Monday, September 16, 2019

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.

Monday, September 9, 2019

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)

Tuesday, September 3, 2019

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).

Monday, August 26, 2019

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?

Monday, August 19, 2019

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.

Monday, August 12, 2019

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.