Monday, September 16, 2019

Using life expectancy and prognosis to support shared decision-making

- Kenny Lin, MD, MPH

Due to competing causes of mortality, the benefits of most screening tests decline with increasing age; for example, screening for breast and colorectal cancers is not recommended in persons with a life expectancy of less than 10 years. However, estimating an individual patient's life expectancy and incorporating that estimate into shared decision-making with patients is challenging. A 2014 U.S. population-based survey found that 31% to 55% of participants with a greater than 75% risk of death in the next 9 years were still receiving breast, colorectal, or prostate cancer screenings.

There are multiple reasons why physicians provide so many unnecessary and potentially harmful screening tests to older persons with limited life expectancies. In an editorial in the September 1 issue of AFP, Dr. Emma Wallace and Norah Murphy observed that "barriers to discussing life expectancy include uncertainty in prognostic estimates, limited time to broach this sensitive topic, and concerns about upsetting the patient or getting negative reactions."

A systematic review of the prognostic value of the "Surprise Question" approach (which asks clinicians, "would you be surprised if this patient died in the next 12 months?") found that the answer has varying degrees of accuracy at identifying patients in their last year of life. The QMortality tool, in contrast, generates a more precise estimate of one-year mortality in persons age 65 to 99 years utilizing multiple clinical and demographic variables, and was found to have good predictive accuracy in 500,000 family practice patients in England.

Some patients may feel uncomfortable about stopping nonbeneficial screening tests even if they are objectively unlikely to benefit from them. In a mailed survey of patients age 50 years or older in the Veterans Affairs health system, nearly 30 percent reported being "not at all comfortable" with discontinuing screening colonoscopy in a hypothetical patient scenario where a colorectal cancer-specific risk calculator predicted a low likelihood of benefit. To help family physicians sensitively incorporate prognostic information into screening discussions, the University of California San Francisco's ePrognosis website provides risk calculators and video examples demonstrating key patient communication skills.

Monday, September 9, 2019

Guest post: AAFP Family Medicine Discovers!

Hello AAFP members!

Family Medicine Discovers seeks to enable practicing family physicians, with little or no research experience, to generate new evidence and innovative models for "what works" in real-world primary care settings. This program is designed for anyone who is curious about conducting research but hasn't had the support to try. Do you have a patient care-inspired question, clinical problem, or clinical conundrum you'd like to investigate? Apply to be an FMD RapSDI Scholar!

What is Family Medicine Discovers?

Family Medicine Discovers is a new scientific signature program offered by the AAFP Foundation in collaboration with the AAFP National Research Network (AAFP NRN). Formally titled, Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation initiative (FMD RapSDI), its vision is to cultivate scholarship and engagement among community family physicians who may not otherwise have the ability to ask and answer questions derived from their practice. 

Stakeholders from key family medicine organizations in the U.S. have developed a program that allows competitively selected AAFP members (FMD RapSDI Scholars) to research innovative, high impact project ideas that can be conducted in a short time-frame. This investment in the profession seeks to bring together mentors with mentees who will develop and implement research studies and participate in professional development activities related to practice-based research.

What does Family Medicine Discovers offer to scholars?

Selected scholars are awarded a monetary grant to cover costs associated with completing their research projects and/or to offset a portion of the scholar’s salary (up to 20% FTE) to develop and complete a project in 12-18 months. The AAFP NRN will provide scholars with research infrastructure and mentoring support to empower scholars to successfully develop and implement their research projects and to stimulate their professional development. FMD RapSDI Scholars will begin projects on June 1, 2020.

The application period for FMD RapSDI will open September 23, 2019 and run through October 31, 2019. During the open period, the application portal will be accessible here.

This investment in building a robust family medicine research infrastructure will advance knowledge and discovery in our specialty; it will also prepare our specialty for the transformation needed to deliver upon the Quadruple Aim. FMD RapSDI has exceptional potential to advance new evidence and knowledge while fostering a culture shift of what it means to participate in family medicine research.

Please spread the word about this program, and/or consider applying yourself!

For more information, please visit the FMD RapSDI website or contact us at nrn@aafp.org.

Best wishes,
Jen Carroll (Director AAFP NRN) and Christina Hester (Research Director AAFP NRN)

Tuesday, September 3, 2019

POEMs spotlight tests and interventions to consider avoiding in practice

- Kenny Lin, MD, MPH

In the fourth installment of this annual series, Drs. Roland Grad and Mark Ebell present the "Top POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign" in the September 1 issue of American Family Physician. Unlike the official list of Choosing Wisely campaign recommendations produced by the American Academy of Family Physicians and many other medical organizations, these suggested clinical actions were generated from recent research studies whose findings were judged by members of the Canadian Medical Association to help reduce overdiagnosis and overtreatment in practice. Drs. Grad and Ebell reviewed 13 of these POEMs (patient-oriented evidence that matters) in a previous article on the top 20 research studies of 2018 for primary care physicians.

The current review article covers musculoskeletal conditions, respiratory disease, infections, cardiovascular disease, and miscellaneous topics. Here is a handy "cheat sheet":

1. Subacromial decompression surgery does not work.

2. Amitriptyline has no long-term benefits for chronic lower back pain.

3. In adults with mild asthma, as-needed budesonide/formoterol is as effective as a daily inhaled steroid.

4. In children with acute respiratory infections, broad-spectrum antibiotics are not more effective, but cause more adverse events, than narrow-spectrum antibiotics.

5. For chronic sinusitis, saline irrigation helps, and irrigation plus an intranasal steroid may help a little more.

6. A lower threshold for defining high blood pressure may harm patients at low risk for cardiovascular disease.

7. Don't order a high-sensitivity troponin level for a patient with a low pretest likelihood of myocardial infarction.

8. For women with symptomatic postmenopausal atrophic vaginitis, a nonprescription nonhormonal lubricant may be as effective as a vaginal estrogen tablet.

9. In adults with type 2 diabetes, NPH insulin is a cost-effective alternative to insulin analogues.

10. Ibuprofen is as effective as oral morphine for pain relief in children after minor outpatient orthopedic surgery, and has fewer side effects.

11. Skip the bath oil in children with atopic dermatitis.

Many of these overused tests and interventions are based on faulty pathophysiologic reasoning (e.g., if lowering blood pressure somewhat is good, then lowering blood pressure more should be even better). In a recent commentary on overuse in BMJ Evidence-Based Medicine, Drs. David Slawson and Allen Shaughnessy (both POEM authors) argued that "reducing overuse begins with the recognition and acceptance of the potential for unintended harm of our best intentions."

Drs. Slawson and Shaughnessy provided five examples of unintended harms of making medical decisions based on "what ought to work" rather than "what does work": activism gone awry (believing that no one is harmed by screening); innocent bystanders (traumatized loved ones of newborns with false positive screening results); the worried well we create (prediabetes); the butterfly effect (higher motor vehicle accident rates in patients with diabetes due to medication-induced hypoglycemia); and out of Oz and back to Kansas (over-extrapolating from research studies performed in ideal circumstances to real-world practice).

Monday, August 26, 2019

Who should treat hepatitis C?

- Jennifer Middleton, MD, MPH

A compelling Close-Ups in the August 15 issue of AFP shares the story of "DN," a patient recently released from prison with hepatitis C. DN reports excellent treatment outcomes after his family doctor treated his hepatitis C. He was able to avoid "going to see an expensive subspecialist I didn't know," and the persistence of his family physician and her office team helped DN overcome his struggles with keeping appointments and adhering to his medication regimen. Recent studies suggest that this family physician is in the minority as a treatment provider for hepatitis C, but DN's story supports the premise that, once armed with knowledge and resources, family physicians can be at least as effective at treating this disease as our subspecialist colleagues.

Despite the hesitation of some family physicians to provide this treatment, a 2018 AFP editorial asserts that "Family Physicians Can Manage Hepatitis C." The family physician author reviews screening recommendations for hepatitis C, defines sustained viral response (SVR), discusses viral genotyping, and describes the current medication options available. The editorialist advises obtaining additional online training (there are several free options) and cites the Centers for Disease Control and Prevention's (CDC) recommendation that primary care physicians provide this treatment.

A 2017 survey of primary care physicians and nurse practitioners identified that few were currently providing hepatitis C treatment, though 84% were interested in obtaining more training to do so:
Willingness to provide treatment was strongly linked to having a high proportion of HCV-infected patients (>20% versus <20%; OR 3.9; 95% confidence interval [CI] 1.5–10) and availability of other services at the primary care site including HIV treatment (OR 6.5; 95% CI 2.5–16.5), substance abuse treatment (OR 3.3; 95% CI 1.3–8.4) and mental health services (OR 4.9; 95% CI 2.0–12.1).
Connecting to local resources in the form of substance abuse treatment (since most hepatitis C infection in the United States is due to injection drug use), mental health services, and integrated clinical pharmacists (as DN's family doctor did) are critical to empowering more family physicians to prescribe hepatitis C treatment. Willingness to care for formerly incarcerated persons may also play a role; this 2018 post from Dr. Lin reminds us of the health risks these patients face when they re-enter society, which are at least partially attributable to the challenges they face accessing primary care.

Resources to learn more include this 2015 AFP feature article on "Diagnosis and Management of Hepatitis C" along with the AFP By Topics on Hepatitis (and Other Liver Diseases) and Substance Abuse. The CDC also has a sizable "Hepatitis C" resource page with multiple resources for physicians and patients. 

If you are treating hepatitis C, what barriers and/or successes have you experienced? If not, what might encourage you to do so?

Monday, August 19, 2019

E-cigarettes and health: some answers, more questions

- Kenny Lin, MD, MPH

As the Centers for Disease Control and Prevention is actively investigating a cluster of severe lung illnesses in 14 states that may be linked to e-cigarette use among adolescents and young adults, an article in the August 15 issue of AFP discusses common questions and answers about vaping and health. Since Dr. Middleton's 2016 blog post on the promise and perils of e-cigarettes, more data has accumulated about the potential harms and benefits of this increasingly common activity. In 2017, one in five high school students reported e-cigarette use in the previous year, leading U.S. Surgeon General Jerome Adams to issue an advisory last year that labeled e-cigarette use in youth a "public health epidemic." More recent data from the Monitoring the Future survey suggested that this epidemic shows no signs of slowing:

Put in historical context, the absolute increases in the prevalence of nicotine vaping among 12th-graders and 10th-graders are the largest ever recorded by Monitoring the Future in the 44 years that it has continuously tracked dozens of substances. These results indicate that the policies in place as of the 2017–2018 school year were not sufficient to stop the spread of nicotine vaping among adolescents.

Although a nationally representative survey of parents of middle and high school students found that nearly all are aware of e-cigarettes, only 44% accurately identified an image of the "pod mod" device Juul; less than one-third reported concerns about their own child's use of e-cigarettes; and nearly three-quarters had received no communication from their child's school regarding the dangers of e-cigarettes. To help family physicians counsel parents and adolescents about vaping and Juuls, a patient education handout accompanying the AFP article highlights important discussion points.

It remains unclear whether e-cigarettes can help adults who are trying to quit smoking. E-cigarettes are not approved by the U.S. Food and Drug Administration as smoking cessation devices; however, a recent randomized trial in the U.K. National Health Service found that in smokers receiving weekly behavioral support, the 1-year abstinence rate in the e-cigarette group was superior to that of smokers using traditional nicotine replacement products. Notably, 80 percent of the e-cigarette group was still vaping after 1 year, compared with only 9 percent of the nicotine-replacement group - a troubling secondary finding given the unknown long-term health consequences of e-cigarette use.

In addition, the AFP article cautions that "unlike nicotine replacement therapy, the advertised nicotine dose on the labeling of e-cigarettes is not always consistent with laboratory analysis of the e-cigarette liquid, and the device and user behavior may affect the dose of nicotine received." Consequently, the authors recommend that clinicians first counsel patients to quit using evidence-based smoking cessation guidelines such as those from the U.S. Preventive Services Task Force, and only discuss using e-cigarettes if these methods are ineffective.

Monday, August 12, 2019

Is "prediabetes" a useful term?

- Jennifer Middleton, MD, MPH

The ADA's goal in defining prediabetes,"blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes," is to identify those persons who would benefit from interventions to reduce their risk of developing type 2 diabetes. While reducing the incidence of type 2 diabetes is a laudable goal, the term "prediabetes" may be problematic; a 2017 meta-analysis found that "[a]s screening is inaccurate, many people will [receive] an incorrect diagnosis and be referred on for interventions while others will be falsely reassured and not offered the intervention." The imprecise label of "prediabetes" may be hampering efforts to identify effective interventions to delay or prevent the onset of type 2 diabetes.

A pair of editorials in the current issue of AFP explore the controversy surrounding metformin prescribing in persons determined to have prediabetes. Dr. Lin reviews these editorials and their evidence base in a recent tweetorial; in summary, asserting that metformin is beneficial in prediabetes, Dr. Tannaz Moin cites the Diabetes Prevention Program (DPP) which found that, in obese persons with prediabetes, metformin delayed onset of type 2 diabetes over three years (number needed to treat = 14). Dr. Moin advocates, however, for considering more than just a prediabetes test result when considering metformin treatment: "higher A1C (i.e., 6.0% to 6.4%), but also other important risk factors, such as family history of diabetes, higher fasting plasma glucose levels, and higher triglyceride levels, may predict greater risk of progression to diabetes." 

Arguing against the use of metformin is Dr. Steven Brown, who describes his concern with using prediabetes as an impetus to prescribe medication. He cites the above-mentioned 2017 meta-analysis' findings that, "[c]ompared with the reference standard of an oral glucose tolerance test, a single A1C measurement is 49% sensitive and 79% specific for prediabetes." He interprets the DPP findings differently:
 At four years, the average A1C was 5.9% in the metformin or lifestyle groups and 6.1% in the placebo group. Although these surrogate outcome differences are statistically significant, they are not clinically meaningful. Treating borderline glucose values does not improve quality of life, mortality, or any other patient-oriented outcomes.
It's quite possible that the DPP's findings were less significant because of the inherent imprecision in the "prediabetes" label. As Dr. Lin wrote in an earlier post on the Community Blog, "the term prediabetes is misleading: many of these patients will not develop diabetes." A more precise risk elucidation may be found in that same 2017 meta-analysis, where "those most at risk of developing diabetes had both impaired fasting glucose and impaired glucose tolerance." 

A reasonable middle ground may be to consider glucose readings between the ranges of normal and diabetic as just one risk factor among many for developing type 2 diabetes. There's an AFP By Topic on Diabetes: Type 2 if you'd like to read more about diabetes screening and diagnosis, and there's an AFP Department Collection with more Controversies in Family Medicine with more pro/con editorial pairs, too.

Monday, August 5, 2019

The continuing plague of gun violence: what family physicians can do

- 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 2018 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 published online ahead of print, Dr. Sexton and the AFP medical editors argued 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 reviewed the evidence of the effects of firearm regulations, mental health counseling, and active shooter training on gun safety and violence:

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 encouraged 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."

**

This post first appeared on the AFP Community Blog on July 17, 2018. Since then, approximately 40,000 more Americans have died from firearm suicide or homicide, including 31 in two separate terrorist attacks in Dayton and El Paso within a 24-hour period this past weekend.

Monday, July 29, 2019

Curbing the use of nonprescription antibiotics

- Jennifer Middleton, MD, MPH

A just-published review found that antibiotics remain readily available in the United States without a prescription. The authors found that between 1-66% of studied populations reported possession and/or planned use of antibiotics obtained from sources other than a prescriber's order. With implications for both personal side effects and population-wide antibiotic resistance, examining the factors contributing to nonprescription antibiotic use may lead to some solutions.

The authors performed a scoping review with the goal of answering these two questions: "What are the prevalence, sources, and characteristics of nonprescription antibiotic use in the US, and what are the factors influencing it?" They identified 31 articles that met their inclusion criteria:
Several studies focused on the availability of antibiotics without a prescription from flea markets, pet stores, botanical or health food stores, or online. Others explored nonprescription use from a range of sources, including leftover prescribed courses, markets or stores, family or friends, and antibiotics obtained without a prescription from other countries. In 1 study, patients in an STI clinic and a county jail were interviewed about self-treatment with antibiotics. All studies of injection drug users examined self-treatment of abscesses and injection-related wounds with antibiotics obtained on the street.
In reviewing these studies, the authors identified several factors that influenced nonprescription use of antibiotics; wait times to see a physician, cost of the physician visit, and lack of transportation were prominent as might be expected, but concerns about judgment by healthcare staff when seeking care for sexually transmitted infections and injection-drug-use-related infections were also noted. Of course, the ready availability of antibiotics from a multitude of sources enabled nonprescription use, too.

According to the basic tenets of health behavior theory, most adults make decisions about their health that they deem rational in the context of their knowledge, environment, and social norms. It makes sense, for example, that persons with ready access to antibiotics who are concerned about the cost and/or stigma of seeking medical care would choose the easier route of bypassing the physician's office. Tackling the problem of antibiotic resistance may need to include efforts to reduce barriers and stigma around receiving treatment for more potentially sensitive conditions.

The AAFP's Everyone Project toolkit contains a wealth of resources to help your patients who have barriers to accessing healthcare. The Canadian Public Health Association has a toolkit to help practices identify and decrease stigmatizing language and behaviors. Limiting inappropriate antibiotic prescribing remains important, too, as Dr. Lin and I discussed on an AFP tweet chat back in 2017; here are the AFP references we used, which contain pragmatic, evidence-based strategies for reducing antibiotic overuse.

Antibiotic overuse remains a complex challenge, and hopefully we'll see future studies continuing to address not only its multifaceted causes but also successful strategies to combat them.

Monday, July 22, 2019

Deliberate clinical inertia: protecting patients from low value care

- Kenny Lin, MD, MPH

Clinical inertia is usually considered to be a negative term, used to refer to situations in which clinicians do not appropriately initiate or intensify therapy for uncontrolled chronic conditions. For example, a recent study in JAMA Internal Medicine found that less than one-quarter of patients with chronic hypercalcemia in the Veterans Affairs health system received parathyroid hormone level testing, and only about 13 percent of patients who met diagnostic criteria for primary hyperparathyroidism underwent parathyroidectomy.

However, clinical inertia has also been described as a "clinical safeguard" against aggressive consensus guideline prescriptions that do not account for patient preferences and/or potential harms of intensifying treatment. For example, an analysis of the incremental benefits of and harms of the 2017 American College of Cardiology / American Heart Association guideline that redefined hypertension as a sustained blood pressure of >= 130/80 mm Hg concluded:

For most adults newly classified as having high blood pressure under the ACC/AHA guideline (the 80% of those newly diagnosed who have <10% 10-year risk), there is no incremental benefit in CVD risk reduction, but potential incremental harms from disease labeling, and, for those who meet the threshold for drug treatment, from adverse drug effects.

In this instance, a large number of patients with systolic blood pressures between 130 and 140 mm Hg could potentially benefit from clinical inertia by avoiding a hypertension diagnosis, additional testing, or prescription medications.

In a 2011 JAMA commentary, Drs. Dario Giugliano and Katherine Esposito observed that clinical inertia "also may apply to the failure of physicians to stop or reduce therapy no longer needed," but that "this neglected side of clinical inertia does not seem to generate as much concern among physicians or scientific associations." A review of polypharmacy in the July 1 issue of AFP noted that regular use of at least five medications is associated with decreased quality of life, increased mobility problems and falls, greater health system use, and increased long-term care placement. As discussed in a previous AFP Community Blog post, judicious deprescribing can help reduce polypharmacy and improve patient outcomes.

Another (sometimes better) strategy is not starting nonbeneficial medications for unclear reasons in the first place. In a 2018 article in Emergency Medicine Australasia, Dr. Gerben Keijzers and colleagues defined "deliberate clinical inertia" as "the art of doing nothing as a positive response." Arguing that doctors generally have a bias to intervene with diagnostic tests, drugs, or procedures, they suggested reframing the typical decision-making approach:

In clinical practice, 'risk versus benefit' is usually considered in terms of missing a diagnosis rather than potential risks of treatment, so a better approach to care may be to ask, 'Is this intervention more likely to cause harm than the underlying condition with its possible harm or risk?' There are many reasons why 'doing nothing' is difficult, but doing what we can to provide excellent care while preventing medical harm from unnecessary interventions must become one of the pillars of modern holistic healthcare.

Family physicians may readily grasp the rationales behind campaigns to avoid harms and costs of low value care such as Choosing Wisely and Right Care, but our patients often need convincing. Dr. Keijzers and colleagues suggested several ways to support deliberate clinical inertia in practice: empathy and acknowledgment; symptom management; clinical observation; explanation of the natural course of the condition; managing expectations; and shared decision-making ("communicating rather than doing").

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.