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.

Farewell to Close-ups

- Caroline Wellbery, MD

Next week we will be publishing AFP’s last Close-ups, a feature that launched in 2007 to give our patients a space to share their illness experiences. We have heard from countless patients about experiences with needle phobia, paradoxical insomnia, pregnancy loss and healthy aging. Patients have written about personal triumphs such as losing weight or surviving cancer, as well as about health-related setbacks such as disability and depression.

At the same time, the family physician has played a key role in these vignettes. Patients have used Close-ups as a forum for thanking their doctors for their diagnostic acumen and their support, and for celebrating long-standing relationships that that contributed to their health and well-being. In one Close-ups, a patient welcomed her doctor to her house to teach him how to can vegetables; in another, a one-time rock-and-roller patient described recording a CD with his doctor. Close-ups has been a little like a family medicine practice, with patients sharing stories in the waiting room, the examining room and in their communities.

It has been wonderful to publish a feature profiling patients. Patient engagement is a potentially powerful tool in research and education. Patient stakeholder participation ensures that those who are both most vulnerable and most directly affected by illness are given a voice in clinical decision-making. We believe that Close-ups has meaningfully contributed to these efforts.

However, research still has a long way to go in assessing the impact of patient involvement in the medical team; even understanding patient priorities in the context of primary care physician practices has not been fully elucidated. Perhaps hardest of all is finding ways of coordinating patient participation given family physicians’ busy schedules and patients’ separate lives outside the clinic.

Some of these obstacles have applied to running Close-ups as well. As much as we’ve wanted to hear directly from patients, it has been challenging at times for our family physician contributors to organize interviews, obtain publication permissions and make sure that the story follows a consistent format. Maybe that is why few medical journals have been able to make space for patients to speak directly to peers and physician readers.

We want to give special thanks to our three long-term Close-ups facilitators – Dr. Jo Marie-Reilly, Dr. Amy Crawford-Faucher, and Dr. Sanaz Majd – for helping to keep up a steady flow of material during the dozen years since the feature began.

Finally, 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. Recently, one of our readers sent in her patient’s story: a man with end-stage renal disease who agonized in silence about how his wife would manage after he died. Until his doctor brought the couple in for counseling, he hadn’t talked to his wife about his fears, and in order to avoid the issue even skipped his dialysis. With his doctor’s support, he was able to take the practical steps he needed to face his illness, and, having received a kidney transplant, is celebrating 25 years of marriage.

With the closure of Close-ups, we make room for new features in AFP. But the relationships and connections between family physicians and their patients will continue to be the greatest reward and the driving force of our discipline.

**

Dr. Wellbery is Associate Deputy Editor of AFP. "A Devoted Couple," a Close-Ups about her late parents' remarkably similar final illnesses, appeared in the December 1 issue.

Testing and treating influenza: 2019 update

- Jennifer Middleton, MD, MPH

The 2019 AFP article on "Influenza: Diagnosis and Treatment," published online ahead of print last week, provides updates on the epidemiology, prevention, and management of influenza. Among this article's highlights are a discussion regarding which patients benefit most from testing, a validated decision rule that can aid this decision to test, and the importance of considering the pros and cons of antiviral medications for patients at low risk for influenza complications.

The article's authors review the classic symptoms of influenza: rapid onset of "cough, fever, myalgias, chills or sweats, and malaise that persists for two to eight days." Patients presenting with this constellation of symptoms have a pre-test probability high enough to obviate the need for testing:

In outpatient and emergency department settings, testing for influenza virus is not necessary to start antiviral treatment in a patient with suspected influenza infection, especially during seasons when influenza A and B viruses are circulating in the local community.

A validated clinical decision rule can assist physicians in making, or excluding, the diagnosis as well (fever and cough = 2 points, myalgias = 2 points, chills or sweats = 1 point, symptom onset within the last 48 hours = 1 point). Patients with 2 or fewer points are considered to be at low risk of having influenza, while patients with 4 or more points are considered to be at high risk. It may be most appropriate, then, to target testing for those patients with a moderate risk of influenza (3 points on this scale). Table 3 in the article reviews commercially available point-of-care tests for influenza.

Antivirals should always be prescribed in hospitalized patients, patients at high risk of complications (Table 1), and children younger than 5 years of age. For healthy older children and adults at low risk of complications, however, the CDC is less directive:

Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk with confirmed or suspected influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset.

The AFP authors, however, cite data showing that the cost and side effects of these medications are likely not worth the limited improvement in symptoms: 

Given their cost, modest benefits, and adverse effects (primarily nausea and vomiting with oseltamivir), these drugs are not routinely recommended for otherwise healthy patients with influenza.

In adults and children treated as outpatients, antiviral treatment does not decrease mortality or hospitalization rates. These medications' side effects can include nausea and vomiting as above "for oseltamivir... Zanamivir can cause bronchospasm, and peramivir can cause diarrhea." Antivirals do decrease the duration of influenza symptoms by about 24 hours when started within 24-36 hours of symptom onset. Family physicians should engage in patient-centered decision making regarding the pros and cons of antiviral treatment in low risk individuals.

Table 4 reviews the antiviral medications currently recommended for treating influenza. Oseltamivir is the first choice for most patients, including patients with severe influenza, pregnant patients, and children under 7 years of age. Since zanamavir is inhaled, it's contraindicated in persons with chronic lung disease. Peravamir is an expensive intravenous option, and baloxavir provides the convenience of single dose treatment.

This entire AFP article is well worth the read as we all prepare for another flu season; there's also an AFP By Topic on Influenza and previous blog posts on the evidence behind antivirals' efficacy, providing effective vaccine counseling, and other ideas to increase influenza vaccination rates if you'd like to read more.

Caring for military veterans: what family physicians should know

- Kenny Lin, MD, MPH

Although the United States government designates a single day (Veterans Day) to specifically honor persons with a history of military service, family physicians provide care to veterans all 365 days of the year. A review article and editorial in the November 1 issue of American Family Physician discussed selected health issues and resources for the estimated 18 million veterans living in the U.S., most of whom seek primary care in the community rather than at a Veterans Health Administration or military treatment facility. A pocket card developed by the U.S. Department of Veterans Affairs (VA) provides a list of suggested questions related to military service that can help clinicians and trainees take more careful, veteran-centered histories.

Conditions highlighted in the AFP review article include lower extremity overuse injuries, osteoarthritis, posttraumatic stress disorder, moral injury, sexual trauma, traumatic brain injury, chronic pain, depression and suicide. A recently published synopsis of the 2018 VA/Department of Defense clinical practice guideline on patients at risk for suicide provided evidence-based recommendations for assessing for current suicide risk and managing persons at low, intermediate, and high acute risk for suicide. In addition to facilitating access to nonpharmacologic and pharmacologic treatments, the guideline also found evidence to support firearm restrictions and safety counseling; reduced access to poisons and medications associated with overdose; and installing barriers to prevent jumping from lethal heights.


Source: U.S. Census Bureau

In an editorial in the Annals of Internal Medicine, Dr. Edward Manning, a physician-scientist who was an officer in the U.S. Marine Corps prior to medical training, made some personal observations about bridging the "cultural divide" between military and civilian life that can present unintended obstacles to the physician-patient relationship. Dr. Manning noted that "from the veteran's point of view ... all physicians in the military are officers," warranting the formal greeting of "Ma'am" or "Sir." However, "one unfortunate aspect of military culture may be the inherent distrust of physicians," whose physical and mental fitness evaluations can exclude candidates from all or some types of military service (e.g., piloting military aircraft). Family physicians who make the effort to ask patients about their military service and empathize with a veteran's point of view will be better equipped to provide personalized care to this diverse population.

What treatments are - and aren't - effective for atopic dermatitis?

- Jennifer Middleton, MD, MPH

Atopic dermatitis, or eczema, is quite prevalent in the United States, and its aggravating itching can significantly disrupt quality of life. Several studies in recent years have explored a range of alternative and additive therapies to treat atopic dermatitis. While some of these therapies have demonstrated potential, some have not; meanwhile, the evidence supporting the benefit of more traditional treatments continues to grow.

A Cochrane for Clinicians in the November 1 issue of AFP casts doubt on one proposed therapy, reviewing a meta-analysis that found minimal benefit, if any, of oral antihistamines compared to typical topical treatments for improving eczema symptoms. Another recent Cochrane review found that probiotics did not help patients with eczema. One of the "Top POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign" found bath oil ineffective for children with eczema.

Regarding effective treatments, however, other recent Cochrane reviews have affirmed the benefit of topical emollients as well as topical corticosteroids and UV light therapy. Another effective option for children and adults with moderate to severe eczema is topical tacrolimus, as reviewed in this AFP Cochrane for Clinicians article. An article on "Complimentary and Alternative Therapies for Atopic Dermatitis" describes small randomized controlled trials supporting the use of both evening primose oil and homeopathy, although additional, larger studies would help to confirm these findings.

The American Academy of Dermatology, as reviewed in this AFP Practice Guideline, further reinforces the importance of moisturizing regularly with products free of fragrance or other sensitizing ingredients. This guideline discusses indications for topical corticosteroids and topical calcineurin inhibitors (such as tacrolimus or pimecrolimus). The 2012 AFP "Atopic Dermatitis: An Overview" reviews diagnosis and classification along with commonly used medications and when to consider referral to a dermatologist. If you'd like to read more, the AFP By Topic on Skin Conditions' subheading on Dermatitis contains several additional resources.

Family physicians caring for fewer children: reversing the trend

- 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.

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.

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.

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:

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.

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.

Should we change how we treat mild asthma?

- Jennifer Middleton, MD, MPH

Inhaled corticosteroids are a mainstay for treating asthma; typically, they are prescribed on a scheduled basis, though many patients struggle with adherence. Two new studies may offer an alternative to scheduled inhaled corticosteroid dosing for patients with mild asthma.

As described in the "Top POEMS of 2018 Consistent with the Principles of the Choosing Wisely Campaign," these two randomized controlled trials compared the twice daily, scheduled use of budesonide (Pulmicort) to the as needed use of budesonide/formoterol (Symbicort) in patients with mild asthma. These researchers defined mild asthma as

asthma being uncontrolled while the patient was using short-acting bronchodilators as needed or as asthma that was well-controlled while the patient was using low-dose glucocorticoid or leukotriene-receptor antagonist maintenance therapy plus a SABA [short-acting beta agonist] as needed.

In the Symbicort Given as Needed in Mild Asthma (SYGMA) 1 trial, researchers randomized participants aged 12 years and older into three groups: twice daily placebo with an as needed terbutaline (a SABA) inhaler, twice daily placebo with as needed budesonide-formoterol, and twice daily budesonide with as needed terbutaline. Participants recorded daily peak expiratory flows, asthma symptoms, and nighttime awakenings using an electronic diary, and an electronic inhaler monitor recorded use of their as-needed inhaler. The researchers' primary outcome was "electronically recorded weeks of well-controlled asthma," a composite of all of these variables along with any documented additional prescribing of steroids (inhaled and/or oral). The as needed budesonide-formoterol group was superior to the as needed terbutaline group regarding mean percentage of weeks of well-controlled asthma (odds ratio 1.14, 95% confidence interval [CI] 1.00-1.30). The as needed budesonide-formoterol group was inferior to the maintenance budesonide group regarding weeks of well-controlled asthma (0.64, 95% CI 0.57-0.73), though there was no statistically significant difference regarding the secondary outcome of severe exacerbation occurrences in these two groups.

In the SYGMA 2 trial, the same group of researchers randomized participants aged 12 years and older into two groups to specifically focus on the outcome of severe exacerbations: as needed budesonide-formoterol versus maintenance budesonide. In contrast to the SYGMA 1 trial, where participants received daily reminders to use their inhalers, SYGMA 2 participants received no reminders. The researchers report that their preliminary results found a lower rate of exacerbations than anticipated (possibly because participants' inhaler adherence was also higher than anticipated), resulting in inadequate power with their sample size to demonstrate superiority of one group. They subsequently amended their study protocol to instead demonstrate noninferiority between the groups. The as needed budesonide-formoterol group had a 75% lower median dose of inhaled glucocorticoids than the maintenance budesonide group.

Both SYGMA trials offer the promise of less frequent inhaled steroid use for patients with mild asthma, though the results might not be convincing enough yet to change practice. Better powered studies would be useful to clarify 1) whether the trade-off of decreased steroid exposure is worth somewhat poorer weekly asthma control, and 2) whether there truly is any superiority between as needed budesonide-formoterol compared to maintenance budesonide regarding exacerbation rates. You can count on AFP to report the results of any future research and/or guideline changes; in the meantime, there's an AFP By Topic on Asthma if you'd like to read more (which includes this 2019 FPIN Clinical Inquiry on the use of intravenous magnesium to treat exacerbations in the emergency department).

Using life expectancy and prognosis to support shared decision-making

- Kenny Lin, MD, MPH

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

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

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

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

Guest post: AAFP Family Medicine Discovers!

Hello AAFP members!

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

What is Family Medicine Discovers?

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

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

What does Family Medicine Discovers offer to scholars?

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

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

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

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

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

Best wishes,

Jen Carroll (Director AAFP NRN) and Christina Hester (Research Director AAFP NRN)

POEMs spotlight tests and interventions to consider avoiding in practice

- Kenny Lin, MD, MPH

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

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

1. Subacromial decompression surgery does not work.

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

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

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

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

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

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

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

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

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

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

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

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

Who should treat hepatitis C?

- Jennifer Middleton, MD, MPH

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

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

A 2017 survey of primary care physicians and nurse practitioners identified that few were currently providing hepatitis C treatment, though 84% were interested in obtaining more training to do so:

Willingness to provide treatment was strongly linked to having a high proportion of HCV-infected patients (>20% versus <20%; OR 3.9; 95% confidence interval [CI] 1.5–10) and availability of other services at the primary care site including HIV treatment (OR 6.5; 95% CI 2.5–16.5), substance abuse treatment (OR 3.3; 95% CI 1.3–8.4) and mental health services (OR 4.9; 95% CI 2.0–12.1).

Connecting to local resources in the form of substance abuse treatment (since most hepatitis C infection in the United States is due to injection drug use), mental health services, and integrated clinical pharmacists (as DN's family doctor did) are critical to empowering more family physicians to prescribe hepatitis C treatment. Willingness to care for formerly incarcerated persons may also play a role; this 2018 post from Dr. Lin reminds us of the health risks these patients face when they re-enter society, which are at least partially attributable to the challenges they face accessing primary care.

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

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

E-cigarettes and health: some answers, more questions

- Kenny Lin, MD, MPH

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

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

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

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

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

Is "prediabetes" a useful term?

- Jennifer Middleton, MD, MPH

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

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

Arguing against the use of metformin is Dr. Steven Brown, who describes his concern with using prediabetes as an impetus to prescribe medication. He cites the above-mentioned 2017 meta-analysis' findings that, "[c]ompared with the reference standard of an oral glucose tolerance test, a single A1C measurement is 49% sensitive and 79% specific for prediabetes." He interprets the DPP findings differently:

 At four years, the average A1C was 5.9% in the metformin or lifestyle groups and 6.1% in the placebo group. Although these surrogate outcome differences are statistically significant, they are not clinically meaningful. Treating borderline glucose values does not improve quality of life, mortality, or any other patient-oriented outcomes.

It's quite possible that the DPP's findings were less significant because of the inherent imprecision in the "prediabetes" label. As Dr. Lin wrote in an earlier post on the Community Blog, "the term prediabetes is misleading: many of these patients will not develop diabetes." A more precise risk elucidation may be found in that same 2017 meta-analysis, where "those most at risk of developing diabetes had both impaired fasting glucose and impaired glucose tolerance." 

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

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

- Kenny Lin, MD, MPH

Family physicians have long recognized that gun violence is a national public health epidemic. In 2015, a coalition of nine medical, public health, and legal organizations, including the American Academy of Family Physicians and the American Bar Association, endorsed several specific recommendations for preventing firearm-related injury and death. These measures included universal criminal background checks for all firearm purchases; educating patients about gun safety and intervening in those at risk of self-harm or harm to others; improving access to mental health care; regulating civilian use of firearms with large capacity magazines; and supporting more research on evidence-based policies to prevent gun violence. A 2014 editorial in AFP also reviewed the role of primary care clinicians in counseling about gun safety based on the best available evidence.

After the February 2018 massacre of 17 people at Marjory Stoneman Douglas High School in Parkland, Florida by a 19 year-old former student wielding a legally purchased semiautomatic AR-15-style rifle, the medical editors of AFP felt that we needed to do more to empower clinicians. Surely, when the Founding Fathers endorsed the necessity of a "well-regulated Militia" in the Second Amendment to the U.S. Constitution, they did not envision mentally disturbed teenagers toting weapons with enough firepower to overwhelm entire regiments of Minutemen.

In a special editorial published online ahead of print, Dr. Sexton and the AFP medical editors argued that family medicine's emphasis on care of the whole person creates a duty to "confront the epidemic of violence by persons using guns." We reviewed the evidence of the effects of firearm regulations, mental health counseling, and active shooter training on gun safety and violence:

A 2018 RAND review of U.S. studies on gun policy published since 2003 concluded that child-access prevention laws (e.g., safe gun storage) reduce self-inflicted and unintentional firearm deaths and nonfatal injuries among youth, and may reduce unintentional firearm injuries among adults. The review also found moderate evidence that laws requiring background checks and prohibiting firearm purchases by individuals with mental illness reduce violent crime and deaths. In contrast, state stand-your-ground laws are associated with increased homicide rates. There was insufficient evidence to determine whether any laws prevent mass shootings. 

Notably, almost two-thirds of the 36,000 firearm-related deaths in the U.S. each year are suicides, leading to our recommendation that "strategies to mitigate firearm suicides should include depression screening and nonjudgmentally asking anyone with depression whether they have a gun in the home." Useful clinical tools include the FIGHTS screening tool for adolescent firearm carrying, the SAD PERSONS suicide risk assessment scale, and the Violence Screening and Assessment of Needs tool for assessing risk of violence in military veterans.

Finally, we encouraged family physicians to address the epidemic by making their voices heard in community meetings, online forums, and local publications and communicating with elected state and federal officials to advocate for funding research to study ways to reduce gun violence: "Whether it is speaking up in clinical settings, within our community, or with our elected officials, our voices can make a meaningful difference for our patients, our communities, and our nation."

**

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