Changing physician behavior to avoid unnecessary steroid prescriptions

- Jennifer Middleton, MD, MPH

"Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care," e-published ahead of print this past week, reviews several diagnoses that steroids are commonly prescribed for along with the evidence base - or lack thereof - to support their use. Regarding the latter, Drs. Dvorin and Ebell review the evidence against short-term steroid use in allergic rhinitis, acute sinusitis, carpal tunnel syndrome, and acute bronchitis (in the absence of an underlying asthma or COPD diagnosis). Besides not improving patient-oriented outcomes for these conditions, the risks of a short-term course of steroids are not negligible. Changing treatment habits can be challenging for physicians, but implementing strategies that do successfully promote physician behavior change may be one worthwhile resolution to make for the upcoming new year.

Two recent articles provide guidance regarding the promotion of physician behavior change. The first, a comprehensive review published in 2017, found that "[c]ollaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective:" 

"Interactive and multifaceted continuous medical education programs including training with audit and feedback, and clinical decision support systems were found to be of benefit in improving knowledge, optimizing prescriptions...enhancing patient outcomes, and reducing adverse events." 

Interestingly, financial incentives were not found to meaningfully effect long-term behavior change regarding physician prescribing and/or treatment habits.

The second article, a rapid review conducted in Australia, specifically examined "changing prescribing behaviors with educational outreach:"

"Educational outreach involves a trained facilitator delivering a face-to-face program in a health professional’s setting (e.g. GP clinic) with the aim to change clinician behaviour, such as prescribing behaviours [sic]. Educational outreach programs can focus largely on education...or include a variety of supplemental or additional strategies like providing reminder letters or audit and feedback." 

This review found that educational outreach can be effective, but it was most effective when it focused on "specifically targeting barriers" to change. Semi-structured interviews of physicians included in the review additionally suggested that the "[c]ontent of EO visits needs to be practical, skills-focused and engaging to facilitate participation and uptake, as opposed to didactic or lecture-based."

These studies found that simple interventions, such as financial incentives and generic didactic content, were not effective, while more complex solutions, such as involving interdisciplinary teams in crafting policy change and tailoring educational outreach, were effective. If healthcare leaders and organizations want to promote meaningful change in physician behavior, then investment in these more complex solutions may be worth the effort.

The transition to a new year is often a time for resolutions regarding behavior change; in addition to avoiding unnecessary steroid prescriptions, perhaps you might also consider resolving to expand how you access AFP's content, such as using the Favorites feature on the homepage, listening to the podcast, viewing our YouTube videos, or following us on Twitter.

The top ten AFP Community Blog posts of 2019

- Kenny Lin, MD, MPH

Looking back over the year, the posts that resonated most with readers explored cardiovascular prevention dilemmas, meaningful outcomes in type 2 diabetes, diagnosis and prevention of serious bacterial infections, and low-value medical care.

1. Should physicians de-prescribe statins in older adults? (May 13) - 4038 views

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.

2. Has aspirin for primary prevention of CVD reached its expiration date? (June 8) - 1848 views

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

3. The family physician's role in vaccine-preventable disease outbreaks (February 11) - 1574 views

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.

4. Bye-bye Benadryl? (December 2) - 954 views

First-generation antihistamines (diphenhydramine, chlorpheniramine, and hydroxyzine) have more worrisome side effects than newer generation antihistamines (loratidine, cetirizine, and fexofenadine), and both generations have equal treatment efficacy.

5. Therapies for type 2 diabetes: improving outcomes that matter (February 19) - 771 views

When comparing therapies for type 2 diabetes, physicians, patients, and quality measures often get caught up in the disease-oriented outcome of glycemic control.

6. Is "prediabetes" a useful term? (August 12) - 770 views

Higher hemoglobin A1c levels (i.e., 6.0% to 6.4%), but also other important risk factors, such as family history of diabetes, higher fasting plasma glucose levels, and higher triglyceride levels, may predict greater risk of progression to diabetes.

7. Deliberate clinical inertia: protecting patients from low-value care (July 22) - 738 views

Ways to support deliberate clinical inertia in practice include: empathy and acknowledgment; symptom management; clinical observation; explanation of the natural course of the condition; managing expectations; and shared decision-making ("communicating rather than doing").

8. Does subspecialist medical care add sufficient value to be worth the added cost? (February 5) - 731 views

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.

9. Farewell to Close-ups (November 25) - 704 views

Our deepest gratitude goes to our patients for taking the time to tell their stories and their family physicians for transcribing and submitting them. The many patients and their physicians who have contributed to Close-ups are a testament to the strong bonds family physicians have with their patients.

10. Ruling out serious bacterial infections in the first weeks of life (October 7) - 684 views

We should resist the temptation to extrapolate this new decision rule to settings beyond the Emergency Department, though further studies 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.

Seasons Greetings from all of us at American Family Physician!

Hair dye and cancer risk

- Jennifer Middleton, MD, MPH

While white women are slightly more likely to get breast cancer than black women, black women are more likely to be diagnosed with aggressive breast cancers and also have a higher mortality rate. A large prospective cohort study examining "Hair dye and chemical straightener use and breast cancer risk in a large US population of black and white women" is making headlines with its findings that purport to explain at least some of this difference.

The researchers examined data from over 46,000 U.S. women with at least one sister with breast cancer who are participants in the Sister Study, a project supported by the National Institutes for Health. The Sister Study enrolled these women between 2003 and 2009, tracking any new onset of breast cancer among them along with possible associations of a wide array of variables. Some of these variables centered on hair products, specifically hair dye and chemical straighteners. Enrollees completed a questionnaire regarding their use of these products in the year prior to their enrollment; 55% reported the use of permanent hair dye. The participants were followed for an average of 8.3 years; during this time, nearly 2,800 of the Sister Study women developed breast cancer.

After controlling for menopausal status, age at menarche, educational attainment, smoking history, and age at first birth, the researchers found that the risk of developing breast cancer was higher in women who had reported hair dye use than those who had not, with a disparity in the effect based on ethnicity. Black women had a 45% increase in risk with permanent hair dye use (hazard ratio 1.45, 95% confidence interval 1.10-1.90) while the 7% higher risk in white women was not statistically significant (HR 1.07, 95% CI 0.99-1.16). The use of chemical straightener was also associated with an increased risk of developing breast cancer, though this risk was also not statistically significant (HR 1.18, 95% CI 0.99-1.41). The use of semi-permanent dye ("highlights") and temporary dyes were not associated with an increased risk of cancer. The researchers note the consistency of their findings with earlier, smaller studies.

When asked whether women should stop using these projects, the co-lead investigator of the study responded:

"We are exposed to many things that could potentially contribute to breast cancer, and it is unlikely that any single factor explains a woman’s risk. While it is too early to make a firm recommendation, avoiding these chemicals might be one more thing women can do to reduce their risk of breast cancer."

It's important to note that an observational study, like this one, can only determine correlation, not causality, between these hair products' use and the development of breast cancer. It also may not be appropriate to generalize this study's findings to women who don't have a sister with breast cancer; the women enrolled in the Sister Study may have been at higher risk of developing breast cancer to begin with since they had a positive family history. Discussing the study design, findings, and limitations with our patients can help them make an informed choice regarding their use of these products. There's an AFP By Topic on Cancer with a Breast Cancer subheading which includes information about risk reduction strategies, screening and diagnosis, and care of survivors if you'd like to read more.

Proposals to lower prescription drug prices: too little, too late?

- Kenny Lin, MD, MPH

A bright spot in the annual U.S. health spending report published last week by the Centers for Medicare and Medicaid Services (CMS) was a 1% decrease in retail prescription drug costs from 2017 to 2018, due to greater use of generics and a slower rise in brand-name prices. According to CMS, this was the first time that these costs have declined since 1973. A previous American Family Physician Community Blog post described ongoing efforts by physician groups, payers, and government to restrain rising drug prices; a 2017 editorial reviewed actions that individual health professionals could take to help patients; and a 2019 editorial discussed the high costs of insulin and what family physicians can do. It's possible that some of these efforts are beginning to bear fruit.

Prescription drug prices vary considerably across pharmacies, geographic regions, and even within the same town or metropolitan area. A cross-sectional study of cash prices for 10 common generic and 6 brand-name drugs in the fall of 2015 obtained using the online comparison tool GoodRx (which AFP uses to estimate drug prices) found that generic drugs were least expensive in big box pharmacies, followed by large chain (more than 100 retail locations) and grocery pharmacies, while small chains (4 to 100 stores) and independent pharmacies had the highest prices. For example, the mean price of one month of generic simvastatin 20 mg was $35 at big box pharmacies, $42 at large chains, $50 at groceries, $112 at small chains, and $138 at independent pharmacies. Cash prices for brand-name drugs varied less; one month of esomeprazole (Nexium) 40 mg, for example, cost between $302 and $345 across pharmacy types.

The American College of Physicians recently joined a growing number of groups advocating that CMS be given the authority to directly negotiate drug prices in Medicare Part D, which is currently forbidden by law. In contrast, the Department of Veterans Affairs (VA) Health System already controls prescription costs through direct negotiation and a closed formulary. A study in JAMA Internal Medicine calculated that in 2017, Medicare could have saved $1.4 billion on inhalers for asthma and chronic obstructive pulmonary disease by paying lower VA-negotiated prices, and $4.2 billion if it had paid VA prices and instituted the VA formulary.

But what about the pharmaceutical industry's assertion that lower negotiated prices would stifle innovation and reduce incentives for drug development? In a recent commentary, Dr. Peter Bach proposed that CMS adopt a "too little" or "too late" strategy, selectively negotiating prices of drugs that have either received conditional FDA approval based on a surrogate rather than a patient-centered outcome ("too little") or have passed their guaranteed 5-year period of FDA monopoly protection ("too late"). In 2019, if CMS had negotiated the prices of the top 10 most costly drugs in each category down to those in the United Kingdom (an average savings of 57%), Dr. Bach estimated that it could have saved $1 billion on the 10 "too little" drugs and $26 billion on the 10 "too late."

The potential savings are substantial. But compared to the staggering $336 billion the U.S. collectively spent on prescription drugs in 2018, are these proposed pricing reforms too little, too late?

Bye-bye Benadryl?

- Jennifer Middleton, MD, MPH

The Canadian Society of Allergy and Clinical Immunology (CSACI) released a statement last month asserting that newer generation antihistamines "should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria." They cite studies demonstrating that first-generation antihistamines (diphenhydramine, chlorpheniramine, and hydroxyzine) have more worrisome side effects than newer generation antihistamines (loratidine, cetirizine, and fexofenadine), and both generations have equal treatment efficacy. They end their statement with a call to move diphenhydramine products behind the counter.

The CSACI discuses studies showing that many physicians perceive first-generation antihistamines to have a faster onset of action, but this perception is inaccurate; in one double-blind study, cetirizine and loradatine were even found to have faster onset than chlorpheniramine. First-generation antihistamines do not relieve allergic symptoms better than newer generation antihistamines, and first-generation antihistamines have more serious side effects. First-generation antihistamines have been implicated in accidental overdoses, torsades de pointes, and significant sedation. This sedation has led to the use of first-generation antihistamines as sleep aids, but they have not been found to improve the quality or duration of sleep in adults. A 2006 randomized controlled trial also found that diphenhydramine use resulted in no sleep benefit to infants.

The 2016 AFP review on "Treatment of Allergic Rhinitis" is consistent with the CSACI's statement. One of the authors' Key Recommendations for Practice states that, "[c]ompared with first-generation antihistamines, second-generation antihistamines have a better adverse effect profile and cause less sedation." Impermeable dust-mite bedding covers, household air filters, and delayed exposure to foods or pets in early childhood have not been found to benefit patients. On the other hand, nasal saline irrigation, nasal corticosteroids, and newer generation oral antihistamines all receive endorsements from the authors' evidence review.

It seems unlikely that diphenhydramine will disappear any time soon. Johnson & Johnson, the manufacturers of Benadryl, released their own statement shortly after the CSACI's: "Benadryl products have been trusted..for more than 60 years" and are "safe and effective." The lay press in the United States has not shown great interest in covering the CSACI statement, and changing well-established habits may be challenging for patients and physicians alike. Recommending safer, more effective treatments, however, can be a first step for family physicians. There's an AFP By Topic on Allergy and Anaphylaxis if you'd like to read more.