Can contact tracing apps slow the spread of COVID-19?

 - Jennifer Middleton, MD, MPH

"Outpatient Management of COVID-19: Rapid Evidence Review," in the current issue of AFP, discusses current testing and treatment recommendations. It includes quarantine recommendations for close contacts of COVID-19 individuals; to identify those contacts, the Centers for Disease Control and Prevention (CDC) recommends that public health departments conduct contact tracing for all confirmed COVID-19 positive persons. With infrastructure challenges limiting contract tracing in many parts of the US, contact tracing apps have been proposed as a possible solution, but they also bring several barriers to widespread implementation of their own.

The CDC advises that all close contacts of COVID-19 positive persons should be tested, and those who test negative should quarantine for 14 days. Robust contact tracing has the potential to dramatically decrease COVID-19 spread, and contact tracing apps promise to do what manual contact tracing has thus far struggled to keep up with:

[Y]our phone will regularly send out a beacon via Bluetooth that includes a random Bluetooth identifier — basically, a string of random numbers that aren’t tied to a user's identity and change every 10-20 minutes for additional protection...Other phones will be listening for these beacons and broadcasting theirs as well.....If you later come down with COVID-19, open the health app on your phone and log a diagnosis. The phone then uploads the last two weeks' worth of beacon data, and asks for your permission to anonymously share your results and notify others.

Similarly, if someone you have been in contact with reports a positive COVID-19 test, you can then be notified to get tested and begin quarantining. Concerns with privacy have affected uptake of these apps, and surveys suggest that many persons using them are unwilling to follow through on testing and quarantine recommendations. Of course, owning a smartphone is a prerequisite to using such an app as well; in the US, 19% of adults don't own a smartphone, and in adults over the age of 65, that percentage is 47%. 

Given these concerns, health leaders in Europe have raised concerns that contact tracing apps may be one part of the solution but cannot fully substitute for manual tracing efforts. Public health has been underfunded in the US for decades, despite data showing that most people find public health to be valuable; indeed, for every $1 spent in public health efforts in high-income countries, $14 in future health expenditures are saved. Perhaps the COVID-19 pandemic will provide the necessary momentum to improve our investment in these vital services.

In the meantime, you can continue to find current COVID-19 information and resources at the AFP By Topic: Coronavirus Disease 2019 site.

Cancer survivorship: what is the family physician's role?

 - Kenny Lin, MD, MPH

Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized. The National Cancer Institute estimated that in 2019, cancer survivors numbered 16.9 million, or about 5 percent of the U.S. population. During the past few years, American Family Physician has published clinical reviews of the American Cancer Society's guidelines on primary care for survivors of prostate cancer, colorectal cancer, and breast cancer. The American Academy of Family Physicians' policy on Cancer Care recommends that "the physician workforce, including family physicians, should be educated about the protocols for survivorship management."

A recent qualitative study published in the Annals of Family Medicine found that the reality on the ground is more complex than current guidelines and policy suggest. Dr. Benjamin Crabtree and colleagues recorded lengthy interviews with 38 clinicians in 14 U.S. primary care practices that had been previously recognized for workforce innovation by the Robert Wood Johnson Foundation. In these interviews, clinicians were "asked to describe how they viewed their role in cancer survivorship, decisions of when and where to refer patients, and knowledge about new primary care–friendly survivorship care guidelines."

Analysis of the interviews revealed a lack of consensus about the role of primary care in cancer survivorship. For example, several clinicians felt that follow-up cancer care was exclusively the responsibility of oncologists, but the majority expressed that providing this care fell within their purview. However, they reported obstacles ranging from inadequate knowledge / education to "an uneasy relationship with oncology" and a lack of clarity about when care could be transitioned from the oncologist to primary care.

Clinicians also disagreed about whether cancer survivors should be treated as a "distinct patient population" (requiring a systematic health system approach) or like any other patient with a chronic disease. The researchers theorized that these divergent views reflected an "identity crisis" about their care roles for these patients:

Several clinicians expressed mixed opinions, contradicted themselves, vacillated on their stance, or paused when asked about their/primary care’s role in cancer survivorship care. In fact, some clinicians struggled to talk about cancer survivorship at all in their interviews. ... These clinicians, with an identity based on delivering whole-person, comprehensive, coordinated care, appeared to hit a wall of identity confusion when confronted with a swiftly changing highly specialized knowledge base and a highly variable group of patients referred to as “cancer survivors.”

Options for resolving this identity crisis, according to the researchers, could involve developing new cancer-focused curricula for primary care residency programs and continuing medical education; constructing more well-defined management boundaries between primary care and oncology; and/or having their professional organizations "consider coproducing and translating new knowledge about care for cancer survivors that primary care clinicians can prioritize, personalize, and integrate to address patients’ needs and values within a shared decision-making framework." With the population of cancer survivors expected to increase by 30 percent over the next decade, clarifying the appropriate role of family physicians remains an urgent national need.

Is intermittent fasting's time up?

 - Jennifer Middleton, MD, MPH

As obesity rates continue to rise, the elusive search for a solution persists. Intermittent fasting (IF) offers a simple approach; eat whatever you want within a designated time interval and then do not eat the rest of the time. Early, small studies suggested that intermittent fasting (IF) was more effective for weight loss than traditional calorie restriction diets, and IF's popularity has been boosted by disease-oriented studies demonstrating improvement in metabolic markers. A multitude of famous adherents have also contributed to IF's rising profile.

More recent, rigorous studies, however, may dampen the enthusiasm for IF. In 2018, a systematic review of intermittent fasting's effectiveness found similar rates of weight loss with IF compared to traditional calorie restriction. Later that year, a trial randomized 150 obese or overweight adults to either continuous energy restriction, IF using the "5:2" method (5 days a week of normal intake and 2 days a week of 25% intake), or placebo and then followed them for 50 weeks. It found that intermittent fasting "may be equivalent but not superior" to the traditional calorie restriction method.

And, now we have a new, 2020 randomized controlled trial. Researchers randomized 141 participants to either a "16:8" IF regimen (eat anything desired between noon-8 pm, then fast for the next 16 hours) or a "consistent meal timing" plan and then followed them for 12 weeks. The difference in weight loss between the two groups was non-significant (-0.26 kg [95% confidence interval −1.30, 0.78]). The IF group also demonstrated a decrease in lean muscle mass (-0.16 kg/m2 [95% CI -0.27, -0.05]) compared to the comparison group. 

If this loss of muscle mass is replicated in other studies, IF's time might truly be up. This seemingly never-ending search for a "magic" diet plan additionally fails to account for the complex mechanisms behind obesity. Systemic environmental factors are the primary drivers of the obesity epidemic, not individual choice and a scarcity of willpower. The over-abundance of super-processed, inexpensive foods set humans, genetically hard-wired to crave fat and sugar, up for failure. Chronic stress and epigenetics affect both dietary preferences and metabolism. As long as we continue to neglect these powerful drivers of behavior, obesity will remain a public health crisis, one that COVID-19 will likely also continue to exploit. 

You can read more in the AFP By Topic on Obesity, which includes this Curbside Consultation on "Obesity: Psychological and Behavioral Considerations."

Guest Post: Virtual Conferences - New Possibilities in the New Normal

- Suzanne Minor, MD; Andrea Berry, MPA; Weichao Chen, PhD

Many conferences have transitioned to a virtual format, including FMX and regional conferences. While many physicians have experience with online CME sessions, attending an entire conference through virtual technology will likely be a new experience for many of us. Even though virtual conferencing is different than our usual conference experience, attending a virtual conference can still be an effective way to learn best practices of clinical care and to engage with colleagues and our professional organizations. In fact, virtual conferencing presents unique opportunities for participation and engagement. This blog post outlines strategies to make the most of virtual conference experiences and seize unique opportunities offered in a virtual format.

Strategies to Maximize Learning

Before the conference begins, take the time to outline your overall goals and plans. According to a recent review, taking time to plan activities and outline a schedule sets you up for success.

Review the conference schedule carefully to identify high-yield sessions to attend live, taking into consideration time zone differences. Virtual conferences offer different types of virtual sessions, ranging from plenary, paper and poster presentations, workshops, small groups, demonstrations, and social events. Some sessions may require live participation at a set time, while others offer more flexibility. Prioritize the sessions that you plan to attend live and watch recordings of other didactic-based sessions on demand. Explore novel formats of participation afforded by virtual conferencing, such as preconference virtual rooms.

Familiarize yourself with the technologies to be used. Different conferences might use a variety of technologies for synchronous sessions, backchannel communication, and social networking. Install the applications (apps) and necessary plug-ins beforehand. If you plan to join the conference from work, check if technology usage might be blocked by your institutional Internet firewall.

Actively combat Zoom fatigue, or the feeling of being overloaded by video conferencing. Recommended strategies include scheduling regular break times between live sessions and avoiding multitasking and reducing on-screen distraction during live sessions, including the distraction from watching your own video. Based on your personal schedule, block time free of patient care and other job and life duties for live or priority sessions. Locate a space with less distraction for you to engage in productive online learning and dialogue during virtual conferencing.

Despite the difference in virtual conference experiences, many strategies useful in traditional conferences remain helpful:

During the conference, network actively, remain open minded to unfamiliar topics, share major take-away and useful resources via social media, and support your colleagues by attending their sessions. After the conference, obtain CME credits, add your presentation into your resume, fill out evaluation forms to provide feedback to conference organizers, reflect on the new ideas gleaned and plan for application in your practice, reach out to newly met colleagues for collaboration opportunities, and thank your institution, office staff or covering colleagues for supporting your attendance.

Unique Opportunities Offered by Virtual Conferences

Virtual conferences provide unique opportunities beyond what is possible in a traditional face-to-face format. Many conferences integrate a twitter connection within the app to allow participants to connect with like-minded physicians by posting thoughts, pearls, and questions about presentation content. This can be especially meaningful for physicians from minority groups who have found these tools invaluable in seeking support and meaningful interactions to combat isolation.

Beyond the unique tools, virtual conferences afford more physicians the opportunity to access learning that may have been previously beyond their reach. Cost and number of days out of the practice are reduced as there is no need to pay for transportation or hotels and no additional time needed to travel to distant locations. Additionally, the influx of new participants brings new opportunities to expand your network and access diverse perspectives throughout the program.

Is physical therapy beneficial for acute back pain with sciatica?

 - Kenny Lin, MD, MPH

Although a referral to physical therapy is a standard part of my treatment plan for patients with subacute or chronic low back pain, there is little data on the effectiveness of physical therapy for acute back pain. A 2018 Family Physicians Inquiries Network (FPIN) Clinical Inquiry published in American Family Physician found that physical therapy begun within 24 hours of clinical presentation provides minimal improvements in pain, satisfaction, and mental health at one week that disappear by one month. Physical therapy started within 48 to 72 hours of presentation had no significant effects on pain or disability. A 2002 randomized trial found no differences in pain or activities of daily living in patients with acute low back pain with sciatica who were assigned to bed rest, physical therapy, or a control group. A 2008 study reported that physical therapy added to usual care from a general practitioner improved patients' global perceived effect but had no effects on pain or disability. Another FPIN Clinical Inquiry on treatments for sciatica concluded that nonsteroidal anti-inflammatory drugs, systemic steroids, topiramate, pregabalin, traction, and best rest were all ineffective and had potential adverse effects. The authors did not review physical therapy.

A single-blind randomized controlled trial published today in the Annals of Internal Medicine compared early referral to physical therapy to usual care in 220 adults aged 18 to 60 years with acute back pain with sciatica for less than 90 days. Participants were recruited from primary care practices in two health care systems (Intermountain Healthcare and University of Utah). All participants received an evidence-based patient education booklet about low back pain; patients assigned to the intervention group were scheduled for 6 to 8 exercise and manual therapy sessions over 4 weeks with one of the study physical therapists. The primary outcome was change in the Oswestry Disability Index (OSW) score from baseline after 6 months.

Compared to the usual care group, intervention group participants reported greater improvements in OSW scores at 6 months (5.4 points) and 1 year (4.8 points). They also had lower back pain intensity and were more likely to report treatment success after 1 year (45% vs. 28% for usual care). However, health care use and missed workdays were not significantly different between groups.

Although this study's results appear to support early referral to physical therapy for patients with acute back pain with sciatica, they come with some caveats. The minimal clinically important difference on the OSW for this condition is 6 to 8 points, greater than the mean point estimates of between-group differences seen in this study. Also, since participants were not blinded to their group assignment and the usual care group did not receive sessions with a comparable contact time as the physical therapy sessions, it's possible that the modest improvement had less to do with the therapy than the caring attention that patients received from the therapists. The cost-effectiveness of referring every patient with this condition to a physical therapist is also uncertain.

Nonetheless, given the limited options currently available for patients with acute back pain with sciatica, it seems reasonable for family physicians to offer a referral to a physical therapist rather than prescribing ineffective pharmacotherapy or obtaining unnecessary and potentially harmful imaging studies.