018

Chronic insomnia: therapies to start, therapies to stop

- Kenny Lin, MD, MPH

Can't sleep? Then spend your extra awake time reading the latest installment of Implementing AHRQ Effective Care Reviews in the September 1 issue of AFP, on management of insomnia disorder in adults. This evidence review, which supported an American College of Physicians practice guideline, examined the effectiveness of behavioral therapies and medications for adults with insomnia disorder, defined as "poor sleep quality or quantity that causes distress or dysfunction and lasts for longer than three months."

The most beneficial sleep intervention overall is cognitive behavior therapy for insomnia (CBT-I), which produced sustained improvements for at least 6 months. CBT-I consists of cognitive therapy, sleep restriction and stimulus control, and sleep hygiene education. Medications that have sufficient evidence demonstrating improvement in short-term (3 months or less) sleep outcomes include eszopiclone, zolpidem, and suvorexant; there was insufficient data to evaluate benzodiazepines or over-the-counter sleep aids (diphenhydramine, doxylamine, or melatonin). For most patients, medications should not be prescribed for longer than five weeks.

Physicians commonly prescribe antipsychotics off-label to treat insomnia in older persons. The Practice Guidelines in the September 15 issue summarized a Canadian guideline for deprescribing antipsychotics for behavioral and psychological symptoms of dementia and insomnia, produced by the Deprescribing Guidelines in the Elderly Project. Due to the potential harms of these medications and the lack of evidence of benefits (a single randomized trial with 13 participants found nonsignificant differences in sleep latency in patients taking quetiapine), the guideline recommends that antipsychotics prescribed for primary or secondary insomnia in which comorbidities are under control be discontinued without tapering, regardless of treatment duration.

AFP's sister journal, FPM, recently published an article on deprescribing unnecessary medications that featured a four-step process (review current medications; identify inappropriate, unnecessary, or harmful medications; plan deprescribing with the patient; and regularly re-review medications) and links to additional resources on medication reconciliation and deprescribing. You can find more information on sleep disorders in adults in our AFP By Topic collection.

Monday, September 17, 2018

Cervical cancer screening in the age of HPV vaccination

- Jennifer Middleton, MD, MPH

A POEM (Patient-Oriented Evidence that Matters) in the current edition of AFP suggests the potential for change in cervical cancer screening practices; screening younger women only with human papillomavirus (HPV) testing, and not cytology, resulted in better identification of high grade pre-cancerous disease in individuals who have received the HPV vaccine.

This study from Australia enrolled nearly 5,000 women aged 25-64 presenting for cervical cancer screening to one of three groups: liquid-based cytology screening followed by HPV testing if abnormal, HPV screening followed by liquid-based cytology as indicated, or HPV screening followed by dual-stained cytology (staining for high-risk HPV markers) as indicated. At the time of the study, women 33 years old or younger had been eligible to receive the HPV vaccine when it was first available in Australia; in these women, both of the HPV screening groups had a higher rate of pre-cancerous disease detection than the cytology-based screening group.

The United States Preventive Services Task Force (USPSTF) currently recommends HPV screening every 5 years as an option only for women aged 30 and older along with screening every 3 years with cytology alone or screening every 5 years with cytology and HPV co-testing; they recommend discussing risks (HPV screening alone and HPV/cytology co-testing both have an increased rate of false positive screening results, while cytology alone may miss some true positives) of each method with individuals to personalize screening decisions. For women aged 21-29, the USPSTF only recommends cervical cancer screening with cytology alone every 3 years. The American College of Gynecology and Obstetrics does not allow for the option of HPV testing alone for women of any age, but otherwise their recommendations align with the USPSTF.

HPV vaccine acceptance and uptake has been quite high in Australia, with the study authors citing that 70-78% of women aged 12-17 years were fully vaccinated in 2013. In the United States, HPV vaccine uptake has been less successful; the Centers for Disease Control (CDC) estimates that half of US teens have not completed the HPV series (you can find specific data for your state using this interactive map). It's possible that this POEM's findings may not be generalizable to the US given this difference in vaccination rates, but studies have also supported the sole use of HPV screening in women who were beyond vaccination age when HPV vaccine was introduced in the US.

Regardless, HPV vaccination rates have plenty of room for improvement in the US. Barriers to increasing HPV vaccination in the US, as outlined in this 2016 AFP Community Blog post by Dr. Lin, include safety concerns and parental worry about the vaccine encouraging earlier initiation of sexual activity (it doesn't). Physicians, too, are sometimes reluctant to discuss or recommend the vaccine. Strategies to overcome these barriers include reviewing vaccinations at every visit (not just well visits) as recommended by the authors of this 2015 AFP editorial on "HPV Vaccination: Overcoming Parental and Physician Impediments." The CDC also advises physicians to recommend HPV vaccine "the same way, the same day as other vaccines." Identifying office workflow barriers, implementing previsit planning, and permitting walk-in vaccinations can help increase vaccine uptake as well. There's an AFP by Topic on Immunizations (excluding Influenza) with several other resources on discussing vaccine hesitancy and increasing vaccination rates if you'd like to read more.

Monday, September 10, 2018

Continue to Choose Wisely: updates to the AAFP Choosing Wisely recommendations

- Sarah Coles, MD and James Stevermer, MD

Providing high value, safe, and cost-effective care is the cornerstone of family medicine. However, there remains significant overutilization of low-value or even harmful care in the U.S. health care system. The American Academy of Family Physicians (AAFP) partnered with the Choosing Wisely Campaign to identify care that may be overused or misused and tackle this pressing issue. Founded in 2012 as an initiative of the American Board of Internal Medicine Foundation, the Choosing Wisely campaign collates lists of procedures and tests that add little or no value to medical care. The AAFP was one of the first organizations to participate, submitting 5 initial recommendations and a total of 15 recommendations by 2013.

Once again, the AAFP has added 5 new recommendations to the Choosing Wisely campaign. Developed by the AAFP's Commission on Health of the Public and Science, these evidence-based recommendations are based on sources such as the Cochrane Collaboration and the Agency for Healthcare Research and Quality systematic reviews. Each recommendation focuses on a practice that is either harmful or has very little supporting evidence of benefit.

Here are the new recommendations:

Don’t perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline-appropriate screening for cervical cancer.

Screening pelvic examinations, except for the purpose of performing cervical cancer screening at recommended intervals, have not led to reduction in mortality or morbidity. Additionally, they increase costs and expose asymptomatic women to unnecessary invasive testing.

Don’t routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes mellitus and are not using insulin.

Self-monitoring of blood glucose (SMBG) has no demonstrated benefit in patients with type 2 diabetes mellitus who are not on insulin or medications associated with hypoglycemia. SMBG should be reserved for patients during the titration of their medication doses or during periods of changes in patients’ diet and exercise routines.

Don’t screen for genital herpes simplex virus infection (HSV) in asymptomatic adults, including pregnant women.

Serologic testing for HSV infection has low specificity and a high false-positive rate. No confirmatory test is currently available and the serologic tests cannot determine the site of infection. Given the prevalence of the infection in the United States, the positive predictive value of the test is estimated at about 50%. A positive test can cause considerable anxiety and disruption of personal relationships.

Don’t screen for testicular cancer in asymptomatic adolescent and adult males.

There is no benefit to screening for testicular cancer due to the low incidence of disease and high cure rates of treatment, even in patients who have advanced disease. Potential harms include false-positive results, anxiety, and harms from diagnostic tests or procedures.

Don’t transfuse more than the minimum of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable patients).

Unnecessary transfusion exposes patients to potential adverse effects without any likelihood of benefit and generates additional costs.

Using tools like Choosing Wisely, family physicians can lead change and reduce unnecessary care in the US to cut costs, improve health outcomes, and limit harms. To help you put Choosing Wisely into practice, you can find the lists from the AAFP and over 80 other specialty organizations at choosingwisely.org and a search tool for primary care-relevant recommendations on the AFP website.

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Drs. Coles and Stevermer are members of the AAFP's Commission on Health of the Public and Science. Dr. Coles is also an AFP Contributing Editor and Assistant Editor, AFP Podcast.

Tuesday, September 4, 2018

Is aspirin effective primary prevention for CVD?

- Jennifer Middleton, MD, MPH

Two recent studies challenge the premise that adults at increased risk of cardiovascular disease (CVD) should take a daily aspirin. More specifically, the United States Preventive Services Task Force (USPSTF) currently recommends that adults aged 50-59 with a 10-year risk of CVD of at least 10% take a daily low-dose aspirin. One of the studies published earlier this week, however, found no benefit to daily aspirin use regarding primary prevention of CVD but did find an increased risk of gastrointestinal (GI) bleeding; the other study found that aspirin did decrease the risk of initial CVD events in its participants with diabetes but it also, again, increased the risk of GI bleeding.

The first study, the ARRIVE study, enrolled over 12,000 participants across several countries (most participants came from the United Kingdom, Germany, and Poland) deemed to be at "moderate" risk of CVD based on a lengthy list of criteria that resulted in a mean ASCVD risk score for participants of approximately 17%. Participants were randomized into either the aspirin (100 mg of enteric-coated aspirin a day) group or the placebo group and were followed for an average of 5 years. The researchers' primary outcome was a composite of first occurrence of cardiovascular death, myocardial infarction, unstable angina, stroke, or transient ischemic attack. There was no difference in the rate of these events between the aspirin and the placebo groups (hazard ratio 0.96; 95% confidence interval [0.81-1.13]), but the aspirin group had a higher rate of GI bleeding events (hazard ratio 2.11; 95% confidence interval [1.36-3.28]).

Interestingly, though the mean ASCVD risk score for enrolled participants was 17.3-17.4%, the rate of CVD events that actually occurred among participants was much lower; only 4.29-4.48% of participants had a CVD event during this study. The researchers attribute this difference to good management of non-acute CVD symptoms and note this trial was intentionally "pragmatic" in this regard, though they do also concede that "risk calculators developed with older data might overestimate risk in current practice." Concerns about the ASCVD risk score's propensity to inflate CVD risk are not new and have even been acknowledged within the cardiology community. Unfortunately, as the USPSTF notes in their statement, "although concerns have been raised about the equations’ potential to overpredict risk and their moderate discrimination, they are the only U.S.-based, externally validated equations that report risk as a combination of cerebrovascular and CHD events."

The second study, the ASCEND study, enrolled over 15,000 participants across the United Kingdom with diabetes but without known CVD and randomized them into daily aspirin (100 mg of aspirin a day) or placebo groups. Participants were followed for an average of 7.4 years. Unlike the ARRIVE study, the ASCEND researchers found that CVD events were decreased in the aspirin group (relative risk 0.88; 95% confidence interval [0.79-0.97]), but, similar to ARRIVE, GI events were increased in the aspirin group (relative risk 1.29; 95% confidence interval [1.09-1.52]). The researchers concluded that "[t]he absolute benefits were largely counterbalanced by the bleeding hazard." Additionally, "91 patients would need to be treated to avoid a serious vascular event over a period of 7.4 years, and 112 to cause a major bleeding event."

Both of these studies looked at relatively high risk populations for CVD and had a large number of participants. The ARRIVE study's participants did not have diabetes, while the ASCEND study's participants did. Both groups of researchers, however, came to the same conclusion: the risks of taking daily aspirin for primary prevention of CVD outweigh any possible benefit.

Dr. Lin and I have both previously written about aspirin as primary prevention on the blog, and you can count on AFP to continue bringing you the latest evidence to inform your practice. Will these new studies change your recommendations about aspirin for primary prevention of CVD?

Monday, August 27, 2018

Fracture prevention in older adults: what does the evidence say?

- Kenny Lin, MD, MPH

Hip fractures are a significant preventable cause of morbidity and mortality in older adults. Strategies to reduce hip fracture rates include preventing falls, screening for osteoporosis and prescribing bisphosphonate drugs to increase low bone density, and vitamin D supplementation. Recent studies and guidelines have clarified some of the evidence surrounding hip fracture prevention.

In a Putting Prevention Into Practice case study in the August 15 issue of American Family Physician, Drs. Tina Fan and Elizabeth Erickson discussed two updated U.S. Preventive Services Task Force (USPSTF) recommendations on interventions to prevent falls and supplements for primary prevention of fractures. Although the USPSTF continues to recommend exercise interventions to prevent falls in community-dwelling adults 65 years or older at increased risk of falls, it no longer recommends vitamin D supplements to prevent falls, due to evidence of no benefit and potential harms (increased falls and kidney stones). The Task Force found insufficient evidence to assess the balance of benefits and harms of vitamin D and calcium supplements at daily doses greater than 400 IU of vitamin D and 1,000 mg of calcium (lower doses are not effective) in postmenopausal women without a history of osteoporosis, which may come as a surprise, given how many are taking such supplements.

The USPSTF also recently reaffirmed its previous recommendation to screen for osteoporosis with bone measurement testing in women 65 years and older. Earlier this year, The Lancet published the first randomized controlled trial of osteoporosis screening with fracture outcomes. Although screening did not affect the primary outcome of all osteoporosis-related fractures over 5 years (HR 0.94, 95% CI 0.85-1.03), it reduced the incidence of hip fractures (HR 0.72, 95% CI 0.59-0.89). More controversial was the Task Force's recommendation to screen postmenopausal women younger than 65 years at increased risk for osteoporosis. In a JAMA editorial, Dr. Margaret Gourlay (a family physician and former AFP editor), argued that the 2-step screening strategy advised by the USPSTF - clinical risk assessment tool followed by bone density testing if indicated - may not produce a net benefit to patients. Although screening women younger than age 65 has potential benefits, it is unclear if these benefits outweigh the opportunity costs:

If complicated risk tools perform no better than age alone to identify screening candidates, women younger than 65 years may be subjected to inefficient screening procedures. … The clinician could spend half of a 15-minute clinical visit accessing a risk tool and asking the patient about unfamiliar risk factors (eg, secondary causes of osteoporosis) to make 1 decision out of the dozen or more compressed into an annual physical examination. … Given the myriad responsibilities of primary care practices caring for patients with high-acuity conditions, implementation of screening programs that are needlessly complex is burdensome and distracts from high-value medical care.

Finally, for patients with osteoporosis who are eligible for treatment, given concerns about long-term adverse effects of bisphosphonates, including rare osteonecrosis of the jaw, for how long should these drugs be prescribed? A FPIN Help Desk Answer found low-quality evidence that for most women, bisphosphonate therapy beyond 5 years does not further reduce clinical vertebral fractures, nonvertebral fractures, or mortality. However, women with persistent femoral neck T-scores lower than -2.5 may benefit from longer treatment durations.

Monday, August 20, 2018

Are mental health apps helpful?

- Jennifer Middleton, MD, MPH

A wide variety of mental health apps are currently available. Two recent studies describe the appeal of these apps yet also advise caution with their use, as some of them may reinforce harmful messages and/or are not based on evidence-based practice. Helping our patients identify reputable apps is becoming an important element of mental health management.

The first study, from the current issue of the Annals of Family Medicine, evaluated the content of 61 mental health apps. The researchers found that many of these apps framed mental health problems as "exist[ing] for everybody" and claimed "their product could help quickly and easy." 49% of the apps provided disclaimers, "thus, app consumers were assigned responsibility not only for using an app, but also for knowing whether it was appropriate for them." Visual images in the apps were predominantly of white individuals, and comments in many apps suggested that app users were expected to be employed and/or have families, which the authors criticized as being non-inclusive. While 61% of apps included claims that their methods were scientifically-based, none cited studies or evidence to support these claims. Although the researchers identified a few reasonably reputable apps, they advise physicians to ask patients with mental health diagnoses about app use and review the above limitations with them.

The second study from June of this year aimed to formally analyze apps which claimed to be following cognitive behavioral therapy (CBT) tenets. They reviewed 31 apps which advertised CBT for depressive symptoms and found that, while user ratings of these apps tended to be quite high, only some of their features were based on CBT. 12 apps only provided 1 feature consistent with CBT; another 9 apps only included 2. They found that CBT features tended to be limited to mood tracking, recording thoughts, and dealing with negative thoughts, and they expressed concern that other CBT elements, such as addressing core beliefs, were absent. "Even though all of their descriptions mentioned CBT, only half of all features provided by apps reflected core competencies of CBT." The authors also analyzed the rating comments of these apps and found that many users appreciated their relative affordability compared to traditional therapy. Some raters describing themselves as therapists stated that they appreciated the use of these apps as adjuncts to their meetings with patients.

Many patients like using apps; many physicians and counselors like being able to recommend useful tools to patients. The challenge for patients and physicians alike is to identify apps that incorporate the best evidence-based practice into their design. Thankfully, FPM has its regular feature "SPPACES: Medical App Reviews" to help guide our decisions. (SPPACES = Source or developer, Platforms available, Pertinence to primary care, Authoritativeness/accuracy, Cost, Ease of use, and Sponsor.) Earlier this year, a SPPACES article identified "Five Mobile Apps to Help Patients with Anxiety and Depression." All five of these apps were developed by reputable experts, and a couple of them were even mentioned in the above studies as being exemplars of evidence-based practice (MoodTools and What's Up-Mental Health App).

Discussing app use with patients and guiding patients to reputable apps is, of course, only one part of good mental health care. You can read more in the AFP By Topic on Depression and Bipolar Disorder and in the AFP By Topic on Anxiety Disorders.

Tuesday, August 14, 2018

Overdiagnosis in lung cancer screening: don't tell, don't ask?

- Kenny Lin, MD, MPH

Although the U.S. Preventive Services Task Force recommended in 2013 that current and recent smokers 55 to 80 years of age with at least a 30 pack-year history receive annual low-dose CT screening for lung cancer, family physicians have been slow to implement this recommendation in their practices. Concerns about this screening test include the quality of the supporting evidence (which the American Academy of Family Physicians judged to be insufficient) and potential harms, including overdiagnosis and overtreatment of tumors that, left undetected, would never have caused symptoms during a patient's lifetime. An analysis of the National Lung Cancer Screening Trial (NLST) suggested that one in five lung cancers were overdiagnosed. In recognition of the balance of benefits and harms of lung cancer screening, the Centers for Medicare & Medicaid Services requires that eligible patients first have a "counseling and shared decision making visit" with a clinician that utilizes a patient decision aid prior to undergoing a scan.

A previous study of screening for other cancer types found that clinicians mentioned overdiagnosis as a potential harm less than 10 percent of the time. Are lung cancer screening discussions any different? In a study published this week in JAMA Internal Medicine, researchers evaluated shared decision making (SDM) using the validated Observing Patient Involvement in Decision Making (OPTION) scale in a sample of transcribed physician-patient conversations. Relative to the mean total visit length (just over 13 minutes), physicians spent a mean of 59 seconds discussing lung cancer screening. None of the conversations mentioned decision aids, and the mean total OPTION score was 6 out of 100 (where 0 indicates no evidence of SDM and 100 indicates SDM at the highest skill level), reflecting that physicians rarely informed patients about harms of low-dose CT scans or asked patients how they valued these harms.

This lack of attention to harms of lung cancer screening is concerning because the magnitude of overdiagnosis may be considerably higher than previous estimates. Researchers recently analyzed data from the Danish Lung Cancer Screening Trial, in which participants underwent 5 annual low-dose CT screenings (compared to 3 in the NLST) and concluded that two-thirds of lung cancers were likely overdiagnosed. In an accompanying commentary that compared the methods used to estimate overdiagnosis, AFP Deputy Editor Mark Ebell, MD, MS and I stressed the importance of communicating with patients about this "often underappreciated harm of screening":

Patients can make informed choices about low-dose CT only if practitioners fully disclose all the potential harms of screening, including the risk of overdiagnosis. It will be important to researchers to continue to refine estimates of lung cancer overdiagnosis, allowing physicians to provide more accurate information to our patients.

To best serve patients, primary care physicians and pulmonologists must do better than 59-second conversations about lung cancer screening that only mention potential benefits. We need to take the time to tell patients about harms such as overdiagnosis, and ask them how they value these harms relative to the benefits, before ordering the scan.

Monday, August 6, 2018

Overcoming rhinitis adherence challenges

- Jennifer Middleton, MD, MPH

The current issue of AFP includes an overview of "Chronic Nonallergic Rhinitis" (the newer term for "vasomotor rhinitis"). The article includes tips to distinguish allergic from nonallergic rhinitis along with treatment regimens. Many of the medications that are useful for allergic rhinitis are also useful for nonallergic rhinitis, including intranasal corticosteroids, intranasal antihistamines, oral decongestants - with the addition of intranasal ipratropium for nonallergic symptoms. Unfortunately, patient adherence to these intranasal medications tends to be low.

For many patients, rhinitis symptoms are inconsistent and episodic, waxing and waning with seasonal changes and exposure to triggers. While not taking intranasal medications when symptoms and triggers are absent may be reasonable, taking them only when symptoms are severe (and not more moderate) can result in decreased efficacy, increased physician visits, and increased healthcare costs. Many intranasal medications for rhinitis also have unpleasant tastes and smells that can affect adherence. Cost is another factor; some of these medications are not available in generic versions and can be expensive. Interestingly, personality type and gender may also correlate with intranasal medication adherence; in one study, men with higher "neuroticism" scores were less adherent to allergy medications, while men with higher "agreeableness" or "conscientiousness" scores were more adherent. Among women in this same study, however, personality traits did not correlate with adherence.

Knowing when patients are not using their intranasal medications is important to accurately assess treatment efficacy as well as the risk of worsening co-morbid conditions like asthma. The Allergic Rhinitis Treatment Satisfaction and Preference (ARTSP) scale provides information about a patient's preferences regarding intranasal treatment, which can guide physician and patient decision-making regarding specific medications. Prescribing an intranasal medication with characteristics that patients prefer (odor, taste, comfort, delivery device, cost) may increase adherence. Other solutions for increasing adherence include problem-solving solutions to identified barriers with patients and using text messaging to send patients daily reminders to use their intranasal medications.

You can read more about rhinitis treatment by using this AFP keyword search. There's also an AFP By Topic on Allergy and Anaphylaxis, which includes this reference on "Diagnosing Rhinitis: Allergic vs. Nonallergic" and an Allergic Rhinitis Treatment Guideline from 2015.

Tuesday, July 31, 2018

Help your patients achieve food security with SEARCH

- Kenny Lin, MD, MPH

As screening for social determinants of health in clinical settings "moves from the margins to the mainstream," research has focused on how to efficiently identify and address social needs in practice. An article in the May/June issue of FPM by Drs. David O'Gurek and Carla Henke provided a suite of practical approaches, including tools, workflow, and coding and payment considerations. Dr. Sebastian Tong and colleagues reported the experiences of primary care clinicians screening for social needs in 12 northern Virginia practices in the Journal of the American Board of Family Medicine. Knowledge of a social need changed care delivery in 23% of patients and improved communication in 53%, but clinicians often felt ill-equipped to help patients with identified needs or connect them to appropriate services.

Help is on the way. The American Academy of Family Physicians (AAFP) recently launched an interactive online tool, the Neighborhood Navigator, to make it easier for family physicians to connect patients with community organizations and social services. This tool complements other resources in the AAFP's EveryONE Project to support patients' health outside of the office that Dr. Jennifer Middleton discussed in a previous Community Blog post.

In the August 1 issue of American Family Physician, Dr. Shivajirao Prakash Patil and colleagues review the problem of food insecurity, defined as "limited availability of nutritionally adequate and safe food or the inability to acquire these foods in socially acceptable ways," which affected an estimated 12% of American households in 2016. According to the authors, food insecurity (FI) has a cyclical relationship with chronic disease, constraining dietary options in ways that increase the risk for development and progression of diseases in children and adults. They recommend that family medicine practices follow the SEARCH mnemonic and utilize food security resources and food assistance programs in appropriate patients:

S (Screen) - "An affirmative response to either of the following statements can identify FI with 97% sensitivity and 83% specificity: (1) Within the past 12 months we worried whether our food would run out before we got money to buy more, and (2) Within the past 12 months the food we bought just didn't last, and we didn't have money to get more."

E (Educate) - "Educate patients at risk of FI about appropriate coping strategies. Although some individuals with limited resources manage without major disruptions to food intake, many eat less or eat less healthy foods to get by."

A (Adjust) - "Adjust the patient's medication if it should be taken with food. Prescribe medications that minimize the likelihood of hypoglycemia for patients with FI who have diabetes."

R (Recognize) - "Recognize that FI is typically recurrent but is usually not chronic."

C (Connect) - "Connect patients with assistance programs and encourage patients with FI to use food banks."

H (Help) - "Help other health care professionals recognize that poor health and FI often exacerbate one another."

Family physicians can also choose to advocate to improve the quality and quantity of food resource programs available in their communities and across the nation.

Monday, July 23, 2018

Top Infectious Disease POEMS of 2017

- Jennifer Middleton, MD, MPH

The current issue of AFP includes the "Top POEMS of 2017 Consistent with the Choosing Wisely Guidelines," an annual round-up of practice-changing studies for family physicians from the last year. 14 POEMs are described in detail (along with 7 more in eTable A). 3 of these practice changers deal with common outpatient infections: oral corticosteroids don't help acute wheezing in adults without asthma, tympanostomy tubes don't improve hearing outcomes in children with recurrent acute otitis media (AOM) or chronic otitis media with effusion (OME), and adding trimethoprim/sulfamethoxale (TMP/SMX) to cephalexin doesn't improve outcomes for adolescents and adults with uncomplicated cellulitis.

The authors of the first study discuss the desirability of avoiding antibiotics for viral lower respiratory tract infections (LRTI), and having an alternative to offer patients may help decrease unnecessary antibiotic prescriptions. Unfortunately, 5 days of prednisolone did not improve the duration or severity of cough or wheezing compared to placebo in this multi-center, randomized controlled trial (RCT) of 401 adults without asthma in the United Kingdom. For now, conservative measures such as rest, fluids, honey (in children over 1 year of age), and antitussives (only in patients older than 6 years) will have to suffice for patients with LRTI as reviewed in this 2010 AFP article on "Diagnosis and Treatment of Acute Bronchitis."

A meta-analysis of 18 RCTs found no difference in hearing after tympanostomy tube placement in children with either recurrent AOM or chronic OME after 12-24 months with age-matched controls. Nearly 7% of US children have had tympanostomy tubes placed, making it the most common ambulatory surgery performed on children in the US at a mean cost of $769 per surgery. That's a lot of parental concern, patient discomfort, and expense for a procedure that's not improving outcomes. This AFP Clinical Evidence Handbook article reminds us that, without antibiotics, AOM symptoms resolve in 80% of children within 3 days. Searching AFP by the keyword "otitis" yields several other useful review articles.

An RCT of 496 patients aged 12 years and older across 5 US emergency departments found no difference in clinical cure rates between patients with uncomplicated cellulitis treated only with cephalexin and patients treated with both cephalexin and TMP/SMX. Dr. Lin discussed this study last year on the blog, reminding us that reducing unnecessary antibiotic prescriptions is an important step to reducing antibiotic resistance. (Patients with a skin abscess requiring incision and drainage, however, may benefit from either oral clindamycin or TMP/SMX.)

Changing established practice habits can be challenging; tools such as office QI projects and pre-visit planning may help, along with using motivational interviewing when patients request inappropriate treatments and using electronic health system reminders. This 2016 AFP editorial reviews "How to Prescribe Fewer Unnecessary Antibiotics: Talking Points that Work With Patients and Their Families." I've added that editorial and the Top POEMS of 2017 article to my AFP Favorites page for quick future reference.

Tuesday, July 17, 2018

Best practices for preventing gun violence in the clinic and the community

- Kenny Lin, MD, MPH

Family physicians have long recognized that gun violence is a national public health epidemic. In 2015, a coalition of nine medical, public health, and legal organizations, including the American Academy of Family Physicians and the American Bar Association, endorsed several specific recommendations for preventing firearm-related injury and death. These measures included universal criminal background checks for all firearm purchases; educating patients about gun safety and intervening in those at risk of self-harm or harm to others; improving access to mental health care; regulating civilian use of firearms with large capacity magazines; and supporting more research on evidence-based policies to prevent gun violence. A 2014 editorial in AFP also reviewed the role of primary care clinicians in counseling about gun safety based on the best available evidence.

After the February massacre of 17 people at Marjory Stoneman Douglas High School in Parkland, Florida by a 19 year-old former student wielding a legally purchased semiautomatic AR-15-style rifle, the medical editors of AFP felt that we needed to do more to empower clinicians. Surely, when the Founding Fathers endorsed the necessity of a "well-regulated Militia" in the Second Amendment to the U.S. Constitution, they did not envision mentally disturbed teenagers toting weapons with enough firepower to overwhelm entire regiments of Minutemen.

In a special editorial recently published online ahead of print, Dr. Sexton and the AFP medical editors argue that family medicine's emphasis on care of the whole person creates a duty to "confront the epidemic of violence by persons using guns." We review the evidence of the effects of firearm regulations, mental health counseling, and active shooter training on gun safety and violence. Unfortunately, evidence for many interventions remains limited:

A 2018 RAND review of U.S. studies on gun policy published since 2003 concluded that child-access prevention laws (e.g., safe gun storage) reduce self-inflicted and unintentional firearm deaths and nonfatal injuries among youth, and may reduce unintentional firearm injuries among adults. The review also found moderate evidence that laws requiring background checks and prohibiting firearm purchases by individuals with mental illness reduce violent crime and deaths. In contrast, state stand-your-ground laws are associated with increased homicide rates. There was insufficient evidence to determine whether any laws prevent mass shootings. 

Notably, almost two-thirds of the 36,000 firearm-related deaths in the U.S. each year are suicides, leading to our recommendation that "strategies to mitigate firearm suicides should include depression screening and nonjudgmentally asking anyone with depression whether they have a gun in the home." Useful clinical tools include the FIGHTS screening tool for adolescent firearm carrying, the SAD PERSONS suicide risk assessment scale, and the Violence Screening and Assessment of Needs tool for assessing risk of violence in military veterans.

Finally, we encourage family physicians to address the epidemic by making their voices heard in community meetings, online forums, and local publications and communicating with elected state and federal officials to advocate for funding research to study ways to reduce gun violence: "Whether it is speaking up in clinical settings, within our community, or with our elected officials, our voices can make a meaningful difference for our patients, our communities, and our nation."

Monday, July 9, 2018

Minimizing adverse effects from antibiotics: short duration + narrow spectrum

- Jennifer Middleton, MD, MPH

Adverse effects are not uncommon with antibiotics, and two recent POEMs (Patient Oriented Evidence that Matters) in AFP review strategies to minimize them. The first POEM found that shorter courses of antibiotics are equivalent to longer courses for several common outpatient infections. The 2nd POEM found that, for outpatient respiratory tract infections in children, narrow-spectrum antibiotics have a lower risk of adverse effects compared to broad-spectrum antibiotics with equivalent treatment efficacy.

The first POEM is a systematic overview of 9 systematic reviews comparing antibiotic treatment durations for urinary tract infection (UTI), acute pyelonephritis, sinusitis, and community-acquired pneumonia (CAP) in adults, and strep pharyngitis, CAP, UTI, and acute otitis media (AOM) in children. They found that:

AOM (children): 7 or less days =  more than 7 days
CAP (children): 3 days = 5 days
CAP (adults): 7 or less days = more than 7 days
Strep pharyngitis (children): 5-7 days = 10 days
Sinusitis (adults): 3-7 days = 6-10 days
UTI (children): 2-4 days =  7-14 days
UTI (non-pregnant, premenopausal women): 3 days = 5 or more days
UTI (older women): 3-6 days = 7-14 days
The authors found a reduced risk of adverse events for patients treated with shorter durations for AOM, sinusitis, and younger women with UTI; they found no difference among patients with pharyngitis, pyelonephritis, or older women with UTI. Adverse event data was not available for patients treated for CAP or children with UTI.

The 2nd POEM included both a large retrospective cohort arm (over 30,000 children) that reviewed outcomes of children with sinusitis, AOM, or strep pharyngitis diagnoses and a prospective cohort arm (almost 2500 children) examining the same conditions. The findings of the retrospective arm and the prospective arm concurred: broad-spectrum antibiotics (amoxicillin/clavulantate, cephalosporins, macrolides) offered no treatment benefit over narrow-spectrum antibiotics (penicillin, amoxicillin) but did increase the rate of reported adverse effects. The retrospective cohort only reported adverse event rates as documented in the medical record, but the prospective cohort included data gathering of adverse events from parents. The prospective cohort had a much higher rate (10.3 times higher) of adverse effects reported by parents, suggesting that many patients and/or their parents are not reporting these events to physicians.

It's possible that some of the patients who received antibiotics in these studies did not need them at all, thus explaining the lack of benefit in longer antibiotic treatment durations; for example, most cases of acute bacterial sinusitis will resolve without antibiotics (consider offering an intranasal corticosteroid instead), and deferring antibiotics for AOM in children over the age of 2 years with non-severe symptoms is a Choosing Wisely recommendation. Determining which patient needs an antibiotic is not always clear, either; Centor scoring can assist with pharyngitis, but, as Dr. Lin reviewed last week on the blog, procalcitonin levels may not distinguish CAP from lower respiratory tract infections that don't improve with antibiotics (such as bronchitis).

Limiting antibiotic overuse benefits patients and communitiesAFP's Choosing Wisely tool facilitates quick review of these recommendations, and there are also AFP By Topics on Pneumonia, Respiratory Tract Infections, and Urinary Tract Infections/Dysuria that include resources on diagnosis and treatment. 

Tuesday, July 3, 2018

Does procalcitonin make it easier to choose antibiotics wisely for respiratory infections?

- Kenny Lin, MD, MPH

American Family Physician has supported the Choosing Wisely campaign in several ways since it began in 2012, from maintaining a searchable database of primary care-relevant recommendations, to including tables of best practices in clinical review articles, to publishing an occasional editorial containing suggestions of how to implement it into practice. Although Choosing Wisely remains very much a work in progress, staff at the American Board of Internal Medicine Foundation recently identified a "Top 12" list of recommendations that are successfully reducing overuse in health systems across the United States. Leading the list is appropriate use of antibiotics for patients with upper respiratory tract infections, a topic that has been previously reviewed in this journal.

A more challenging task for family physicians may be deciding which patients with lower respiratory tract infections need antibiotics - distinguishing acute bronchitis from chronic obstructive pulmonary disease exacerbations or community-acquired pneumonia. Although clinical decision tools exist, their usefulness in outpatient settings is limited. A Cochrane for Clinicians in the July 1 issue reviewed the benefits and harms of procalcitonin-guided antibiotic therapy compared with routine care for acute respiratory infections on mortality, treatment failure, duration of antibiotic exposure, and antibiotic-related adverse effects. In a meta-analysis of 26 randomized, controlled trials (n = 6708), patients receiving procalcitonin-guided therapy had lower 30-day all-cause mortality (NNT=71) across all settings, but no difference in primary care settings. Rates of treatment failure were similar. Total duration of antibiotic exposure was 2.4 days lower in the procalcitonin group, corresponding to a lower percentage of patients in the procalcitonin group experiencing antibiotic-related adverse effects (16.3% vs. 22.1% in the control group).

Should this evidence lead clinicians to adopt procalcitonin-guided therapy algorithms to improve antibiotic stewardship for acute respiratory infections? Limitations of the Cochrane review are worth noting: the studies were relatively small (mean 258 participants); most were in Europe rather than in the U.S.; and most were in emergency department rather than primary care settings. After the review's publication, Dr. D.T. Huang and colleagues reported the results of a large (n=1656) RCT in 14 U.S. hospitals that compared procalcitonin-guided antibiotic therapy with usual care for patients with lower respiratory tract infections in the emergency department and on the inpatient service, if applicable (782 patients were subsequently hospitalized). In contrast to the Cochrane review, the investigators found no significant differences between the groups in duration of antibiotic exposure or adverse outcomes. They concluded that the addition of procalcitonin results did not significantly improve antibiotic decision-making or patient outcomes.

A take-home message from the Cochrane review and the recent U.S. trial is that the effects of procalcitonin measurement on diagnosis and management of acute respiratory infections depend on the clinical setting, patient characteristics, and preexisting adherence of clinicians to high-value care guidelines for antibiotic prescribing. This test may be helpful in certain cases, but probably should not be used routinely.