The top ten AFP Community Blog posts of 2018

- Kenny Lin, MD, MPH

This year's list includes (#1 and #2) two of the top five most-viewed posts since this blog began in 2010. (In case you are wondering, the best-read post of all, on acetaminophen for nasal congestion from the common cold, has been viewed nearly 10,000 times.)

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1. PSA screening: USPSTF recommendations changed, but the evidence did not (October 22) - 3061 views

The first question family physicians ought to ask is: what new evidence compelled the Task Force to move from recommending against PSA screening in all men to determining that there was a small net benefit for screening in some men?

2. Acute Flaccid Myelitis: what family physicians should know (October 29) - 3018 views

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. Family physicians can aid the CDC's investigation by recognizing AFM's presentation and reporting suspected cases to their local health departments.

3. Guest Post: Practicing what I preach about generic drugs (May 30) - 1152 views

I am a cancer survivor. I am alive today because of the love and support of my family, friends, and co-workers. I am alive because of the incredible doctors and medical staff at Walter Reed. I am also alive because of generic drugs. Generic drugs saved my life.

4. For hypertension and diabetes, lower treatment targets not necessarily better (March 21) - 891 views

Primary care clinicians 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.

5. Continue to Choose Wisely: updates to the AAFP Choosing Wisely recommendations (September 10) - 806 views

Developed by the AAFP's Commission on Health of the Public and Science, each of these evidence-based recommendations focuses on a practice that is either harmful or has very little supporting evidence of benefit.

6. For mild hypertension in low-risk adults, harms of drug therapy outweigh benefits (November 6) - 712 views

After a median follow-up duration of 5.8 years, there were no differences 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).

7. Summer travel tips for you and your patients (June 18) - 667 views

Readers of American Family Physician should know about all of the resources available in our archives for prevention and management of medical conditions in travelers, the best of which are included in our Travel Medicine collection.

8. Supporting our patients' health outside of the office (May 7) - 661 views

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.

9. Increasing pneumococcal vaccination rates (April 9) - 649 views

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.

10. Top research studies of 2017 for primary care practice (April 30) - 589 views

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.

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On behalf of all of us at AFP, happy holidays and many blessings for the New Year.

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.

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.