Monday, July 15, 2019

Updates in CVD diagnosis, treatment, and prevention

- Jennifer Middleton, MD, MPH

Updates on diagnosis, treatment, and prevention of cardiovascular disease (CVD) abounded in the medical literature over the last month. While these studies' findings were largely non-significant or limited, they still provide clarity regarding current best practices while paving the way for future research.

First, the search for a clinical decision rule to stratify patients presenting to primary care with chest pain regarding risk of acute coronary syndrome (ACS) will have to continue, as the results of a "flash mob" study, published this month in the Annals of Family Medicine, failed to validate the Marburg Heart Score for use in primary care. The investigators recruited nearly 20% of the family physicians in the Netherlands to gather data on patients with suspected ACS during a 2 week time period. The family physicians sent information back to the investigators using a brief case report form, filed either electronically or on paper. Although the study results were disappointing, the feasibility of this novel research method was more promising. Perhaps we'll see more "flash mob" studies in the near future.

In an AFP Medicine By the Numbers summary out today, a Cochrane review of early reperfusion therapy in patients with STEMI received a "no benefits" rating by the thennt.com. The meta-analysis examined data from 8 randomized controlled trials including a total of over 8900 participants, all with chest pain at rest and either EKG changes consistent with STEMI (ST-segment myocardial infarction), NSTEMI (non-ST-segment myocardial infarction), or a previously established diagnosis of coronary artery disease. Participants were randomized to either receive reperfusion immediately or to receive medical therapy first with reperfusion only if symptoms persisted. There was no mortality benefit to early reperfusion, and participants who underwent early reperfusion were also more likely to have a periprocedural myocardial infarction (MI) or a major bleeding event. The risk of these adverse events was deemed to outweigh the found benefits of increased relief from refractory chest pain, decreased repeat hospitalization, and decreased risk of a susbsequent MI in the next year with early reperfusion.

Finally, an umbrella review (a systematic review of prior meta-analyses) sought to identify the best current evidence regarding diet changes and supplements on improving CVD outcomes. These investigators found moderate quality evidence to support reduced salt intake (lower all-cause mortality in individuals without hypertension, and lower cardiovascular mortality in individuals with hypertension). Lower quality evidence correlated omega-3-fatty-acid intake with lower risks for MI and CAD. Folic acid intake correlated with lower stroke risk, though the authors caution that this finding was largely driven by a study based in China, where fewer foods are fortified with folate than in the United States. Interestingly, calcium and vitamin D intake correlated with a higher stroke risk. "Other nutritional supplements, such as vitamin B6, vitamin A, multivitamins, antioxidants, and iron and dietary inter- ventions, such as reduced fat intake, had no significant effect on mortality or cardiovascular disease outcomes (very low– to moderate-certainty evidence)." Given the relative low quality of many studies, the authors' call for further, more rigorous research is understandable.


Studies finding a lack of benefit (the Marburg score "flash mob" and the early reperfusion meta-analysis) are still useful to help family physicians avoid harm and to spur the search for better alternatives. Hopefully, more rigorous research will come to verify the findings of the nutrition and supplement umbrella review. We'll look forward to reporting on these hoped-for follow-up studies; in the meantime, what research would you like see to regarding CVD in primary care?

Tuesday, July 9, 2019

Drugs for patients with chronic heart failure: making evidence-based choices

- Kenny Lin, MD, MPH

Two regular features in the July 1 issue of AFP addressed medication management for patients with chronic heart failure.

In Cochrane for Clinicians, Dr. Pamela Obi discussed a 2018 Cochrane review that evaluated whether therapies that improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF) also help patients with heart failure with preserved ejection fraction (HFpEF). The review included 37 randomized controlled trials (RCTs) with more than 18,000 patients; outcomes assessed included cardiovascular mortality, heart failure hospitalization, all-cause mortality, and quality of life. Beneficial drug classes included mineralocorticoid receptor antagonists (reduce hospitalizations, NNT=42) and beta blockers (reduce cardiovascular mortality, NNT=26). Curiously, although the review found no benefits from angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), the American College of Cardiology recommends considering ARB treatment to reduce hospitalizations in persons with HFpEF.

In FPIN's Help Desk Answers, Drs. Scott Christensen and Rebecca Davis investigated whether the combination of an ACE inhibitor and an ARB improves cardiovascular or overall mortality in patients with symptomatic HFrEF or HFpEF. A 2012 meta-analysis of 7 RCTs (n=8,260) comparing dual therapy vs. monotherapy found that dual therapy was associated with fewer myocardial infarctions and heart failure hospitalizations, but no changes in mortality. Dual therapy was also associated with a greater risk of patients withdrawing from trials due to adverse drug effects (RR=1.34). A small 2008 RCT found that patients with heart failure who received irbesartan in addition to an ACE inhibitor had improvements in disease-oriented outcomes (6-minute walk test distance, metabolic equivalents achieved) and quality of life, but no difference in a composite outcome of mortality and cardiovascular hospitalizations. Overall, the benefits of dual therapy seem to be outweighed by the harms.

Clinicians seeking additional information on diagnosis and management of acute and chronic heart failure should also check out our AFP By Topic collection.

Monday, July 1, 2019

Helping our patients reduce unhealthy alcohol use

- Jennifer Middleton, MD, MPH

The June 15 issue of AFP includes several excellent resources to aid family physicians in efficiently and effectively responding to unhealthy alcohol use. With an estimated 88,000 deaths every year in the United States related to alcohol, screening and intervening can be lifesaving and are recommended by the United States Preventive Services Task Force (USPSTF) (B recommendation).

This AFP USPSTF update article reviews the definition of unhealthy alcohol use:

The USPSTF uses the term unhealthy alcohol use to define a spectrum of behaviors, from risky drinking to alcohol use disorder (e.g., harmful alcohol use, abuse, dependence). Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts, resulting in increased risk for health consequences but not meeting criteria for alcohol use disorder.

The article discusses optimal screening instruments, all of which are very brief, such as the AUDIT-C and the SASQ. The perhaps better known CAGE is less useful because it can miss risky alcohol use that doesn't meet criteria for alcohol dependence disorder. A positive screen should prompt follow-up with a more in-depth instrument such as AUDIT. The meta-analysis that informed the USPSTF recommendation statement, however, noted that in "population groups with lower prevalence of unhealthy alcohol use—older adults, pregnant women, and adolescents—the estimated positive predictive value [of AUDIT] was much lower." For older adults, consider using CARET, and, for pregnant women, consider using TWEAK or T-ACE. Although the USPSTF deemed the evidence insufficient for making a recommendation regarding screening adolescents (I recommendation), CRAFFT is one tool available for family physicians wishing to screen this group.

The USPSTF found that a median of 30 minutes of brief intervention was effective in reducing unhealthy alcohol use. Screening, Brief Intervention, and Referral to Treatment [SBIRT] was commonly employed in these studies as was motivational interviewing, simple education regarding alcohol consumption recommendations, and several cognitive behavioral strategies. 6-12 months following these interventions, the previously mentioned meta-analysis found a mean decrease of 1.6 drinks per week; in binge drinkers (heavy episodic use), total drinks per week decreased from a mean of 26.0 to a mean of 19.1. Trials in pregnant women, which tended to use abstinence as an outcome, found pooled odds ratio [OR] for abstinence after intervention, compared to no intervention, of 2.26 (95% CI, 1.43 to 3.56)

After reading the AFP USPSTF update article, you can test your knowledge by reviewing these case studies and accompanying answers. The Substance Abuse and Mental Health Services Administration's (SAMHSA) SBIRT website includes a lengthy list of online resources covering different patient care settings with a variety of methods (articles, videos, patient education, and even a free online training course). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has both in-depth and pocket guides titled "Helping Patients Who Drink Too Much" available online. This FPM article, referenced in an accompanying AFP editorial, reviews alcohol screening and brief intervention strategies, includes an excellent 4-minute video example of a brief intervention, and also reviews billing and coding for these services.

Monday, June 24, 2019

Guest Post: Transcend helplessness, advocate for transgender patients

- Hayley E. Cummingham, MD and Tonia Poteat, PA-C, PhD

Do you remember that feeling as a medical student, back against a wall as you watched life and death unfold? You may have felt disappointed when that sense of helplessness did not disappear with a medical degree. It is easy to feel helpless when your patients fear being “defined out of existence.” In October 2018, the New York Times uncovered a memo from the U.S. Department of Health and Human Services (HHS) that proposed redefining “sex” as written in numerous anti-discrimination laws to be “based on immutable biological traits identifiable by or before birth.” This represented a dramatic policy reversal from 2016, when HHS passed a regulation clarifying that discrimination on the basis of sex encompasses gender identity.

Emboldened by the current administration’s perceived animosity toward the transgender community, conservative state representatives and organizations sued the HHS in 2016, rendering it unable to enforce protections against gender identity discrimination as the executive branch reviewed the regulation. The outcome was a proposed rule issued last month, which includes a narrowed definition of “sex” that will allow health care providers and insurers to refuse to provide or cover medically necessary and potentially life-saving care.

According to a 2015 survey, 40% of transgender adults have attempted suicide and 82% have seriously considered it. Rates of suicidal ideation and attempts among transgender adolescents reach 51% and 30%, respectively. A growing body of evidence indicates that access to gender affirming therapies, including but not limited to exogenous hormones and surgery, can reduce the risk for suicide among transgender people.

It is easy to feel helpless in the face of injustice, but physicians have the power to influence social and political determinants of health. For example, having entered a 60-day period for public comment on the proposed HHS regulation, physicians and others can voice their opposition at https://protecttranshealth.org. Physicians can attend advocacy events wearing white coats, meet with elected representatives, or publish opinion pieces. Consider keeping a de-identified record of patient stories and reach out to an advocacy organization for guidance on using them to advocate for those patients. Physician educators, testing boards, and residency programs can train future physicians on the health care needs of gender-diverse individuals.

Within your own practice, ensure that you are not part of the problem, and empower yourself to provide gender-affirming care. One third of transgender persons have had at least one negative experience with a clinician in the past year related to being transgender, including verbal harassment (6%), treatment denial (8-11%), invasive or unnecessary questioning (15%), or clinician ignorance requiring education by the patient (24%). Reading the December 2018 AFP article, Caring for Transgender and Gender-Diverse People: What Clinicians Should Know, is an excellent place to start. In addition to the steps outlined in the article, you can offer to write “carry letters,” which explain that a patient is undergoing gender transition and that appropriate pronouns and facilities are medically necessary. These documents advocate for patients in situations involving bathrooms, airport security, police interactions, employers, residential placement, etc. You can dive deeper by familiarizing yourself with national and global guidelines and utilize online resources offered by the Fenway Institute. Before making referrals, contact providers to assess their level of comfort caring for transgender patients or use a gender-affirming provider directory.

Every day that we care for patients, we put ourselves at risk for feeling helpless. When our patients face increasing social and political injustice, we cannot be wallflowers. For the well-being of our patients and ourselves, we must advocate.

Friday, June 14, 2019

Behind the scenes of the AAFP guideline on depression after acute coronary syndrome

- Kenny Lin, MD, MPH

The June 15 issue of AFP features the original publication of an updated guideline from the American Academy of Family Physicians (AAFP) on screening and treatment of patients with depression following acute coronary syndrome. This is the first product of a new partnership between the best-read journal in primary care and the AAFP's Clinical Practice Guidelines development team. As a past Chair (2015-2017) of the AAFP's Subcommittee on Clinical Practice Guidelines (SCPG) of its Commission on Health of the Public and Science (CHPS), I know how much time and effort goes into creating evidence-based guidelines for family physicians. A series of four short videos on the AAFP website provides a general overview of the clinical practice guideline development and assessment process, which is documented in detail in its Clinical Practice Guideline Manual.

For this specific topic, a panel of 4 family physicians, an internist, a patient representative, and a PhD clinical policies strategist with no relevant conflicts of interest updated a 2009 AAFP guideline on detection and management of post-myocardial infarction depression. This topic was deemed still relevant to family medicine and nominated by the AAFP in 2016 to the Agency for Healthcare Research and Quality (AHRQ)'s Effective Health Care Program for an updated systematic evidence report. The independent systematic review team solicited input from subject experts and panel members to develop a structured research protocol that focused on answering two key questions:

1. What is the accuracy of depression screening instruments or screening strategies compared to a validated criterion standard for post-acute coronary syndrome (ACS) patients?

2. What are the comparative safety and effectiveness of pharmacologic and nonpharmacologic depression treatments in post-ACS patients?


The completed evidence report, posted on AHRQ's website and published in condensed form in the Annals of Internal Medicine in November 2017, served as the basis for the panel's recommendations. The panel rated the evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which differs somewhat from AFP's Strength of Recommendation Taxonomy. GRADE provides a framework to assess the certainty of the evidence and develop structured statements based on that evidence and the values/considerations that influenced the recommendation.

The draft post-ACS depression guideline was internally peer reviewed by members of the SCPG and the AAFP's Science Advisory Panel, followed by external reviews by cardiology experts, mental health professionals, and representatives of other relevant organizations. After changes were made in response to peer review comments, the revised guideline was reviewed by the full SCPG and CHPS, then forwarded to the AAFP's Board of Directors for approval. The guideline makes two major recommendations:

1. The American Academy of Family Physicians recommends that clinicians screen for depression, using a standardized depression screening tool, in patients who have recently experienced an acute coronary syndrome event (weak recommendation, low-quality evidence). Individuals should undergo further assessment to confirm the diagnosis of depression (good practice point).

2. The American Academy of Family Physicians strongly recommends that clinicians prescribe antidepressant medication, preferably selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, and/or cognitive behavior therapy to improve symptoms of depression in patients who have a history of acute coronary syndrome and have been diagnosed with depression (strong recommendation, moderate-quality evidence).

Notably, although treating depression after ACS improves depression symptoms, there remains insufficient evidence that depression treatments reduce cardiovascular or overall mortality. A Practice Guidelines synopsis in the June 15 issue also discusses barriers to implementing the guideline in practice such as lack of time, reimbursement, and institutional support for routine depression screening; and limited access to behavioral health services. Implementation resources available in the guideline itself include Tables comparing depression screening tools and medications and advice about use of practice champions.

Saturday, June 8, 2019

Has aspirin for primary prevention of CVD reached its expiration date?

- Kenny Lin, MD, MPH

A daily low-dose (81 mg) aspirin was once considered an essential component of cardiovascular disease (CVD) prevention for middle-aged and older adults. In 2006, the National Commission on Prevention Priorities ranked "discussing aspirin use in high-risk adults" the highest priority preventive service based on clinically preventable burden and cost effectiveness, and two years ago, in an updated set of rankings, it still rated aspirin use as the fifth highest priority for improving utilization. However, in 2018 the results of three large randomized trials suggested that the harms of aspirin taken to prevent a first CVD event outweigh its benefits for most persons. In an editorial in the June 1 issue of AFP, Dr. Jennifer Middleton and I reviewed the latest evidence and concluded:

The new data do not exclude the possibility that aspirin may still benefit adults at very high CVD risk (e.g., 20% or more over 10 years) or those at lower risk who are unable to tolerate statins, but the data otherwise suggest that the risks of low-dose aspirin therapy for primary prevention outweigh any potential benefits. For most patients, we should be deprescribing aspirin for primary prevention of CVD. To prevent heart attacks and strokes, family physicians should focus instead on smoking cessation and lifestyle changes, controlling high blood pressure, and prescribing statins when indicated.

In a 2019 clinical practice guideline, the American College of Cardiology / American Heart Association largely concurred, recommending against prescribing aspirin for primary prevention of CVD in adults older than age 70 and downgrading its role in other adults at high risk to "may be considered" on a case-by-case basis.

Although aspirin is still strongly recommended to prevent recurrent CVD events, its rise and fall in primary prevention seems to have become another case of medicine reversing itself. Unlike other notable examples of medical reversal such as menopausal hormone therapy and tight glucose control in type 2 diabetes, the effectiveness of aspirin was supported by many well-conducted randomized, controlled trials. Aspirin worked ... until it didn't. In a recent commentary in the Journal of General Internal Medicine, Palmer Greene and colleagues suggested that it may be a good idea to consider established evidence-based practices as having an "expiration date":

An “evidentiary statute of limitations” would require the occasional reassessment of accepted therapies to consider which might no longer be of use—possibly because of changes in the population as a whole, a changing understanding of whom the treatment is appropriate for, or evolving therapies for the prevention or treatment of the disease in question. Not only should we consider if older data still applies, we should also strive to anticipate the factors to which the results of a newly published positive study might be sensitive. For instance, is there an event rate in the control group below which the harms of the therapy might outweigh the benefit? Is there a treatment success rate that, when achieved, would make screening inefficient?

Not starting aspirin is relatively straightforward, but patients who have taken aspirin for many years without adverse effects or CVD events may resist discontinuing it. What approaches have you taken to this complex discussion?

Sunday, June 2, 2019

Making the most of screen time: recommendations for families

- Jennifer Middleton, MD, MPH

With the academic year wrapping up, planning for the summer months is a reality for many American families. While planning for vacations and other away activities is often paramount, considering in advance how to spend days at home can be equally valuable. Setting expectations and limits on screen time at the beginning of the summer break can set families up for success in encouraging physical activity and good sleep habits.

The American Academy of Pediatrics (AAP) recommends no screen time for children younger than ages 18-24 months and limiting screen time to one hour of “high-quality programming” for children aged 2-5 years. For older children, the AAP advises setting limits that are consistent with “your family’s values and parenting style.” Engaging in media use with children and teens is preferred to unsupervised use, and families are discouraged from placing televisions, computers, and video game consoles in children’s bedrooms. Parents and guardians can use a Family Media Plan tool to develop personalized screen time expectations.

Last summer, the American Heart Association (AHA) also weighed in on screen time recommendations, publishing a scientific statement in Circulation describing concerns with increased sedentary behavior, obesity, and future health risks linked to excessive screen time. The authors cited data showing that adolescents who exceed two hours of screen time daily are 1.8 times more likely to be obese (odds ratio 1.82 [95% confidence interval 1.06-3.15]); this study also found that “screen time is a stronger factor than physical activity in predicting weight status in both children and adolescents.” The AHA has similar recommendations as the AAP regarding screen time use: set time limits, keep screens out of bedrooms, and engage in media together as a family.

You can find more recommendations from the AAP, including specifics about social media safety for teens, at this website. A wealth of parent and patient education materials is available at healthychildren.org’s Media page, including advice about when to give children their first smartphone, identifying age-appropriate media, and combating cyberbullying. The American Academy of Family Physicians' Familydoctor.org website also offers a helpful patient education handout on healthy habits for TV, video games, and the Internet.

Thursday, May 23, 2019

Counseling families about water safety

- Jennifer Middleton, MD, MPH

Memorial Day weekend traditionally marks the opening of outdoor pools across the United States, and balmier temperatures mean that recreational boating, swimming, and other water activities will begin to increase. With nearly 4,000 drowning deaths in the U.S. annually, now is the time of year to counsel families regarding safety in and around natural or man-made bodies of water.

A 2016 AFP article on “Prevention and Treatment of Drowning” reminded readers that “[d]rowning is rarely caused by a single factor” and “prevention strategies should not be pursued in isolation.” The American Academy of Pediatrics (AAP) recently updated its policy statement on prevention of drowning, noting that the highest death rates occur in children 12 to 36 months of age, followed by adolescents age 15 to 19 years, with alcohol consumption being a leading risk factor. The AAP has created an online Drowning Prevention Toolkit that features resources for physicians and child safety advocates, including public service announcements, infographics, information for parents, and sample social media posts with the hashtag #DrowningPrevention.

The American Red Cross encourages swimming lessons and avoidance of alcohol around pools and bodies of water for persons of all ages. They further recommend fences around home pools and to “actively supervise kids whenever around the water.” There’s even a “Swim” IPhone app by the American Red Cross (also available on Google Play) that can track progress through swim lessons and includes educational games for children that reinforce water safety tips.

The Centers for Disease Control and Prevention (CDC) reminds swimmers to check for pool safety and cleanliness before getting in by ensuring that drain covers are intact and clear of debris, along with ensuring that no cleaning chemicals or supplies are accessible. If no lifeguard is present, swimmers should familiarize themselves with the location of first aid and rescue equipment.  The CDC also discourages urinating or defecating in a pool; all swimmers should take a break once an hour, which is perfect for checking younger children’s diapers and encouraging older children to take a restroom break. You can find patient education handouts on water safety on the AFP website and the American Red Cross website.

Monday, May 20, 2019

Reducing medication cost burden in primary care: challenges and opportunities

- Kenny Lin, MD, MPH

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) finalized a new rule requiring that pharmaceutical companies disclose drug list prices in direct-to-consumer television advertisements for drugs that cost more than $35 for a month's supply or usual course. A fact sheet further explaining the rule noted that "the 10 most commonly advertised drugs have list prices ranging from $488 to $16,938 per month or usual course of therapy." Although pricing transparency could push patients to select more affordable or non-pharmacologic alternatives, and help clinicians improve high-value prescribing, it unfortunately does not make these drugs any less expensive.

In an editorial in the April 1 issue of AFP, Dr. Randi Sokol discussed four strategies for helping patients with type 2 diabetes mellitus afford insulin while providing evidence-based care: 1) Relax A1c goals to 8% or less; 2) Switch to human insulins instead of insulin analogues; 3) use Health Resources and Services Administration-certified 340B pharmacies and patient assistance programs; and 4) join advocacy efforts to reduce the high cost of insulin and other drugs, such as the Lown Institute's Right Care Alliance and the American Medical Association's Truth in Rx.

Family physicians can take a systematic approach to reducing prescription costs for all of their patients. In an article published in FPM, Dr. Kevin Fiscella and colleagues described the approach taken by 7 primary care practices in New York, Georgia, and California. Office staff screen patients for prescription cost concerns by privately asking them, "Is the cost of any of your medications a burden for you?" For patients who answer yes, clinicians briefly explore the circumstances (e.g., unmet deductible, use of brand name drugs) and employ several cost-reducing strategies, including deprescribing unnecessary medications, using extended (90-day) prescriptions, and substituting lower-cost medications or referring patients to large chain pharmacy discount programs (e.g. "$4 lists").

In a preliminary study published in a supplement to the Annals of Internal Medicine, Dr. Fiscella's team found that a single 60-minute training for clinicians and staff on cost-of-medication importance, team-based screening, and cost-saving strategies increased the frequency of cost-of-medication conversations from 17% to 32%. Other helpful articles in the same supplement supported by the Robert Wood Johnson Foundation included "The 7 Habits of Highly Effective Cost-of-Care Conversations" and "Tools to Help Overcome Barriers to Cost-of-Care Conversations." The American College of Physicians offers several additional cost-of-care conversation resources on its website.

Monday, May 13, 2019

Should physicians de-prescribe statins in older adults?

- Michael J. Arnold, MD

I work hard to de-prescribe unnecessary medications in my older patients, but I have never known what to do with statins. Are they preventing cardiovascular events or just causing trouble? Published studies included limited numbers of participants aged 75 years and older, so it has been difficult to know what to recommend.

A recent meta-analysis in The Lancet divided the subjects of 28 statin randomized trials by age groups, and identified over 14,000 who were over 75 years old. The analysis found that older adults benefit from statins for prevention of recurrent cardiovascular events (secondary prevention), but did not see a benefit for primary prevention. In the 6,000 older patients without a prior cardiovascular event, those taking statins weren't any less likely to have an event within 5 years than those taking placebos.

Unfortunately, the results aren’t definitive for primary prevention in older adults. Patients had less than a 3% risk of a cardiovascular event in the 5 years, leading to fewer than 100 events in each group - numbers too small to make firm conclusions. However, the low event rate should reassure primary prevention patients who wish to stop statins that any potential benefit is small. In addition, a large retrospective cohort study found that adults 75 years or older without vascular disease or diabetes did not benefit from statins. An ongoing primary prevention trial involving 18,000 adults over 70 years old will hopefully settle this question.

Even statins for secondary prevention in adults over 75 years old are not as valuable as in younger patients. The number needed to treat (NNT) is 125 to prevent a recurrent vascular event in 5 years, higher than the NNT for any other age group.

Another issue relevant to the decision to deprescribe a statin is the legacy effect. There is evidence of a significant benefit from having taken statins in the past, even in patients who have stopped taking them. Numerous studies have shown long-term benefit from taking statins during trials lasting only a few years. Another meta-analysis suggested that the legacy effect could be stronger for primary prevention.

Outside of the cardiovascular benefit, there isn’t much other evidence of statin benefits for older adults. The Lancet meta-analysis saw no difference in cancer incidence with statins. A Cochrane review showed that statins have no benefit for decreasing incidence of dementia.

Yet the argument for stopping statins is not strong either. Trials show that statins don’t have many adverse effects. They aren’t more likely to be associated with myalgia, rhabdomyolysis, hemorrhagic stroke or liver enzyme elevations than placebo. They do seem to increase the risk of developing diabetes at higher doses.

Deprescribing decisions will still require individualized shared decision making. An older adult without vascular events can likely stop a statin with minimal effect on risk, while a patient with a prior event will still benefit from continuing the statin, provided that he or she isn't experiencing adverse effects. You can find more in-depth information about statin use in this 2017 article on hyperlipidemia and the Practice Guidelines in the May 1 issue of AFP.

**

Dr. Arnold is AFP's 2019-20 Jay Siwek Medical Editing Fellow. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, nor the U.S. Government.

Sunday, May 5, 2019

Team doctor or Grandma's doctor?

- Barry D. Weiss, MD

The Association of American Medical Colleges reports that there are only 39 family medicine geriatrics fellowships in the U.S. The combined total of family medicine and internal medicine allopathic and osteopathic physicians graduating from U.S. residency programs who entered geriatrics fellowships in 2019 was only 84, with more than 80% of fellowship positions remaining unfilled.

At the same time, there were 180 primary care sports medicine fellowships, the majority of which (140) are offered by family medicine programs. More than 90% of these programs filled in the 2019 Match, with 188 allopathic and osteopathic U.S. residency graduates entering these fellowships.

What’s wrong with this picture?

In the 2010 U.S. Census, 13% of the population (one of every eight people) was 65 years of age or older. This year, the number is closer to 17% (one of every six). By 2050, just 30 years from now – well within the working careers of current family medicine residents – close to a quarter of the population will be 65 or older. Moreover, these older adults are big users of the medical system. The number of physician office visits/100 persons by older adults is more than double the rate in any other age group.

Based on these statistics, it’s not likely that our current residency graduates will be devoting their careers to being team doctors or focusing on sports medicine. Rather, it is inevitable that they, and indeed all practicing generalist physicians, will spend a substantial portion of their practice time caring for older adults.

Why, then, is there so little interest in geriatrics in family medicine training programs? Pretty much all our current trainees are going to do in their future practices is take care of aging baby boomers. Why isn’t geriatrics front and center in our training programs?

Furthermore, it’s not only students and residents who lack interest in geriatrics. One of my professional roles is serving as medical editor of AAFP’s FP Essentials monographs. When we issued a call for authors for an upcoming monograph on a musculoskeletal/sports medicine topic, we received proposals from 18 teams of family medicine authors interested in writing the monograph. In contrast, a call for authors for a geriatrics monograph brought in only a handful of proposals.

Key reasons for a lack of interest in geriatrics have been identified – among them are a preference for treating less complex patients who have curable conditions, and the relatively low compensation for geriatric care. But, we also know that providing exposure to and education about care of older adults can increase physicians’ interest in geriatrics. Geriatrics rotations should expose trainees to a broad range of older adult populations, from institutionalized adults to vigorous, physically active seniors.

Working with students, residents, colleagues, and our communities, we all have a responsibility to increase awareness of the special issues involved in providing high-quality care for older adults, and to highlight the rewards and satisfaction gained from providing that care. Family physicians can be the leaders in geriatric care. All we need to do is: do it.

**

Dr. Weiss is an AFP Associate Medical Editor and Editor of FP Essentials.

Sunday, April 28, 2019

Hypertension management: can lifestyle interventions replace ARBs?

- Kenny Lin, MD, MPH

Since July 2018, the U.S. Food and Drug Administration (FDA) has issued more than 20 recalls of the angiotensin-receptor blockers (ARBs) valsartan, irbesartan, and losartan because they contained potentially carcinogenic contaminants. As a result, there are now widespread shortages of these anti-hypertensive drugs. Although the FDA's internal analyses and published studies suggest that the excess cancer risk is small even with long-term use, and the FDA has posted a list of currently available ARBs that have been tested and found safe, identifying substitutes may be difficult. Many patients prescribed ARBs may already take other first-line anti-hypertensive drugs at maximum doses and/or be unable to tolerate angiotensin-converting enzyme (ACE) inhibitors due to cough.

One underutilized alternative is motivating patients with high blood pressure to make therapeutic lifestyle changes. In a Lown Right Care article in the March 15 issue of AFP, Drs. Ann Lindsay, Ajay Sharma, and Alan Glaseroff observed that "physicians ... often go straight to telling patients what to do without listening to what the patient thinks or is willing to do." Evidence suggests that patients are more likely adhere to treatment plans if physicians first get to know the patient's story and health goals, and that five key clinician behaviors are associated with better health outcomes: "(1) emphasizing patient ownership—work on patient goals; (2) partnering with patients on what they are willing and able to do; (3) identifying small steps to ensure success; (4) scheduling frequent follow-up visits to cheer successes or problem solve; and (5) showing care and concern for the patient."

A recent commentary in the Annals of Internal Medicine noted that the 2017 ACC/AHA hypertension guideline barely mentioned the value of lifestyle interventions for persons with hypertension or the barriers to providing them in primary care settings:

Practices that are not structured and staffed to systematically assess patient lifestyle factors, support behavior modification counseling, and provide follow-up will face obstacles to implementation. Clinicians in these practices also must be supported by relevant competencies; professional guidelines; routine feedback; and on-site training in practice change, such as academic detailing and practice facilitation. ... Ensuring that clinicians knowledgeable in behavior change theory and evidence-based lifestyle interventions are part of the primary care team is even more important.


Clinicians and patients may question if exercise programs have the same blood pressure-lowering benefits as medications. Although no randomized, controlled trials have directly compared exercise against medication, a systematic review and network meta-analysis of 391 trials found that in persons with hypertension, endurance or dynamic resistance exercise was equally effective for lowering systolic blood pressure as ACE inhibitors, ARBs, beta-blockers, and diuretics.

Monday, April 22, 2019

Preventing lawn mower injuries with simple safety steps

- Jennifer Middleton, MD, MPH

Although lawn mowers don't seem to get a lot of press, over 80,000 persons in the United States are injured by them every year; children under the age of 19 make up a substantial minority of these injuries (estimates range from 4,000 to 13,000 children per year). Most injuries are lacerations or burns, but some lead to serious skin infections, and some are severe enough to require limb amputation. Lawn mower injuries are largely preventable with some simple safety measures. With spring weather upon us in the U.S., it's worth discussing lawn mower safety with patients, especially parents of young children and teens.

Young children (ages 1-3 years) and adolescents are the most likely youth to be injured by a lawn mower; young children are more likely to be accidentally struck when a lawn mower is put into reverse or hit by objects discharged into the air by a lawn mower in use, such as sticks, stones, or toys; teenagers are less likely to follow standard safety measures when operating a lawn mower themselves. The American Academy of Orthopedic Surgeons advises parents to forbid children from playing on a lawn as it is being mowed; they also discourage children from riding on riding lawn mowers with adults. The American Academy of Pediatrics recommends that children be at least 12 years of age before independently operating a push lawn mower and 16 years of age before using a riding lawn mower. Checking and clearing the lawn of debris prior to mowing, ensuring that children are playing elsewhere while mowing, and wearing closed-toed shoes, hearing protection, and eye protection are crucial safety actions for all operators of lawn mowers.

Adults sustain the largest numbers of injuries, however, and need to follow appropriate safety measures for themselves as well. The American Society for the Surgery of the Hand advises keeping blades in good condition and avoiding alcohol prior to or during mowing. They also discourage putting hands or feet into the mower to clear debris, lifting the mower from the bottom, and tampering with safety devices and guards. The mower's engine should be turned off, and the blades should stop moving, before crossing a gravel path, removing the grass catcher, or walking away from the mower.

With these simple safety steps, mowing the lawn can be an enjoyable and healthy activity. Pushing a lawn mower is beneficial aerobic exercise, which qualifies as an activity requiring at least 4 METs of functional capacity. Certainly many homeowners enjoy the calm rhythm of lawn mowing, too. You can find more safety tips for spring and summer activities in this 2018 post by Dr. Lin and a previous AFP article on prevention of unintended childhood injury.

Monday, April 15, 2019

Migraine prevention - what's changed?

- Michael J. Arnold, MD

Since getting a migraine headache every Friday during junior high school, I have always been interested in preventing migraines. In medical school, I realized that it was likely the nitrates in the hot dogs served on Fridays at the school cafeteria that were to blame – perhaps with a boost from adolescent hormones.

Powerful Placebo Effect

A recent study on migraine prevention in children opened my eyes to the power of the placebo effect. A 2017 National Institutes of Health-sponsored trial comparing topiramate (the only FDA approved drug for migraine prophylaxis in children) and amitriptyline was stopped early because placebo was more effective than either active drug. Although both medications were effective, placebo was even better, producing a 50% reduction in headache frequency in 61% of children assigned to that arm of the study.

In adult studies, the placebo effect is nearly as strong. Between 20 and 50% of patients achieve a 50% reduction in headache frequency with placebo, and few medications do much better. While a portion of this is likely due to the waxing course of migraine, the placebo response rate tends to be over 20% even for patients with more than 15 migraines per month. The best medications, including topiramate, valproate, and some beta blockers, help 25% more people than placebo halve their migraine frequency, leading to a Number Needed to Treat (NNT) of four. Amitriptyline works 9% better than placebo, with a NNT of 12.

Complementary Therapy

If matching placebo gives at least a 25% response rate, could it be worth trying a safe herbal medication with some evidence of being better? Herbal medications such as feverfew, 6.25 mg three times daily, riboflavin 400 mg daily and magnesium 600 mg daily have limited evidence of being better than placebo with only mild side effects. Another small trial suggested that nightly melatonin was better at reducing migraines than amitriptyline and placebo, with the only common side effect being fatigue. Acupuncture has a NNT of 10 for halving the number of migraines when compared to sham acupuncture, but only 4 when compared to usual care.

A complementary therapy to avoid is butterbur (petasites), which has the best evidence for benefit but can be hepatotoxic. Without FDA regulation of the supplement industry, use is not recommended in the United States.

New Injections for Migraine Prevention

You may have heard of erenumab, a monthly injected medication for migraine prevention comprised of antibodies focused on the calcium gene related peptide system. Erenumab is joined by similar medications fremanezumab and galcanezumab, all of which are priced at $575 per monthly injection, compared to the $150 retail price for 60 tabs of topiramate at 50 mg. These injections have evidence of benefit over placebo with NNTs of either 5 or 6 to reduce headache frequency by 50%.

The American Headache Association recommends trying at least two other medication classes before prescribing these injections, but most studies of these drugs specifically excluded patients who had failed multiple previous medications. A single trial did study erenumab in patients who had failed two medications, and the 50% headache frequency reduction was met in 14% with placebo and 30% with erenumab, leading to a NNT of 7.

Short term side effects were rare and minor (injection site reactions and constipation). However, none of these trials followed patients for longer than three months. These medicines may be valuable for selected patients, but much is yet to be proven. An article in the January 1, 2019 issue of AFP covers migraine prophylaxis in more depth.

**

Dr. Arnold is AFP's 2019-20 Jay Siwek Medical Editing Fellow. The views expressed in this blog post are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, or the U.S. Government.

Monday, April 8, 2019

Reimagining advance care planning for patients with serious illness

- Kenny Lin, MD, MPH

It is difficult to overstate the damage done by the fictional political term "death panel," which claimed that a 2009 legislative proposal to pay physicians for providing counseling to Medicare patients about advance directives and end-of-life care options amounted to a group of federal bureaucrats deciding whether an older or disabled person would be permitted to live or die. Not until 2016 did the Centers for Medicare & Medicaid Services (CMS) create Current Procedural Terminology (CPT) codes that allowed billing for advance care planning services, and clinicians have been slow to use them. According to a recent study in JAMA Internal Medicine, only about 2% of Medicare fee-for-service beneficiaries age 65 years or older had advance care planning visits. As expected, geriatricians and palliative medicine specialists were more likely to use the codes than other physicians. Even so, two-thirds of hospice and palliative medicine specialists did not use the codes at all in 2017, which suggested that billing did not reflect actual counseling practices.

Other articles have documented the challenges of incorporating patients' values and preferences into care plans when they are already experiencing serious illness. An analysis of recorded clinician-family conferences about critically ill patients found that in more than half, "there was no deliberation about how to apply patients' values and preferences in the current clinical situation," and in 1 out of every 4 discussions, the patient's values and preferences were not even mentioned. Similarly, a medical oncologist reflected in Health Affairs about the care team's failure to manage expectations of a patient with advanced (and ultimately fatal) lung cancer who, "because she was looking for rescue," declined to discuss goals of care as an outpatient even as treatments proved ineffective and her health deteriorated:

I'm not sure how well we managed Wendy's care at the end of her life. On the one hand, she achieved her short-term goal of attending the family gathering. On the other hand, she spent nearly the entire last month of her life hospitalized. She died in an intensive care unit, intubated, on a ventilator, and unable to say goodbye to love ones. She was not enrolled in hospice. We don't know whether we met Wendy's goals of care because we never managed to define them.

Two editorials in the March 1 issue of AFP addressed how family physicians can prepare patients better for end-of-life decisions by "thinking about [advance care planning] as an iterative and integrative process," rather than as a document to be filled out and then filed away. Primary care teams can use the Serious Illness Conversation Guide to assess patients' understanding of their illness, explore what matters most to them, and communicate goals of care to family members and subspecialists. Lack of training and time constraints remain barriers, however. Innovative residency curricula on advance care planning, such as this medical-legal partnership described in Family Medicine, may improve physicians' comfort level with these conversations. Having Medicare and private insurers pay for advance care planning discussions is a helpful first step, but as Drs. Joanna Paladino and Erik Fromme observed, "clinicians cannot improve the care of people with serious illness alone—to be successful, they need health system changes that support better conversations over the continuum of care."

Monday, April 1, 2019

Introducing Dr. Mike Arnold, the first Jay Siwek Medical Editing Fellow

- Jennifer Middleton, MD, MPH

It's my pleasure to introduce the first Jay Siwek Medical Editing Fellow at AFP, Dr. Mike Arnold, whose fellowship year began on March 1. Here are some highlights from a recent interview I had the privilege to conduct with Dr. Arnold:

Tell us a little about yourself and your background.

I’m a bit of a late-comer to medicine. The Navy paid for my college in exchange for weekly marching and four years of service after graduation. They sent me to submarines, and I stayed for eight years. My medical training was through Uniformed Services University (USU), the only medical school where students are paid a salary to attend. In my opinion, NYU’s tuition-free plan is only starting to catch up to that hidden gem. In the thirteen years since graduation, I’ve been stationed as far away as Naples, Italy and the Pacific island of Guam. I recently served as residency faculty at the Naval Hospital in Jacksonville, Florida where I was trained. I’ve been able to practice in tents, ships and run-down gymnasiums. The Navy returned me to USU as faculty last year, where I am blown away by the intelligence and enthusiasm of our medical students.

What got you interested in medical editing and writing?

The journals. Military family physicians have a tradition of packing a large stack of journals when going on deployment. We also love apps because they lighten our load. We often fall behind at our stateside hospitals, but during deployment we read voraciously. Being stationed overseas with limited specialists leads to the same. I believe that this is why you see so many journal authors with military rank. We have come to read, appreciate and depend on them, so we aspire to contribute.

What are you hoping to get out of the fellowship?

I have learned so much about writing articles from editors. I relish trying to assemble evidence to help colleagues in their daily work. Everything I have written has been vastly improved by peer reviewers and editors, the best of whom are able to say “I see what you were trying to do there, but this sentence is very confusing.” I want to get that skill: the ability to partner with authors to improve an article without taking over or losing the author’s voice. I also want to see what the secret formula is for selecting topics to keep thousands of colleagues up to date in the broadest medical specialty.

Is there anything else you'd like AFP readers to know about you?

Just that I try to be well rounded. I’m an intermittent scuba diver, skier, marathon runner, swimmer, biker and sailor. I am getting older and question how long before I have to take things off that list. I spent two years as a Ford engineer designing a V6 engine upgrade and still like to tinker. I’ve been married for twenty years and we have a nineteen year-old college sophomore who is passionately pursuing economics.

Michael J. Arnold, MD
CDR, MC, USN
Uniformed Services University

Dr. Arnold's most recent article, "Interventional Radiology: Indications and Best Practices," was published in the May 1 issue of AFP.

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, or the U.S. Government.

Tuesday, March 26, 2019

Apps can detect atrial fibrillation, but benefits and harms are uncertain

- Kenny Lin, MD, MPH

The March 15 issue of AFP included a recommendation statement from the U.S. Preventive Services Task Force (USPSTF) and Putting Prevention Into Practice case study on screening for atrial fibrillation with electrocardiography (ECG). The USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of testing for atrial fibrillation in primary care patients without suggestive symptoms. In an accompanying editorial, Drs. John Mandrola and Andrew Foy discussed several potential downsides of ECG screening for atrial fibrillation: low prevalence, a high number needed to screen to prevent one stroke, high costs, false positive results, and uncertainty about the effects of anticoagulants in persons with subclinical atrial fibrillation.

At the American College of Cardiology meeting last week, Dr. Mandrola interviewed Dr. Mintu Turakhia, a co-principal investigator of the Apple Heart Study, regarding initial findings reported at the conference. More than 400,000 U.S. adults with Apple Watches installed an app that used an algorithm to analyze heart rate variability and notified users if five out of six samples over a 48-hour period suggested an irregular heart rate. Of the 2100 individuals (~0.5%) who received these notifications, the positive predictive value for ECG-confirmed atrial fibrillation was 84%. The app's sensitivity and false negative rate are unknown because users who did not receive notifications did not have ECG monitoring. Also, the study was not designed to evaluate health outcomes.

A planned pragmatic randomized trial will enroll adults age 65 years and older to determine if screening for atrial fibrillation and other heart rhythm abnormalities using the Apple Watch app leads to reduced stroke rates and/or improved cardiovascular health. In the meantime, family physicians will likely start seeing more patients for evaluation of possible cardiac rhythm abnormalities detected by wearable devices. A recent JAMA article reviewed the limitations of such devices at detecting atrial fibrillation, tachycardia, and bradycardia and offered a suggested approach to evaluation and management.

Monday, March 18, 2019

Connecting chronic stress and disease

- Jennifer Middleton, MD, MPH

The March 1 issue of AFP includes a feature article on "Gas, Bloating, and Belching: Approach to Evaluation and Management" which discusses the high prevalence of functional gastrointestinal disorders (FGIDs). The authors note that "[t]hese disorders are characterized by disordered motility and visceral hypersensitivity that are often worsened by psychological distress." FGIDs, of course, are far from the only conditions precipitated or worsened by stress; a new study out last week found a correlation between years of stressful employment and type 2 diabetes in women. Increasingly, a history of highly stressful experiences, such as interpersonal violence (IPV) and/or adverse childhood experiences (ACEs), has been linked to diabetes, cardiovascular disease, and cancer. Identifying and responding to our patients' stress, regardless of degree or cause, may help them to lead healthier lives.

A recent article in Annals of Family Medicine elucidates the relationship between stress and physical symptoms:
Chronic stress profoundly impacts the body’s cardiovascular, endocrine, and immune systems, increasing the risk of atherosclerosis, diabetes, and infection. Even when controlling for traditional risk factors, diseases like obesity, heart disease, asthma, and even certain cancers are more likely to occur in survivors of violence. The link between medical disease and history of abuse, however, is often obscured by the way these patients present: survivors rarely volunteer their histories of violence, often making somatic and nonspecific complaints the only tip-off to a deeper problem.
A willingness to explore our patients' sources of stress, and potentially dive into deeper issues, is a critical first step to making these connections. The BATHE technique is one way to explore these issues; there are also tools available to screen for a history of ACEs and/or IPV.

Several resources exist to help our patients respond to their stress. The American Academy of Pediatrics has information on their website to enable practices to become trauma-centered to better help patients with a history of ACEs. The National Domestic Violence Hotline website has resources for patients who are experiencing IPV, and additional local resources may be available in your area as well. Family physicians may choose to provide counseling in their offices and/or refer to a local counseling center. Basic stress management techniques can benefit most patients, regardless of the severity of their stress; familydoctor.org has a page on "Managing Daily Stress" with practical, simple steps.

Our willingness to engage with our patients' stressors, and normalize the strength of the mind-body connection, may help them improve their health-related quality of life. As family physicians who often have meaningful, long-standing relationships with our patients, we are well-suited to engage in these processes.

Monday, March 11, 2019

Guest Post: Family doctors can easily treat hepatitis B "in-house"

- Richard Andrews, MD, MPH

In 2008, I replaced another family physician as the sole physician at HOPE Clinic, a federally qualified health center in southwest Houston. The clinic was founded by members of the local Asian community to ensure that Asians would have a place to receive linguistically and culturally-appropriate medical care. From the outset, we treated anyone who came in the door, including many non-Asian patients. Due to our core mission, we cared for a large proportion of foreign-born patients from all over the world, speaking more than eighty different languages.

Many of our patients' countries of origin, including China, Vietnam, Myanmar, Iraq, and Nigeria, have a high (>= 8%) or intermediate (2-7%) prevalence of chronic hepatitis B (CHB), leading to a high prevalence in our patients. Initially, they were reflexively referred to hepatologists, but due to access and cost barriers, the community asked us to start treating hepatitis B right at HOPE.

I was an experienced, board-certified family physician, but I had never done any hepatitis B management. I sought training with local hepatologists, mostly through lectures and question-and-answer sessions, and gradually became comfortable with the vocabulary, epidemiology, concepts, and pharmacology of care for patients with hepatitis B.

Because of the HOPE Clinic's origins, most of our hepatitis B patients are of Asian ancestry. In the United States as a whole, roughly half of patients with CHB are of Asian descent, but in your community you might find a different ethnic/language mix. We are seeing an increasing number of non-Asian patients with CHB, including younger native-born Anglo patients with a history of unsafe drug use. Significantly, many American adults have not received hepatitis B vaccinations, leaving them susceptible to infection from sex, injection drug use, or snorting cocaine.

Different social approaches to drug use and addiction in some European countries (such as Portugal) have coincided with marked reductions in the number of new cases of viral hepatitis and HIV. Conversely, infection rates in Americans appear to be increasing. Now that a two-dose hepatitis B vaccine is available, family doctors have a valuable role to play in screening and immunizing susceptible patients, and in managing their patients with CHB.

Factors that make uncomplicated CHB care easy to learn for family physicians

Factor
Remarks

Many patients don’t need antiviral medications

These visits are particularly simple

Very few medications are used, usually just one at a time

1.       Entecavir
2.       Two forms of tenofovir:  TAF or TDF
3.       Interferon use is rare at primary care level
4.       Older medications not used in USA due to resistance

Medications are well tolerated

One pill per day, side effects are uncommon

Medications are effective

Most patients achieve viral levels below the limits of detection, viral resistance is uncommon.

Straightforward liver cancer surveillance

RUQ abdomen ultrasound and serum AFP every six months in cirrhotics.
Other patients:  RUQ u/s + AFP q 6-12 mos. based on guidelines.
Consider CT/MRI as appropriate

Infrequent visits needed

Once patient is established, 2-3 visits per year is a typical pattern

Telehealth/telemedicine

The availability of free online-video specialist consultation is increasing.
Example:  check for availability in your region, at https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/

Though there are only two listed ECHO hepatitis B-specific programs in the USA, there are 64 infectious disease programs, many of which include viral hepatitis

Knowing when to refer

Decompensated cirrhosis:  ascites, esophageal variceal bleed, hepatic encephalopathy, bacterial peritonitis, hepatorenal syndrome, liver cancer.

Monday, March 4, 2019

Minimizing "spring forward" sleep disruptions

- Jennifer Middleton, MD, MPH

For most of the United States, next weekend marks the transition to Daylight Savings Time (DST), when we’ll “spring forward” an hour over the night of March 10 to allow for our dawns to start later and our daylight to last longer into the evening. While the pros and cons of DST continue to be debated, the health risks from disrupted sleep schedules certainly fall into the cons. Preparing in advance may help mitigate these negative effects.

Moving our clocks forward one hour may not seem like a big transition, but disrupted sleep schedules and sleep latency may last for at least a week afterward. An increased prevalence of heart attacks is noted in the United States the Monday after DST begins, as are an increased number of work-related injuries. A review of Australian suicide rates found an increase after DST arrives in the spring. Parents of young children, along with caregivers for developmentally disabled and cognitively impaired individuals, can struggle to transition their loved ones to a new time schedule. 

Sleep experts recommend beginning the transition at least a week prior to the official start of DST, gradually shifting bedtimes and wake-up times by 10-15 minutes every couple of days. Catching up any pre-existing sleep deficit before the DST transition can help, as can getting plenty of sunlight in the morning and dimming lights in the evening. 

Emphasizing good sleep hygiene is also important, as reviewed in this AFP article on the “Management of Common Sleep Disorders.” Minimizing late day caffeine and alcohol use, along with evening screen time, can help improve sleep quality year-round. For children struggling with sleep issues, this AFP article on “Common Sleep Disorders in Children” provides guidance regarding age-appropriate norms and strategies. Both of these articles are in the AFP By Topic on Sleep Disorders in Adults and the AFP By Topic on Sleep Disorders in Children, respectively, each of which also include useful patient education materials.