Monday, September 20, 2021

The challenge of correctly diagnosing hypertension in adults

 - Kenny Lin, MD, MPH

Screening for high blood pressure in adults can be straightforward or quite complex. The U.S. Preventive Services Task Force (USPSTF) recently reaffirmed its longstanding recommendation to screen for hypertension with office blood pressure measurement but advises confirming the diagnosis with measurements outside of the clinical setting. The diagnostic standard for out-of-office measurement is 24-hour ambulatory blood pressure monitoring (ABPM), but ABPM is often unavailable, not covered by insurance, or inconvenient for patients.

A more accessible alternative, reviewed by Dr. Jeffrey Weinfeld and colleagues in the September issue of AFP, is home blood pressure monitoring (HBPM). In addition to confirming a hypertension diagnosis, HBPM can be used to identify white coat hypertension (elevated readings in the office but normal readings at home) and masked hypertension (elevated readings at home but normal readings in the office). Patients can purchase a clinically validated blood pressure monitor for $37 to $100 without insurance, and this expense may be reimbursed from a health care flexible spending account. The downside of HBPM is that patients sometimes forget to check their blood pressures at home or forget to record and bring in the readings. 

What is the role of automated oscillometric office blood pressure (AOBP) devices such as those used in the Systolic Blood Pressure Intervention Trial (SPRINT)? A systematic review and meta-analysis previously summarized in AFP found that AOBP systolic measurements were on average 14.5 mm Hg lower than manual blood pressures in patients with hypertension and better aligned with values obtained with ABPM. In a Letter to the Editor in the August issue, Dr. Lenard Lesser argued that the USPSTF "missed an opportunity to promote AOBP measurements as an easier-to-implement alternative to ambulatory blood pressure monitoring." Dr. Lesser pointed out that the only randomized trial of hypertension screening cited by the USPSTF that reported improvements in clinically meaningful outcomes actually used AOBP.

In the latest entry in JAMA's Rational Clinical Examination series, Dr. Anthony Viera and colleagues systematically reviewed studies that addressed the question, "Does This Adult Patient Have Hypertension?" Comparing AOBP with HBPM, they found that 

The thresholds for defining hypertension and the prevalence of hypertension were similar in office BP measurement and home BP measurement studies, and the estimated predictive values of office oscillometric BP measures and HBPM were numerically nearly identical. ... The combination of results from office BP measurement and HBPM has better diagnostic accuracy than the independent results alone, and when concordant, is likely sufficient for diagnosis. However, 24-hour ABPM should be considered when results are discordant, especially for patients with a higher pretest probability of hypertension.

Monday, September 13, 2021

Do salt substitutes improve mortality in persons at high risk of CVD?

 - Jennifer Middleton, MD, MPH

The current Dietary Guidelines for Americans recommend limiting daily sodium intake to 2,300 mg or less, but 90% of Americans aged 2 years and older consume more salt than this amount daily. The best evidence to date recommends lowering sodium intake to reduce the risk of cardiovascular disease (CVD), but given the pervasiveness of sodium in the American diet, lowering salt intake can be challenging. Replacing table salt with a lower-sodium product could be a more feasible change, and a large randomized controlled trial now suggests that doing so may decrease mortality from CVD in those persons at higher risk. 

The study researchers enrolled nearly 21,000 participants from 600 villages in rural China. The researchers randomized villages to either continued usual salt use or use of a provided salt substitute (75% sodium chloride and 25% potassium chloride). Participants either had a history of stroke or were at least 60 years of age with hypertension:

The mean duration of follow-up was 4.74 years. The rate of stroke was lower with the salt substitute than with regular salt (29.14 events vs. 33.65 events per 1000 person-years; rate ratio, 0.86; 95% confidence interval [CI], 0.77 to 0.96; P=0.006), as were the rates of major cardiovascular events (49.09 events vs. 56.29 events per 1000 person-years; rate ratio, 0.87; 95% CI, 0.80 to 0.94; P<0.001) and death (39.28 events vs. 44.61 events per 1000 person-years; rate ratio, 0.88; 95% CI, 0.82 to 0.95; P<0.001).  

The difference in adverse events due to hyperkalemia was not statistically significant between groups. 

Generalizing the results of this study may be risky; I would presume that most Americans, for example, consume more processed foods and foods prepared outside of the home than the rural Chinese participants in this study. Since "[m]ost sodium consumed in the United States comes from salt added during commercial food processing and preparation, including foods prepared at restaurants," simply decreasing sodium intake in foods prepared at home may not have as great of an effect among persons eating the standard American diet. Then again, even a small benefit could have a sizable effect on population outcomes, and salt substitutes are inexpensive and simple to incorporate into home cooking. Given the minimal harms associated with the salt substitute product in this study, recommending a salt substitute for home use still seems like a reasonable recommendation for our patients at higher risk of CVD.

Taking the time to discuss these recommendations with patients is worthwhile; the United States Preventive Services Task Force (USPSTF) gives a "B" grade to "Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for CVD Prevention in Adults with Cardiovascular Risk Factors." As with all behavior change, tailoring strategies to each patient's circumstances increases the likelihood of success. In addition to recommending salt substitutes, we can teach our patients to read food labels for sodium content, recommend low salt recipes, and discourage frequent restaurant meals. For patients having difficulty making changes, this 2018 AFP article on "Diets for Health: Goals and Guidelines" includes this table with suggestions for overcoming common barriers to eating a healthier diet.

Monday, September 6, 2021

Alliance of international health journals calls for emergency action to limit climate change

 - Kenny Lin, MD, MPH

Today, one week ahead of the 76th session of the United Nations General Assembly, more than 200 health journals worldwide have simultaneously published an editorial calling on health professionals, policy makers, and governments to support emergency actions to limit average global temperature increases to below 1.5 degrees Celsius. Asserting that increases above that level would "risk catastrophic harm to health that will be impossible to reverse," the editorial's authors advocate for "fundamental and equitable changes to societies" to alter the world's current catastrophic temperature trajectory:

Equity must be at the center of the global response. Contributing a fair share to the global effort means that reduction commitments must account for the cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond. Wealthier countries will have to cut emissions more quickly, making reductions by 2030 beyond those currently proposed and reaching net-zero emissions before 2050.

Last month, a landmark report from the Intergovernmental Panel on Climate Change (IPCC) concluded that human activities since 1850, primarily burning of fossil fuels, have already warmed the planet by 1.1 degrees Celsius. At 1.5 degrees, the IPCC warned, extreme weather patterns would become more frequent, and rising sea levels, vector-borne diseases, life-threatening heat waves, and severe droughts would affect billions of people worldwide. Currently, the 10 countries with the greatest greenhouse gas emissions (China, the U.S., the European Union, India, Russia, Japan, Brazil, Indonesia, Iran, and Canada) account for more than two-thirds of global emissions.

American Family Physician strongly supports this global effort to prevent future environmental catastrophes. Our first full-length clinical review article about the health impacts of global warming appeared in 2011. An accompanying editorial highlighted the physician's role in efforts to slow global warming, including reducing the carbon footprints of hospitals and health care facilities. In 2016, Associate Deputy Editor Caroline Wellbery, MD, PhD observed that the 2015-2020 Dietary Guidelines for Americans' "heart-healthy recommendations align with ... environmental concerns," making eating less meat a healthy and environmentally responsible dietary choice.

A 2019 update on managing health impacts of climate change discussed ways that clinicians can mitigate "morbidity and mortality from worsening cardiopulmonary health, worsening allergies, and greater risk of infectious disease and mental illness, including anxiety, depression, and posttraumatic stress disorder from extreme weather events." Health professionals must recognize how their workplaces directly contribute to making climates less healthy: "The U.S. health care sector is responsible for 10% of all greenhouse gas emissions, 10% of smog formation, 12% of air pollution emissions, and smaller but significant amounts of ozone-depleting substances and other air toxicants." The article also suggested counseling patients on the personal and environmental benefits of utilizing active transport and a consuming plant-based diets.

Physicians' lack of training in climate science and global warming's negative impacts on health may be an obstacle to leveraging the collective authority of the medical profession to address the climate crisis. This gap is closing, though, as recent editorials in Academic Medicine have called for critical curricular reforms in medical school and residency education, and in some cases, medical students themselves have been leading these educational efforts.

Monday, August 30, 2021

Supporting patients with stomas

 - Jennifer Middleton, MD, MPH

Family physicians are likely to care for patients with colostomies and ileostomies, so comfort with both the basics of stoma care and the common psychosocial challenges of managing a stoma are a must. Patients may have temporary colostomies for several reasons, including the need to divert stool away from the perineum for surgical procedures and with bowel resections for diverticular disease or malignancy. Patients with cancer, severe fecal incontinence, inflammatory bowel disease, and/or recurrent diverticular disease may have permanent colostomies or ileostomies. 

Patients should receive instructions from their colorectal care team about the frequency of emptying and changing their stoma bags. Some patients will be advised to empty their stoma bag 1-3 times a day and will then replace the bag every 2-4 days; some patients will be advised to simply replace the bag when full every 1-2 days. The odor of stool from a stoma can be more intense than with usual defecation, and patients may want to choose an air freshener product to keep handy during bag emptying and changing. Patients should be prepared for the potential of bag leaking by either carrying or keeping nearby an extra set of supplies (new ostomy bag, adhesive remover, new adhesive, small trash bag/plastic bag for disposal).

There are different types of ostomy bag systems and a wide variety of products to protect the skin around the stoma (including powders and barrier wipes). Although colorectal care providers usually manage product recommendations and orders, keeping track of the products your patients are using will help if they ever need you to reorder them. Familiarity with these supplies and general management of ostomy bags can also lead to more meaningful conversations with patients about ostomy management. This 5-minute video gives an overview of emptying and changing ostomy bags. Healthy stomas are pink or red and often have a somewhat raw or abraded appearance. Skin care around the stoma site is important, and patients should be checking the skin around the stoma with every bag change. If patients are experiencing skin irritation, encourage them to should reach out to their colorectal team to discuss skin care product options; if their stoma is blue, purple, or tender, urge patients to reach out to their colorectal care team immediately for evaluation.

Having provided care for a family member with a stoma, I can personally relate to the challenges of adapting to a colostomy or ileostomy. Talking about stool and bowel problems is often stigmatized, and, consequently, patients may not feel that they can discuss the challenges of dealing with a stoma with friends and family. It's not surprising that persons with a stoma have higher rates of depression and social isolation compared to the general population. Dyspareunia and erectile function are also more common in patients with stomas. This article contains several pragmatic tips for managing situations such as returning to work, traveling, and intimacy. Patients can also find positive depictions of life with a stoma on social media and connect with both local and online support groups for "ostomates." 

Although stomas may seem intimidating at first, family physicians are more than capable of learning the basics of stoma care and supporting patients with stomas throughout their experience.

Monday, August 16, 2021

What are the risks of tapering chronic opioids?

 - Jennifer Middleton, MD, MPH

The Centers for Disease Control and Prevention (CDC) recommends tapering chronic opioid doses when patients do not have meaningful pain benefit and/or show signs of a substance use disorder. Despite increased opioid tapering by physicians in the last few years, however, deaths from opioid use continue to escalate. A new study suggests that tapering long-term opioid doses may be contributing to this increased mortality by increasing affected patients' risks for mental health crisis and/or opioid overdose.

This retrospective cohort study of a national database included over 113,000 participants' records from 2008-2019. The study authors defined tapering as a "at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period." Their main outcomes were emergency department and/or hospital visit for drug overdose, drug withdrawal, and/or mental health crisis. Patients with tapered opioid doses were more likely to present with drug overdose or withdrawal in the subsequent 12 months than patients maintained on their chronic opioid regimen (9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years), and patients with tapered opioid doses were also more likely to present with mental health crisis (depression, anxiety, and/or suicide) than patients maintained on their chronic opioid regimen (7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years). The confidence intervals for both absolute risk differences were statistically significant (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6] and adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3], respectively). 

This study's observational design can only determine correlation, not causation, though the authors cite earlier published studies demonstrating the "potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress." They recommend "more gradual dose reductions" (the CDC recommends reducing doses by no more than 10% a month for patients taking chronic opioids) to reduce the risk of adverse events and call for further research to better define optimal patient selection and dose reduction protocols for opioid tapering. A 2020 AFP Curbside Consultation provides an overview of one current tool to manage opioid tapering, the BRAVO (Broaching the subject, Risk-benefit calculation, Addiction, Velocity and validation, Other strategies) protocolUnfortunately, some patients with chronic opioid use develop opioid use disorder, and these patients require additional treatment beyond tapering off opioids. The AFP By Topic on the Opioid Epidemic - Key Resources provides articles to guide diagnosis and management, including this overview of "Opioid Use Disorder: Medical Treatment Options." 

The COVID-19 pandemic is accelerating opioid-related mortality; as we await further research, tapering chronic opioid doses, when appropriate, remains a useful tool if we proceed slowly and engage in thoughtful patient-centered decision making regarding its potential risks.

Tuesday, August 10, 2021

Should risk calculators be used in lung cancer screening decisions?

 - Kenny Lin, MD, MPH

The American Academy of Family Physicians recently endorsed the U.S. Preventive Services Task Force (USPSTF)'s 2021 recommendation to offer annual lung cancer screening with low-dose computed tomography (LDCT) to adults aged 50 to 80 years with at least a 20 pack-year smoking history who have smoked within the past 15 years. Although a meta-analysis of 8 randomized controlled trials found that people screened with LDCT are 19% less likely to die from lung cancer (NNS = 250), it also concluded that about 20% of tumors are overdiagnosed, in line with a previous report from the U.S. National Lung Screening Trial. Unfortunately, doctors do not often discuss harms of lung cancer screening such as overdiagnosis, overtreatment, and complications of diagnostic procedures performed for positive tests.

Deciding if the potential benefits outweigh the harms of lung cancer screening for an individual patient requires a way to personalize estimates of benefit based on patients' risk factors. In a Letter to the Editor regarding a 2019 American Family Physician article on the pros and cons of lung cancer screening, Dr. Abbie Begnaud and colleagues suggested:

If an eligible patient is reasonably healthy, clinicians could consider calculating individualized lung cancer risk using one of several well-validated risk models. We and others have developed web-based tools to help clinicians incorporate individualized risk calculations into decision-making. Individualized risk assessment can be helpful because patients at higher risk of developing lung cancer are also more likely to benefit from early detection through screening. When lung cancer risk increases, uncertainty about whether to recommend screening decreases when the person has a reasonable life expectancy.

Unlike risk prediction tools for cardiovascular disease and breast cancer, however, there is no consensus on which lung cancer risk calculator should be used. A systematic review published earlier this year in the Journal of General Internal Medicine identified 10 publicly available risk calculators and assessed their performance in 16 hypothetical patients across the continuum of lung cancer risk. The calculators used varying inputs (demographic factors, cancer history, smoking status, and personal and environmental factors) to generate lung cancer risk estimates; unsurprisingly, there were substantial differences in risk estimates for 10 of the 16 hypothetical patients. The authors concluded that the lack of standardization of lung cancer risk factors and consistency in risk estimates from web-based calculators may be an obstacle to shared decision making.

Notably, the USPSTF statement "recommends using age and smoking history to determine screening eligibility rather than more elaborate risk prediction models because there is insufficient evidence to assess whether risk prediction model–based screening would improve outcomes relative to using the risk factors of age and smoking history for broad implementation in primary care." In a Putting Prevention Into Practice case study in the July issue of AFP, Drs. Howard Tracer and James Pierre explained how to apply the Task Force recommendations in clinical practice.