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.

Monday, February 25, 2019

Does diet soda consumption increase stroke risk?

- Jennifer Middleton, MD, MPH

Perhaps your patients have been asking you, as several of mine have, about a new study getting lay press attention regarding stroke risk and artificially sweetened beverages. Published last week, this study from the Women’s Health Initiative (WHI) found an increased risk of stroke, coronary heart disease (CHD), and mortality among post-menopausal women who consumed 2 or more artificially sweetened beverages a day. Although observational studies like this one can only demonstrate correlation, and not causation, it still may provide an opportunity for discussing dietary changes that can meaningfully affect health.

This WHI observational study examined the diet soda habits of over 80,000 postmenopausal women. Participants self-reported their artificially sweetened beverage consumption, and researchers followed them for an average of 11.9 years. Only 5.1% of participants consumed 2 or more artificially sweetened beverages a day, but these participants were more likely to have a stroke (hazard ratio 1.23 [95% confidence interval 1.02, 1.47]) or coronary heart disease (HR 1.29 [1.11, 1.51]), and the risk of stroke was even higher in women with a body mass index of 30 or greater (HR 2.03 [1.38-2.98]). It’s difficult to know, in an observational study such as this one, whether these women had other risk factors that increased their stroke and CHD risk; the researchers state that recalculating their results excluding women with known diabetes, hypertension, and/or CHD from their analysis “did not materially change the association with risk.” As this study only included postmenopausal women, any conclusions generalizing its results to men or premenopausal women could be premature.

Certainly, however, this study may prompt some people to decrease their diet soda consumption. Plain water, water infused with fruit, and unsweetened sparkling/seltzer beverages are all reasonable alternatives. Working with parents and our youngest patients to avoid developing a preference for sweetened beverages is also important, as outlined in this Centers for Disease Control and Prevention (CDC) Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages. From a public health perspective, education campaigns such as this one urging people to “Stop. Rethink Your Drink. Go on Green,” which categorizes beverages as “Red: Drink Rarely” (sugar sweetened beverages), “Yellow: Drink Occasionally” (100% fruit juice, artificially sweetened beverages), and “Green: Drink Plenty” (water, seltzer water, milk) may help encourage new beverage consumption norms.

Conversations about beverage choice can easily lead to overall diet discussions as well; emphasizing a diet rich in whole foods and recommending apps to help with healthy food choices can empower our patients to make better choices. There's an AFP By Topic on Nutrition if you'd like more resources for yourself and/or your patients.

Tuesday, February 19, 2019

Therapies for type 2 diabetes: improving outcomes that matter

- Kenny Lin, MD, MPH

When comparing therapies for type 2 diabetes, physicians, patients, and quality measures often get caught up in the disease-oriented outcome of glycemic control. However, a 2014 editorial in AFP pointed out that of the medications then available to lower blood sugar levels, only metformin reduced mortality and clinically relevant complications. Since that time, studies of newer diabetes medications have demonstrated mortality benefits in patients with cardiovascular disease. However, the best second-line medication after metformin remains unclear. Although the World Health Organization guideline recommended inexpensive sulfonylureas as second-line therapy in low-resource settings, the American College of Physicians and the American Academy of Family Physicians suggested "the choice of drug [after metformin] should be based on a conversation with the patient about benefits, possible harms, and cost."

In the February 15 issue of AFP, Drs. Joshua Steinberg and Lyndsay Carlson applied the STEPS criteria (safety, tolerability, effectiveness, prince, and simplicity) to each of the 10 categories of diabetes medications (including insulin). Their analysis confirmed that metformin should be first-line pharmacotherapy for most persons with type 2 diabetes. Other key points from this article include:

Safety - Sulfonylureas, insulins, meglitinides, and pramlintide increase risk of hypoglycemia. Metformin and acarbose require monitoring, dose adjustments, or discontinuation in patients with chronic kidney disease.

Tolerability - Side effects across different drug classes range from gastrointestinal effects (metformin, acarbose, meglintinides, pramlintide, GLP-1 receptor agonists, SGLT-2 inhibitors) to weight gain (sulfonylureas), edema (TZDs), severe arthralgias (DPP-4 inhibitors), and genital and urinary tract infections (SGLT-2 inhibitors).

Effectiveness - Recent trials showed improved patient-oriented outcomes from some GLP-1 receptor agonists and SGLT-2 inhibitors in patients at high cardiovascular risk or with known cardiovascular disease. Acarbose also reduces cardiovascular events.

Price - Metformin, acarbose, sulfonylureas, and generic pioglitazone are the most affordable options.

Simplicity - Acarbose and meglitinides are taken three times daily before meals, while insulins, GLP-1 receptor agonists, and pramlintide require subcutaneous injections.

Monday, February 11, 2019

The family physician's role in vaccine-preventable disease outbreaks

- Jennifer Middleton, MD, MPH

The Centers for Disease Control and Prevention (CDC) is monitoring 3 current measles outbreaks in the United States, and most of the affected individuals are children under the age of 10 who did not receive the measles, mumps, and rubella (MMR) vaccine. Infected travelers to the US appear to be the sources for these outbreaks, but the disease's spread after its arrival has primarily been due to under-vaccination. Reporting suspected cases, discussing vaccine hesitancy with caregivers, and optimizing our office vaccination processes are all tangible ways for family physicians to respond.

Coughing and sneezing spread the highly contagious measles virus, and individuals are infectious from 4 days prior to 4 days after the appearance of its pathognomonic rash. Measles infection complications include pneumonia, ear infections, permanent hearing loss, encephalitis, permanent brain injury, and death. Physicians who suspect a patient may have measles should promptly contact their local health department. Unfortunately, CDC data demonstrate that these current measles outbreaks in the US are nothing new. Pockets of under-vaccinated communities across the US have provided easy targets for measles' spread once it's introduced.

Increasing vaccination rates is a critical but challenging component of the solution. With vaccine hesitancy now among the World Health Organization's (WHO) top 10 threats to global health, it's critical that we redouble our efforts to combat the spread of misinformation about vaccines. Discussions with vaccine-hesitant parents in the office can feel futile, but family physicians should remember that their recommendation is the most common reason cited when parents do decide to vaccinate. Phrasing vaccine recommendations as statements instead of questions correlates with higher vaccination rates. Eliciting and responding to caregivers' specific concerns can also be useful.

Our office staff can work with us to reinforce these messages, too. This 2016 AFP Editorial on Strategies for Addressing and Overcoming Vaccine Hesitancy includes links to several additional resources. An FPM article on improving influenza vaccination rates includes office strategies relevant to all types of vaccinations. The WHO's Addressing Vaccine Hesitancy website provides "a guide for exploring health worker/caregiver interactions on immunization" along with an online training module on "conversations with hesitant caregivers."

In the face of these outbreaks, combating vaccine hesitancy remains as critical as ever. What strategies have you found useful?

Tuesday, February 5, 2019

Does subspecialist medical care add sufficient value to be worth the added cost?

- Kenny Lin, MD, MPH

The latest Graham Center One-Pager in the February 1 issue of AFP contained good news and bad news for Family Medicine. Examining the entry of medical students into residency programs between 2008 and 2018, Dr. Robert Baillieu and colleagues reported that the total number of graduates who entered Family Medicine through the National Residency Matching Program increased by 64% over the past decade. However, the annual proportion of U.S. allopathic (MD) graduates remained static at around 50%, reflecting the continued migration of most students into higher-paying medical subspecialties.

Two previous AFP Community Blog posts reviewed research demonstrating that students entering family medicine are more likely to make patient-centered, cost-conscious clinical decisions and that primary care physicians who trained in low-cost hospital service areas are more likely to provide high-value care in practice. The late health services researcher Barbara Starfield, MD, MPH once argued that a lack of investment in primary care is a major reason that the U.S. health system spends so much but produces poor outcomes:

The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality. [This] is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. ... We have done a reasonably good job at making subspecialty care available, but a lot of subspecialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily.

In a recent nationally representative study in JAMA Internal Medicine, Dr. David Levine and colleagues examined associations between receipt of outpatient primary care and care value and patient experience. Using Dr. Starfield's definition of primary care as "first-contact care that is comprehensive, continuous, and coordinated," the authors compared the quality and experience of care in more than 70,000 U.S. adults with and without primary care who participated in the Medical Expenditure Panel Survey from 2012 to 2014. 70% of the primary care clinicians identified by patients were family physicians (19% were general internists). After adjustment for potential sources of confounding, respondents with primary care were more likely to receive high-value preventive care and counseling and to report better patient experiences than those without primary care. However, respondents with primary care were also slightly more likely to receive low-value prostate cancer screening and antibiotics for respiratory infections.

In an accompanying editorial that noted the disparity in primary care investment between the U.S. (7% of total health care spending) and the health systems of other industrialized nations (20%), Dr. Allan Goroll asked: "Does primary care add sufficient value to deserve better funding?" Although this formulation recognizes that the American status quo is a subspecialist-oriented health system, it seems to me that the question ought to be, "Does subspecialist medical care add sufficient value to primary care be worth the added cost?" From this study and previously published evidence, the answer appears to be no.

Monday, January 28, 2019

Lung cancer screening: harms, costs, and shared decision making

- Jennifer Middleton, MD, MPH

Controversy continues regarding screening for lung cancer with low dose computed tomography (LDCT). Last fall, Dr. Lin wrote on the blog about overdiagnosis concerns related to LDCT, and now a new study describes the harms and costs that can result from the diagnostic tests that typically follow positive screening results.

 The United States Preventive Services Task Force (USPSTF) gave a B recommendation to screening with LDCT in adults aged 55 to 80 years with at least a 30-pack year tobacco history in 2013, following the National Lung Screening Trial's (NLST) findings that LDCT screening modestly reduced lung cancer mortality. Of note, the American Academy of Family Physicians disagreed with the USPSTF, giving lung cancer screening with LDCT an insufficient evidence rating, both because of its high number needed to treat (312) and its high rate of false positives:

Forty percent of patients screened will have a positive result requiring follow-up, mostly CT scans, although some will require bronchoscopy or thoracotomy. The harms of these follow-up interventions in a setting with a less strict follow-up protocol in the community is not known.

This new study, a retrospective cohort review of over 344,000 patient records, provides information regarding the potential harms of follow-up interventions in a community setting. While the NLST described an estimated complication rate of 8.5-9.8% from invasive diagnostic procedures following a positive LDCT screening result, this larger community study found a much higher complication rate of 22.2-23.8%. Mean complication costs ranged from $6320 for minor complications to $56,845 for major complications.

The Centers for Medicare & Medicaid Services (CMS) mandates shared decision making prior to ordering LDCT for lung cancer screening, but Dr. Lin's post last fall described a 2018 study describing that this shared decision making occurs infrequently and superficially. A 2019 study examining over 8 million Medicare patient records found that only 9% of encounters documented any shared decision making prior to LDCT; interestingly, nearly 40% of patients who did have documented shared decision making opted not to participate in screening.

Shared decision making prior to LDCT is even more imperative given this new data regarding complication rates and costs. Our patients need to understand both LDCT's potential risks and benefits if they are to make a decision about lung cancer screening that aligns with their values.

Tuesday, January 22, 2019

Lessons from recent trials of localized prostate cancer treatments

- Kenny Lin, MD, MPH

From 2012 to 2018, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommended against screening for prostate cancer, based on evidence that the then-widespread practice produced no net benefit. As a result, fewer family physicians subsequently screened their patients with the PSA test, and fewer men were diagnosed (or overdiagnosed) with localized prostate cancer. However, the USPSTF's recent change to a more permissive approach to PSA-based screening has increased the likelihood that more men will need to make difficult decisions regarding what to do about a prostate cancer diagnosis.

As discussed in a previous AFP Community Blog post, surveyed men with newly diagnosed localized prostate cancer expected to gain an average of 12 years of life expectancy by undergoing surgery or radiation. In fact, two randomized, controlled trials found no gains in prostate cancer-specific or all-cause mortality. After nearly 20 years of follow-up, the U.S. Prostate Cancer Intervention versus Observation Trial (PIVOT) reported in 2017 that radical prostatectomy reduced the likelihood of treatment for asymptomatic, local, or biochemical (PSA) disease progression compared to observation, but caused more urinary incontinence, erectile dysfunction, and limitations in activities of daily living. Similarly, the U.K. Prostate Cancer for Testing and Treatment (ProtecT) trial found that active surveillance was comparable to radiotherapy or prostatectomy, with a slightly greater likelihood of clinical progression and metastatic disease in the active surveillance group.

An older Swedish randomized trial comparing radical prostatectomy to watchful waiting in men with predominantly clinically-detected (rather than PSA-detected) localized prostate cancer found that radical prostatectomy was associated with less than 3 years of life gained after 23 years of follow-up. Altogether, the evidence suggests that curative treatments may be worthwhile for selected men with symptoms, but that there is little or no benefit to looking for prostate cancer in men who feel well.

A 2018 AFP article reviewed the evolving National Comprehensive Cancer Network guidelines for treatment of localized prostate cancer, which recommend incorporating comorbidity-adjusted life expectancy into screening and treatment decisions:

The comorbidity-adjusted life expectancy is particularly important because the number of comorbid diseases is among the most significant predictors of survival after prostate cancer treatment. Prostate cancer is usually slow growing, and the survival benefit of treatment may present only after 10 years. Therefore, patients with low-risk or very low-risk prostate cancer should be treated only if the patient has a comorbidity-adjusted life expectancy of at least 10 years.

Monday, January 14, 2019

AFP Clinical Answers at the point of care

- Jennifer Middleton, MD, MPH

Family physicians have an average of 15-20 clinical questions every day while caring for patients. Identifying trustworthy sources of online or app-based content requires family physicians to identify "whether the reference clearly states how strong the evidence is to support recommendations about patient care." If AFP is one of your trusted sources of answers, you may find our new department, AFP Clinical Answers, of particular interest.

The January 1, 2019 issue of AFP includes the first AFP Clinical Answers article covering nausea in pregnancy, knee osteoarthritis, hormone therapy, and the shingles vaccine. Each content area has a brief paragraph providing key information along with a hyperlink to a more in-depth AFP article. As AFP Editor-in-Chief Dr. Sumi Sexton writes introducing the department, "The goal of this department is to share key clinical questions and their evidence-based answers directly from the journal's content. Our hope is that readers will find these answers useful for patient care and serve as a reminder of the topics we've covered."

If you're interested in further expanding your point of care resources, AFP's Point-of-Care Guides collection provides one-page commentary on the latest evidence base pertinent to many common patient care issues. FPM's (formerly Family Practice Management) SPPACES: App Reviews Department includes reviews for both point-of-care apps for clinicians as well as useful apps for patients. The Agency for Healthcare Research and Quality (AHRQ) also has a "Practical Tools for Primary Care Practice" website with tools and guides on everything from clinical practice guidelines to becoming a high-performing team. 

Don't forget about the "Favorites" feature on the top of the AFP home page, where you can bookmark common resources (from AFP and/or anywhere on the internet) for quick access. You can connect to the Evidence-Based Medicine toolkit from the home page for a refresher on reviewing strength of evidence terms, and you can access the AFP podcast from the home page, too, which frequently features suggestions for additional resources related to content in the print journal.

How are you planning to expand your point of care acumen in 2019?


Tuesday, January 8, 2019

When deprescribing is the best medicine

- Kenny Lin, MD, MPH

Physicians who care for older adults or other patients with multiple chronic conditions understand that deprescribing unnecessary or inappropriate therapies is central to providing high-quality care and improving patient safety. An editorial by Drs. Barbara Farrell and Dee Mangin in the January 1 issue of AFP reviewed the health risks associated with polypharmacy (taking five or more chronic medications) and provided a table of resources for each step of the deprescribing process, including several evidence-based guidelines co-written by the authors. AFP's Practice Guidelines department summarized their guideline on deprescribing antipsychotics for dementia and insomnia last September and reviewed how to taper benzodiazepine receptor agonists for insomnia in adults in the January 1 issue.

A 2018 systematic review in the British Journal of General Practice reviewed data from 27 randomized, controlled trials of deprescribing a range of drug classes in adults aged 50 years or older in primary care settings. In 19 studies, at least half of patients in the intervention groups were able to stop their medications completely, and adverse effects were uncommon. However, the risk of "relapse" (needing to resume the drug after completely discontinuing it) ranged from 2 to 80 percent.

Patient expectations, medical culture, and organizational constraints can present barriers to deprescribing. A qualitative study of New Zealand primary care physicians in the Annals of Family Medicine described deprescribing as "swimming against the tide." Study participants recommended several practice and system-level interventions to support deprescribing that could also be applied to practices in the U.S.:

- Targeted funding for annual medicines review
- Computer alerts to prompt physicians’ memories
- Computer systems to improve information sharing between prescribers
- Improved access to non-pharmaceutical therapies
- Research to build the evidence base in multimorbidity, education and training
- Ready access to expert advice and user-friendly decision support
- Updating guidelines to include advice on when to consider stopping medicines
- Tools and resources to assist in the communication of risk to patients
- Activating patients to become more involved in medicines management and alert to the possibility that less might be better

Along those lines, the AFP editorial also provided a Table of examples of language that family physicians can use to discuss deprescribing with patients and facilitate shared decision-making.

Tuesday, January 1, 2019

Approaches to behavior change that work

- Jennifer Middleton, MD, MPH

It's time for New Year's resolutions, and many of our patients will ask us for help implementing them. The December 15 issue of AFP includes the timely article on "Counseling Patients in Primary Care: Evidence-Based Strategies" which reviews several useful counseling techniques. This article adds to the growing literature of simple methods that can help our patients make healthy changes.

The AFP authors review key tenets of FRAMES, motivational interviewing, BATHE, the stages of change, and the 5A's, providing recommendations about choosing techniques and examples of phrasing to use with patients. All techniques share an emphasis on empathetic patient engagement. The authors also advocate for addressing multiple issues within a visit (such as tobacco use, weight loss, and hazardous alcohol use) and cite data demonstrating that doing so leads to increased change for all of the behaviors addressed.

A 2016 study examined which physician techniques best increased patients' activation scores, a proxy measure for behavior change. More successful physicians used an average of 4 out of the 5 following strategies: "emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients." Less successful physicians reported instead "telling patients the negative health outcomes they can expect if they do not change their unhealthy behaviors." In this same study, more successful physicians also reported spending more time counseling and had higher interest in behavior change than those physicians whose patients had lower activation scores. 

Additional studies' findings are along similar lines. Spending more time counseling patients correlates with higher rates of behavior change regarding weight loss and tobacco cessation. Patients are more willing to engage in counseling related to behavior change with tobacco and alcohol use when their overall health, and not their undesirable habit, is emphasized. Although leveraging our longitudinal relationships with patients is valuable, it's encouraging to note that just one motivational interviewing session can result in meaningful change, too.

You can read more in the AFP By Topic on Health Maintenance and Counseling. I'm adding this new AFP article to my AFP Favorites page for easy reference. Which of these techniques are you adding to your repertoire for 2019?