- Kenny Lin, MD, MPH
In 2005, a Robert Graham Center report, whose key findings later appeared as a Policy One-Pager in American Family Physician, sounded an alarm. The authors reported that the share of children who saw family physicians for primary care had declined from one in four to one in six since the early 1990s. A subsequent article in Family Practice Management (now FPM) explored some reasons for the decline: expansion of the pediatrician workforce; fewer family physicians providing prenatal, newborn, and pediatric inpatient care; and a lack of awareness among the public and the media about the broad scope of family medicine training. The FPM article recommended several strategies for individual family physicians to increase their opportunities to recruit children to their practices:
- Build relationships with Ob/Gyns and pediatricians in your community.
- Heighten your visibility in the hospital.
- Get to know the nurses in labor and delivery and the nursery.
- Don't rely solely on word-of-mouth marketing.
- Talk with patients whose children might be outgrowing their pediatrician's office about transferring.
- Create a kid-friendly environment.
- Make sure your hours and appointment access are sensitive to the needs of young families in your community.
Nearly 15 years later, according to the American Academy of Family Physicians member census, 80 percent of family physicians are caring for adolescents, while 74 percent see infants and younger children. AFP continues to update child-centered clinical review topics such as well-child visits for infants and young children and health maintenance in school-aged children. But a recent population-based analysis of an all-payer claims database in Vermont suggested that family physicians' share of children's health care has continued to erode. Between 2009 and 2016, children residing in Vermont were 5% less likely to be attributed to a family physician practice, a trend that included urban and rural areas. Older children, girls, and children with Medicaid were somewhat more likely than others to see family physicians.
Caring for children benefits family physicians and their patients. In an article in the September/October issue of FPM, Drs. Sumana Reddy and Jaydeep Mahasamudram observed that "the satisfaction that comes from taking care of children shouldn't be underestimated in a time of increasing physician burnout." Not only can family physicians smooth young patients' transitions from child to adult care, but by caring for parents and grandparents, they gain perspectives on inter-generational social interactions that pediatricians don't. One example: "As family physicians, we can see all of the ill members together, we can care for both the newborn and the breastfeeding mother with postpartum depression, and we can understand the teenager's mood disorder because we know the parents have been dealing with severe stressors even if the teen doesn't disclose this."
So how can family physicians counter national trends and provide care to more children? In addition to the strategies already mentioned, Drs. Reddy and Mahasamudram suggested taking advantage of opportunities to refresh one's knowledge on child-specific issues (e.g., Kawasaki disease); asking local internists and obstetricians for referrals; volunteering to give community talks on child health topics; and becoming more familiar with Current Procedural Terminology (CPT) codes for visits with young patients, especially those for vaccine administration.
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Sunday, October 27, 2019
Monday, October 21, 2019
Topical retinoids for acne: challenges for prescribers and patients
- Jennifer Middleton, MD, MPH
The October 15 issue of AFP includes an article on "Acne Vulgaris: Diagnosis and Treatment;" for many types of acne (Figure 4), a topical retinoid medication is the first line of treatment. Although topical retinoids are highly effective, many physicians don't prescribe them, follow-up appointments often don't happen, and adherence to these sometimes irritating treatments can be spotty at best.
For acne primarily composed of comedones and/or mild inflammatory papules and pustules, a topical retinoid is first-line treatment; even moderate severity acne regimens should include a topical retinoid. Only severe, nodular acne regimens begin with a different treatment (isotretinoin) and, even then, once clinical improvement is noted, transitioning to a topical retinoid is often appropriate. Despite the near-ubiquity of topical retinoids in these recommendations, though, physicians are not consistently prescribing them first-line. A study of prescribing practices in the United Kingdom found that only 38% of patients receiving a topical antibiotic prescription for acne also received a topical retinoid.
Patients also struggle with adherence to topical retinoids. In one study, 65.7% of adolescents and young adults self-discontinued their topical retinoid medication due to side effects such as irritation, redness, and scaling. They also found, however, that patients who were instructed to use their topical retinoid every other night had much lower discontinuation rates, possibly because their side effects were less bothersome.
The challenges of adhering to a topical retinoid regimen may explain poor follow-up and refill rates. A large database study of acne medication prescribing practices found that 66.1% of patients with new diagnosis of acne had no subsequent visit with that diagnosis for the year following, and 60.1% of patients did not have a documented refill for their medication within 90 days of their initial visit (despite most prescriptions being written for no more than 2 months' supply/refills).
Given the evidence in the above AFP article supporting retinoids' efficacy, these data present opportunities for both prescribers and patients to improve the use of this class of medications. Prescribing topical retinoids to be used every other night - or even every third night - may minimize irritation. Scheduling follow-ups a bit sooner may help patients and physicians problem-solve any challenges with adherence or side effects. Family physicians already prescribe generics and less-expensive acne treatments more often than other specialists, which can hopefully help any adherence issues related to cost.
There's an AFP By Topic on Skin Conditions which includes STEPS (Safety, Tolerability, Effectiveness, Price, Simplicity) articles on several acne treatments as well as this editorial on prescribing isotretinoin as a family physician if you'd like to read more.
The October 15 issue of AFP includes an article on "Acne Vulgaris: Diagnosis and Treatment;" for many types of acne (Figure 4), a topical retinoid medication is the first line of treatment. Although topical retinoids are highly effective, many physicians don't prescribe them, follow-up appointments often don't happen, and adherence to these sometimes irritating treatments can be spotty at best.
For acne primarily composed of comedones and/or mild inflammatory papules and pustules, a topical retinoid is first-line treatment; even moderate severity acne regimens should include a topical retinoid. Only severe, nodular acne regimens begin with a different treatment (isotretinoin) and, even then, once clinical improvement is noted, transitioning to a topical retinoid is often appropriate. Despite the near-ubiquity of topical retinoids in these recommendations, though, physicians are not consistently prescribing them first-line. A study of prescribing practices in the United Kingdom found that only 38% of patients receiving a topical antibiotic prescription for acne also received a topical retinoid.
Patients also struggle with adherence to topical retinoids. In one study, 65.7% of adolescents and young adults self-discontinued their topical retinoid medication due to side effects such as irritation, redness, and scaling. They also found, however, that patients who were instructed to use their topical retinoid every other night had much lower discontinuation rates, possibly because their side effects were less bothersome.
The challenges of adhering to a topical retinoid regimen may explain poor follow-up and refill rates. A large database study of acne medication prescribing practices found that 66.1% of patients with new diagnosis of acne had no subsequent visit with that diagnosis for the year following, and 60.1% of patients did not have a documented refill for their medication within 90 days of their initial visit (despite most prescriptions being written for no more than 2 months' supply/refills).
Given the evidence in the above AFP article supporting retinoids' efficacy, these data present opportunities for both prescribers and patients to improve the use of this class of medications. Prescribing topical retinoids to be used every other night - or even every third night - may minimize irritation. Scheduling follow-ups a bit sooner may help patients and physicians problem-solve any challenges with adherence or side effects. Family physicians already prescribe generics and less-expensive acne treatments more often than other specialists, which can hopefully help any adherence issues related to cost.
There's an AFP By Topic on Skin Conditions which includes STEPS (Safety, Tolerability, Effectiveness, Price, Simplicity) articles on several acne treatments as well as this editorial on prescribing isotretinoin as a family physician if you'd like to read more.
Tuesday, October 15, 2019
To prevent maternal mortality, clinical care is just the beginning
- Kenny Lin, MD, MPH
According to the Centers for Disease Control and Prevention (CDC), about 700 U.S. women die from pregnancy-related complications every year. The U.S. maternal mortality rate has increased over the past 30 years and is considerably higher than rates in other high-income countries, and 60 percent of maternal deaths were potentially preventable through medical care. Around one-third of deaths occur during pregnancy, one-third during delivery or the first week postpartum, and one-third from one week to one year postpartum. In an article in the October 15 issue of AFP, Dr. Heather Paladine and colleagues discussed an overall approach to the "fourth trimester" (the first 12 weeks postpartum) and optimal strategies for prevention and prompt detection of some of the most frequent causes of postpartum deaths identified by the CDC: hemorrhage, hypertensive disorders, thromboembolic disorders, and infections. They also reviewed other common issues with health implications for the mother and newborn, such as thyroiditis, depression, urinary incontinence, constipation, weight retention, and breastfeeding problems.
In an accompanying editorial on "What Family Physicians Can Do to Reduce Maternal Mortality," Drs. Katy Kozhimannil and Andrea Westby encouraged clinicians to look beyond clinical risks to also address social determinants of health. These factors, which include "housing instability, food insecurity, community violence, firearms access, financial insecurity, and social isolation," are likely responsible for the large and persistent racial and ethnic disparities in pregnancy-related deaths. For example, the CDC reported that black and American Indian/Alaska Native women aged 30 years and older are four to five times as likely to die as a result of pregnancy complications than white women in the same age group.
Outside of the clinic, Drs. Kozhimannil and Westby suggested several strategies for family physicians to support pregnant patients in their communities: advocating for continuous health insurance coverage for the more than half of women who have public insurance at the time of delivery; supporting increased access to postpartum doulas and community health workers; continuing to provide obstetric services at rural hospitals; and reflecting on "one's own privilege and role in perpetuating or disrupting systems of oppression" that remain obstacles to achieving health equity.
For its part, the American Academy of Family Physicians (AAFP) took aim at the maternal mortality crisis by convening a Maternal Mortality Task Force in April and June to recommend evidence-based methods to decrease maternal morbidity and mortality, reduce implicit bias and disparities, and collaborate with other key stakeholders to explore solutions to the accelerating loss of rural obstetrical services. In its report to the 2019 Congress of Delegates (access restricted to AAFP members), the Task Force made a series of recommendations for improving maternal care quality and data collection; retaining family physicians and other clinicians who deliver babies in rural communities; and working with departments and residency programs in family medicine to develop sustainable maternity care workforce goals.
According to the Centers for Disease Control and Prevention (CDC), about 700 U.S. women die from pregnancy-related complications every year. The U.S. maternal mortality rate has increased over the past 30 years and is considerably higher than rates in other high-income countries, and 60 percent of maternal deaths were potentially preventable through medical care. Around one-third of deaths occur during pregnancy, one-third during delivery or the first week postpartum, and one-third from one week to one year postpartum. In an article in the October 15 issue of AFP, Dr. Heather Paladine and colleagues discussed an overall approach to the "fourth trimester" (the first 12 weeks postpartum) and optimal strategies for prevention and prompt detection of some of the most frequent causes of postpartum deaths identified by the CDC: hemorrhage, hypertensive disorders, thromboembolic disorders, and infections. They also reviewed other common issues with health implications for the mother and newborn, such as thyroiditis, depression, urinary incontinence, constipation, weight retention, and breastfeeding problems.
In an accompanying editorial on "What Family Physicians Can Do to Reduce Maternal Mortality," Drs. Katy Kozhimannil and Andrea Westby encouraged clinicians to look beyond clinical risks to also address social determinants of health. These factors, which include "housing instability, food insecurity, community violence, firearms access, financial insecurity, and social isolation," are likely responsible for the large and persistent racial and ethnic disparities in pregnancy-related deaths. For example, the CDC reported that black and American Indian/Alaska Native women aged 30 years and older are four to five times as likely to die as a result of pregnancy complications than white women in the same age group.
Outside of the clinic, Drs. Kozhimannil and Westby suggested several strategies for family physicians to support pregnant patients in their communities: advocating for continuous health insurance coverage for the more than half of women who have public insurance at the time of delivery; supporting increased access to postpartum doulas and community health workers; continuing to provide obstetric services at rural hospitals; and reflecting on "one's own privilege and role in perpetuating or disrupting systems of oppression" that remain obstacles to achieving health equity.
For its part, the American Academy of Family Physicians (AAFP) took aim at the maternal mortality crisis by convening a Maternal Mortality Task Force in April and June to recommend evidence-based methods to decrease maternal morbidity and mortality, reduce implicit bias and disparities, and collaborate with other key stakeholders to explore solutions to the accelerating loss of rural obstetrical services. In its report to the 2019 Congress of Delegates (access restricted to AAFP members), the Task Force made a series of recommendations for improving maternal care quality and data collection; retaining family physicians and other clinicians who deliver babies in rural communities; and working with departments and residency programs in family medicine to develop sustainable maternity care workforce goals.
Monday, October 7, 2019
Ruling out serious bacterial infections in the first weeks of life
- Jennifer Middleton, MD, MPH
Diagnosing serious bacterial infections (bacteremia, meningitis, and urinary tract infection) in the first 60 days of life can be challenging; the risks of missing these infections can be quite serious, but many infants with fever also receive empiric antibiotics and lumbar punctures that may be unnecessary. A new decision rule, reviewed in this October 1 AFP POEM, may help clinicians better predict which infants with fever are more likely to have a serious underlying cause.
The study researchers prospectively enrolled over 1800 infants aged 60 days or younger presenting to Emergency Departments (EDs) across the United States with fever. They excluded infants who appeared critically ill, had a history of prematurity, and/or had received antibiotics in the last 48 hours. Enrolled participants had an evaluation by a pediatric emergency medicine physician and received care however each physician felt was best indicated. All infants had blood and urine cultures obtained along with a complete blood count and serum procalcitonin. The researchers then followed these infants' outcomes; 9.3% (170) had a serious bacterial infection, and the researchers compared their lab values to those infants who did not end up with a diagnosed serious bacterial infection by using, as described by Dr. Barry in the AFP POEM summary, "a variety of statistical gymnastics" to derive their prediction rule:
We should also resist the temptation to extrapolate this newest decision rule to settings beyond the Emergency Department, though further studies validating this rule (and possibly comparing it directly to the Step-by-Step approach) in those settings could cement its role in helping us better predict which young infants with fever need aggressive testing and treatment - and which do not. There's an AFP By Topic on Neonatology/Newborn Issues that includes several articles about neonatal infections, management of respiratory distress, and an overview of neonatal resuscitation if you'd like to read more.
Diagnosing serious bacterial infections (bacteremia, meningitis, and urinary tract infection) in the first 60 days of life can be challenging; the risks of missing these infections can be quite serious, but many infants with fever also receive empiric antibiotics and lumbar punctures that may be unnecessary. A new decision rule, reviewed in this October 1 AFP POEM, may help clinicians better predict which infants with fever are more likely to have a serious underlying cause.
The study researchers prospectively enrolled over 1800 infants aged 60 days or younger presenting to Emergency Departments (EDs) across the United States with fever. They excluded infants who appeared critically ill, had a history of prematurity, and/or had received antibiotics in the last 48 hours. Enrolled participants had an evaluation by a pediatric emergency medicine physician and received care however each physician felt was best indicated. All infants had blood and urine cultures obtained along with a complete blood count and serum procalcitonin. The researchers then followed these infants' outcomes; 9.3% (170) had a serious bacterial infection, and the researchers compared their lab values to those infants who did not end up with a diagnosed serious bacterial infection by using, as described by Dr. Barry in the AFP POEM summary, "a variety of statistical gymnastics" to derive their prediction rule:
Using the validation sample, the combination of a negative urinalysis, an absolute neutrophil count less than 4,090 per mL, and a procalcitonin level of less than 1.71 ng per mL was accurate at ruling out serious infections: 97.7% sensitivity (95% CI, 91.3 to 99.6) and 60.0% specificity (56.6 to 63.3).Procalcitonin has shown promise before as a predictor of serious illness. The Step-by Step approach, outlined in this 2018 AFP Point-of-Care Guide, uses urinalysis and procalcitonin but also includes c-reactive protein (CRP) to exclude serious bacterial infections in young infants with fever. Last year on the blog, though, Dr. Lin reviewed conflicting evidence regarding procalcitonin's utility in identifying adult respiratory illnesses that would benefit from antibiotics. There's a Choosing Wisely recommendation to not perform procalcitonin testing "without an established, evidence-based protocol." A recent review also reminds us that procalcitonin elevations can be due to several other physiologic processes besides infection, and warns that procalcitonin-guided "algorithms for antibiotic stewardship may not be universally applicable across heterogeneous patient settings and in the 'real world' outside the framework of clinical trials."
We should also resist the temptation to extrapolate this newest decision rule to settings beyond the Emergency Department, though further studies validating this rule (and possibly comparing it directly to the Step-by-Step approach) in those settings could cement its role in helping us better predict which young infants with fever need aggressive testing and treatment - and which do not. There's an AFP By Topic on Neonatology/Newborn Issues that includes several articles about neonatal infections, management of respiratory distress, and an overview of neonatal resuscitation if you'd like to read more.
Tuesday, October 1, 2019
Should dietary guidelines suggest that people eat less meat?
- Kenny Lin, MD, MPH
There is a widespread consensus among nutrition and environmental scientists that reducing dietary meat intake, particularly red and processed meats, is not only beneficial for personal health, but also benefits the planet by reducing deforestation, freshwater consumption, and greenhouse gas emissions associated with cattle farming. Dr. Caroline Wellbery wrote in a 2016 AFP editorial: "According to the 2015–2020 [U.S.] dietary guidelines, moderate to strong evidence demonstrates that healthy dietary patterns that are higher in fruits, whole grains, legumes, nuts, and seeds, and lower in animal-based foods are associated with more favorable environmental outcomes."
Although the effects of individual dietary counseling in patients without cardiovascular risk factors are limited, the Dietary Guidelines for Americans, which are updated every 5 years, have been influential in changing eating patterns. A recent analysis of cross-sectional data from the National Health and Nutrition Examination Survey found small but significant decreases in consumption of refined grains and added sugar and increased consumption of plant proteins, nuts, and polyunsaturated fats from 1999 to 2016. Bigger changes could be on the horizon, if the efforts of entrepreneurs profiled in a recent article in The New Yorker to bioengineer and distribute plant-based hamburger patties and other products that are indistinguishable from real meat prove to be successful.
The next iteration of the Dietary Guidelines will need to consider new evidence that beneficial health effects of eating less meat may not be as large or as certain as previously thought. In a clinical guideline published this week in the Annals of Internal Medicine, an international panel from the Nutritional Recommendations and Accessible Evidence Summaries Based on Systematic Reviews (NutriRECS) consortium made the somewhat shocking suggestion that adults can continue their current (over)consumption of red and processed meats without major health consequences. Four linked systematic reviews found low-quality evidence of small to no benefits on cardiometabolic and cancer outcomes from consuming less red and processed meat in cohort studies and in randomized trials, and a review of health-related values and preferences suggested that "omnivores are attached to [eating] meat and are unwilling to change this behavior when faced with potentially undesirable health effects." Importantly, none of the guideline authors or systematic reviewers received any financial support from the meat industry.
Critical responses from the medical and public health community have been swift and plentiful. Some experts challenged the guideline panel's assessment of the magnitude of beneficial health effects of eating less meat as "very small." For example, meta-analyses estimated that after about 11 years, dietary patterns with 3 fewer servings of red meat per week are associated with absolute risk differences of 6 fewer cardiovascular-related deaths (number needed to treat = 167) and 14 fewer persons developing diabetes (NNT = 71) out of every 1000 persons. To an individual, these differences seem small, but they compare favorably with the NNTs of established clinical preventive services such as colorectal cancer screenings and therapy for osteoporosis. Others faulted the guideline for excluding benefits to animal welfare and the environment from lower population-wide meat consumption. Goals and guidelines for what constitutes a healthy diet will continue to evolve, but this one has provided much food for thought.
There is a widespread consensus among nutrition and environmental scientists that reducing dietary meat intake, particularly red and processed meats, is not only beneficial for personal health, but also benefits the planet by reducing deforestation, freshwater consumption, and greenhouse gas emissions associated with cattle farming. Dr. Caroline Wellbery wrote in a 2016 AFP editorial: "According to the 2015–2020 [U.S.] dietary guidelines, moderate to strong evidence demonstrates that healthy dietary patterns that are higher in fruits, whole grains, legumes, nuts, and seeds, and lower in animal-based foods are associated with more favorable environmental outcomes."
Although the effects of individual dietary counseling in patients without cardiovascular risk factors are limited, the Dietary Guidelines for Americans, which are updated every 5 years, have been influential in changing eating patterns. A recent analysis of cross-sectional data from the National Health and Nutrition Examination Survey found small but significant decreases in consumption of refined grains and added sugar and increased consumption of plant proteins, nuts, and polyunsaturated fats from 1999 to 2016. Bigger changes could be on the horizon, if the efforts of entrepreneurs profiled in a recent article in The New Yorker to bioengineer and distribute plant-based hamburger patties and other products that are indistinguishable from real meat prove to be successful.
The next iteration of the Dietary Guidelines will need to consider new evidence that beneficial health effects of eating less meat may not be as large or as certain as previously thought. In a clinical guideline published this week in the Annals of Internal Medicine, an international panel from the Nutritional Recommendations and Accessible Evidence Summaries Based on Systematic Reviews (NutriRECS) consortium made the somewhat shocking suggestion that adults can continue their current (over)consumption of red and processed meats without major health consequences. Four linked systematic reviews found low-quality evidence of small to no benefits on cardiometabolic and cancer outcomes from consuming less red and processed meat in cohort studies and in randomized trials, and a review of health-related values and preferences suggested that "omnivores are attached to [eating] meat and are unwilling to change this behavior when faced with potentially undesirable health effects." Importantly, none of the guideline authors or systematic reviewers received any financial support from the meat industry.
Critical responses from the medical and public health community have been swift and plentiful. Some experts challenged the guideline panel's assessment of the magnitude of beneficial health effects of eating less meat as "very small." For example, meta-analyses estimated that after about 11 years, dietary patterns with 3 fewer servings of red meat per week are associated with absolute risk differences of 6 fewer cardiovascular-related deaths (number needed to treat = 167) and 14 fewer persons developing diabetes (NNT = 71) out of every 1000 persons. To an individual, these differences seem small, but they compare favorably with the NNTs of established clinical preventive services such as colorectal cancer screenings and therapy for osteoporosis. Others faulted the guideline for excluding benefits to animal welfare and the environment from lower population-wide meat consumption. Goals and guidelines for what constitutes a healthy diet will continue to evolve, but this one has provided much food for thought.