Did eliminating annual pap tests worsen chlamydia screening rates?

- Jennifer Middleton, MD, MPH

Despite the USPSTF's recommendation to screen all sexually active women aged 15-24 for chlamydia annually (along with women over age 24 at increased risk), many women do not receive this testing. Even worse, a recent study in the Annals of Family Medicine found that the rate of annual chlamydia screening in young women in one health care system decreased after 2009, the year the American College of Obstetrics and Gynecology (ACOG) updated their cervical cancer screening recommendations and increased both the initial age of screening and the recommended screening interval for cervical cancer (which is consistent with the United States Preventive Services Task Force [USPSTF]'s current recommendations). Given that asymptomatic chlamydia infections can cause serious, potentially permanent complications in women, this study should prompt each of us to examine how and when we are screening for chlamydia in our offices.

The study researchers obtained data from 5 outpatient family medicine offices in a university-based health care system. They looked at the number of visits made by women aged 15-21 for any reason and calculated the percentage of women who had received chlamydia screening during two 13-month intervals, the first spanning 2008-2009 and the second 2011-2012. The total number of office visits for each cohort was similar. The odds ratio for having chlamydia screening done in the 2008-2009 group compared to the 2011-2012 group was 13.97 (95% confidence interval 9.17-21.29); in these offices, at least, chlamydia screening happened significantly more often when annual gyn exams were still the norm.

As discussed in the current issue of Family Practice Management, the Choosing Wisely campaign's goal is to eliminate medical overuse - unnecessary, potentially harmful care. Annual cervical cancer screening certainly falls into this category, as do annual screening pelvic examinations. Many of us family physicians currently practicing, however, learned to associate sexually transmitted disease (STD) screening with these no-longer annual visits; a decrease in chlamydia screening may be an unintended consequence of scaling back on cervical cancer screening.

The importance of this screening regarding our female patients' reproductive health cannot be overstated; the Centers for Disease Control (CDC) estimates that 60% of female infertility could be eliminated with appropriate chlamydia screening. Family physicians may find it helpful to measure the rate of chlamydia screening in their own practices, and, if suboptimal, consider implementing an office quality improvement initiative to increase screening. Using a urine sample to screen, which is as accurate as a cervical sample, may be one way to reduce barriers for both patients and clinicians. The National Committee for Quality Assurance (NCQA) has a publication addressing chlamydia screening which includes several additional strategies to try.

There's an AFP By Topic on STDs if you'd like to read more, and the collection contains this 2012 article on chlamydia infection screening, diagnosis, and management.

How is your office screening women for chlamydia?

How to make sure your patients understand health information

- Kenny Lin, MD, MPH

In the July 15th issue of AFP, associate medical editor Barry Weiss, MD shares an anecdote about a hospitalized patient's confusion about a conversation between himself and a consultant who said that it was okay to move her from the intensive care unit to the floor. The perplexed patient interpreted "floor" literally to mean that the hospital was so overcrowded that she would not be able to sleep in a bed! Although this mildly comical story might elicit chuckles at health professional gatherings, it also highlights the serious potential for limited health literacy to lead to misunderstandings between doctors and patients.

Health literacy encompasses essential skills that patients need to access health services, understand and apply health information, and make good decisions: reading, writing, numeracy, and communication. A large body of evidence demonstrates strong associations between low health literacy and poorer health outcomes; compared to patients with high health literacy, patients with low literacy have more hospitalizations, more emergency department visits, and are less likely to receive appropriate preventive and chronic care services. According to a clinical review by Dr. Lauren Hersh and colleagues, "More than one-third of U.S. adults, an estimated 80 million persons, have limited health literacy, making it more difficult for them to read, understand, and apply health information. ... Although U.S. adults on average read at an eighth-grade level, more than 75% of patient education materials are written at a high school or college reading level." Limited health literacy is more common in patients age 65 years and older and in minority populations.

How can family physicians make sure their patients understand health information? Rather than routinely screening for low health literacy, which has not been shown to improve outcomes, Dr. Hersh and colleagues recommend taking "universal health literacy precautions," a group of strategies for enhancing verbal and written communication, and visual aids (including online videos). For example, clinicians can use "teach back" to ask patients to restate the medical concept or plan in their own words to confirm understanding. Online tools are available to quickly assess the reading level of written patient materials. Patients also benefit from being encouraged to participate actively in formulating their care plans and being connected to community literacy resources, if needed.

For more information on how to bridge the health literacy gap with your patients, see this recent Family Practice Management article and the Agency for Healthcare Research and Quality's Health Literacy Universal Precautions Toolkit.

Which antidepressants have the highest suicide risk?

- Jennifer Middleton, MD, MPH

All antidepressant medications carry a black box warning regarding an increased risk of suicidal behaviors, especially in teens and young adults. That black box warning assigns equal culpability to all antidepressants, but a POEM in the July 1 issue of AFP describes a study that found a higher risk of suicide with mirtazapine and venlafaxine compared with selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). 

The study researchers used a primary care patient database from the United Kingdom and identified patients between the ages of 20-65 with a depression diagnosis. They excluded patients who had other co-morbid psychiatric disease and/or who received a mood stabilizer or antipsychotic medication, ending up with a final cohort of about 240,000 patients. The researchers tracked rates of completed suicides and suicide attempts among these patients and compared these rates among patients taking various antidepressants. 

Citalopram was the most commonly prescribed antidepressant, followed by fluoxetine, with venlafaxine and mirtazapine prescriptions in fifth and seventh place, respectively. The adjusted hazard ratios for venlafaxine and mirtazapine for suicidal behavior (successful or not) were 1.70 (1.44 to 2.02) and 1.85 (1.61 to 2.13), respectively, compared with citalopram. All of the SSRIs and TCAs had non-significant hazard ratios compared with citalopram. The highest rates of completed suicide and suicide attempt, regardless of antidepressant, were in the first 28 days of a new prescription and the first 28 days after stopping an antidepressant medication. The researchers did not find a statistically significant difference in suicide risk by age. 

It is possible that, in the study cohort, patients taking venlafaxine and mirtazapine had more serious and/or refractory depression compared to patients taking an SSRI or TCA. These patients' physicians may have prescribed venlafaxine or mirtazapine after an SSRI or TCA treatment failure, for example. The researchers attempted to account for patients' depression severity in their analysis, but the documentation of depression severity in the database was inconsistent. They concluded that "the severity of depression is likely to still have a confounding influence on our results." Regardless of the reason, the difference in suicide risk for patients taking venlafaxine or mirtazapine is significant. These medications may still serve a need in certain clinical situations, but they require careful monitoring and should not be first-line medications.

This study compliments the already sizable evidence base regarding SSRIs' efficacy and tolerability; SSRIs remain the first choice for treating most patients with depression. Regardless of antidepressant choice, we need to carefully monitor patients during the first 28 days of any new antidepressant medication as well as during the first 28 days after stopping one. Family Practice Management provides an Immediate Action Protocol for physicians to use once patients screen positive for suicidal thoughts. This protocol provides guidance regarding follow-up questioning and can help physicians determine if a need exists for immediate psychiatric evaluation. Using a protocol like this one can help physicians avoid any language that might, unintentionally, inhibit suicide disclosure by patients. You can read more about depression treatment at the AFP By Topic on Depression and Bipolar Disorder.

Will this POEM change how you prescribe antidepressants and/or monitor patients for suicidal risk?

No benefit to extensive occult cancer workup after unexplained VTE

- Kenny Lin, MD, MPH

The diagnosis and and treatment of patients with deep venous thrombosis and pulmonary embolism is a common task in family medicine. In many instances, venous thromboembolism (VTE) is "provoked" by one or more predisposing risk factors, such as prolonged immobility, major surgery, pregnancy, or thrombophilia. In patients with a first episode of VTE without any known risk factors, one question that arises is how aggressively to test for a possible occult cancer, which may be present in up to 10 percent of cases. A Cochrane review of two small studies found inconclusive evidence that extensive testing for cancer improved cancer-related mortality compared to limited testing, although one study suggested that extensive testing advanced the time of cancer diagnosis.

A multicenter, randomized, controlled trial of 854 adults (mean age 54 years) with unprovoked VTE published in the New England Journal of Medicine provided more evidence to guide clinical decision-making. The control group underwent basic blood testing, chest radiography, and screening for breast, cervical, and prostate cancer; the intervention group received these tests and a computed tomography (CT) scan of the abdomen and pelvis. (25 percent of both groups had already received CT pulmonary angiography to diagnose a pulmonary embolism.) The primary outcome was confirmed cancers detected after one year of follow-up that were not diagnosed by the initial screening strategy. The trial found no statistical differences between the two groups in the primary outcome (missed cancers), mean time to a cancer diagnosis, or cancer-related mortality.

Since a CT of the abdomen and pelvis exposes a patient to a considerable dose of radiation and greatly increases the risk of detecting an incidentaloma, the harms of routinely providing this test to search for occult cancers in patients with unexplained VTE clearly outweigh the benefits.

Gloves for minor skin procedures: sterile or not?

- Jennifer Middleton, MD, MPH

When I ask my medical assistant to gather supplies for a simple skin lesion excision, I often hear this question in return: "Sterile gloves or not?" The decision of which type of gloves to wear has potential implications for both individual patients and overall healthcare costs. A POEM in the June 15 AFP asserts that, for most uncomplicated minor skin surgeries, sterile gloves are no better at preventing infection than clean, non-sterile gloves.

The authors randomized 493 patients who were receiving minor skin excisions in a primary care office to either a sterile glove or regular glove group. They had very broad inclusion criteria but did exclude patients taking antibiotics or immunosuppressives, and they did not include patients undergoing sebaceous cyst removal. They found no difference in post-procedure infection rates (-0.6%, 95th CI [-4.0%, 2.9%]) and noted that the use of non-sterile gloves saved an average of AUD $1 (USD $0.78) per procedure. These findings are consistent with a 2011 AFP article on shave and punch biopsies that lists non-sterile gloves on its "materials" table.

78 cents less for a pair of gloves may not seem like much, but The Institute of Medicine estimates that 30% of health care spending in the US is on waste. We could potentially save $53 billion a year by decreasing the costs of episodes of care. If every family doctor used non-sterile gloves for these procedures, how much might we save?

We have a finite healthcare resource pool, and every dollar spent unnecessarily is a lost opportunity. The small decisions we make every day in our offices - whether to order a CT scan, prescribe an antibiotic, or use sterile gloves for a simple excision - add up. Being a good financial steward doesn't have to equal substandard care. The Choosing Wisely campaign's primary aim is to prevent patient harm, yet avoiding unnecessary care also allows those healthcare dollars to be allocated elsewhere. True, bigger gains in healthcare cost savings require system initiatives, but we should not feel that we, as individual physicians, are powerless to make a difference. Even a simple decision about which pair of gloves to don can help.

You can read more about the Choosing Wisely campaign here, and the AFP website also has a handy Choosing Wisely search tool if you'd like to learn more about a particular initiative.

Antibiotics for acute appendicitis?

- Kenny Lin, MD, MPH

Until recently, the most well-studied clinical questions about acute appendicitis have been how to efficiently diagnose it using the history and physical examination and laboratory and imaging tests. Once appendicitis was identified, the next step was to perform an appendectomy, using a laparoscopic or open surgical approach. However, a recent review discussed evidence that some cases of acute appendicitis resolve spontaneously rather than leading to perforation. A 2011 Cochrane review of five randomized, controlled trials found that three-quarters of patients with acute appendicitis who were initially treated with antibiotics rather than surgery recovered completely within two weeks and did not experience a recurrence within one year. Due to the small sizes and other limitations of these trials, the American College of Surgeons has continued to recommend surgery as the "standard" treatment for acute appendicitis.

A study published in this week's JAMA may change a few minds about the utility of antibiotics for this condition. Dr. Paulina Salminen and colleagues randomized 530 Finnish adults aged 18 to 60 years with CT-confirmed uncomplicated acute appendicitis to a 10-day course of intravenous followed by oral antibiotics versus open appendectomy. 73 percent of patients in the antibiotic group did not need an appendectomy within 1 year; the rest, who underwent delayed appendectomies for signs of progressive or recurrent infections, did not develop intra-abdominal abscesses or other major complications as a result of waiting. Although the antibiotic "failure rate" of 27 percent exceeded the authors' pre-specified non-inferiority margin of 24 percent (compared to a 0.4 percent failure rate for initial surgery), the results confirm the viability of a medical approach to acute appendicitis.

A few issues would need to be addressed before antibiotics for acute appendicitis could be routinely implemented in American clinical practice. Unlike in Europe, most appendectomies in the U.S. are laparoscopic, which may make surgery more appealing to some patients. Children and adults older than age 60, who were not included in the JAMA study, may be at higher risk for complications from delayed surgery. Since acute appendicitis is common, we don't know if treatment with broad-spectrum antibiotics could worsen the problems of antibiotic resistance and Clostridium difficile infection. Finally, the lack of consensus on the "clinically important" difference needed to choose antibiotics over surgery may favor a shared decision making approach, which could be a challenge to carry out in the acute care setting.