Sunday, January 30, 2011

Who should teach patients about nutrition?

A recent national survey published in the journal Academic Medicine found that on average, U.S. medical students receive less than 20 hours of education about nutrition in all four years of medical school, a figure that has decreased since 2004. Since improving patients' dietary habits plays a crucial role in the management of many common conditions, AFP is committed to providing our readers with practical nutritional information in articles such as "Diet and Exercise in the Treatment of Hyperlipidemia," in the May 1, 2010 issue.

In a Letter to the Editor in the January 15th issue, however, Dr. Sean Lucan points out that translating advice about food constituents into guidance that patients can easily understand is easier said than done:

[The article] mentions a food constituent, saturated fats, as a prime target for dietary reduction in patients with dyslipidemia. The problem is that people do not eat saturated fat; they eat foods. So what foods should patients avoid to limit their intake of saturated fat? Dr. Kelly describes one option, the Mediterranean Diet, as recommending “low consumption of saturated fats” and “limited consumption of red meat and dairy products.” In fact, with regard to lipids, red meat, dairy, and saturated fats are one and the same; the former two being the principal dietary sources of the latter. Unfortunately, few people know this because medical science tends to reduce foods to their constituent parts, and because the beef and dairy industries work hard to ensure that consumers do not make connections between undesired abstract nutritional constituents and food.

One might question whether family physicians are really the most qualified professionals to educate patients about basic and specialized nutrition issues, given the limited education that we receive. Wouldn't it be nice to have a nutritionist routinely available to counsel patients about what to eat? Unfortunately, most insurers will not pay practices for dietary education given by anyone except a physician, if they pay anything at all.

Friday, January 21, 2011

Will vaginal birth after Cesarean section (VBAC) make a comeback?

My daughter, who turns three years old in June, is becoming something of a medical rarity. This isn't because she has a congenital disorder or extraordinary ability for her age; it's because she came into the world as a vaginal birth after Cesarean section (VBAC). Although 75 percent of women who choose a trial of labor over a repeat Cesarean section successfully deliver vaginally, studies showing slightly higher risks of uterine rupture with VBAC, concerns about lawsuits, and restrictive guidelines discourage most women from trying. After reaching a high in 1996 of 28.3 percent of U.S. women who previously delivered by Cesarean, the VBAC rate today is considerably less than 1 in 10.

The AAFP's 2005 guideline on trial of labor after Cesarean (TOLAC) noted that there was no good evidence that having surgical and anesthesia personnel "immediately available" (i.e., on site) during a trial of labor, as required in a 1999 ACOG guideline, improves maternal or infant outcomes. At an NIH conference last year, an expert panel also concluded that the scientific evidence did not support ACOG's position. However, the panel found that this restrictive requirement had led many hospitals without 24-hour availability of these services to discontinue VBAC entirely.

The January 15th issue of AFP summarizes the updated ACOG recommendations on VBAC, which state that a trial of labor is a reasonable option for the vast majority of women who desire a vaginal delivery after a previous Cesarean, including those who have had more than one prior Cesarean and those carrying twins. While continuing to assert that mothers and babies are best served by immediate access to emergency resources, the guideline adds: "Respect for patient autonomy also argues that ... [an institutional no-VBAC policy] cannot be used to force women to have Cesarean delivery or to deny care to women in labor who decline to have a repeat Cesarean delivery."

In a thoughtful and informative editorial in the January 15th issue, "Increasing Patient Access to VBAC: New NIH and ACOG Recommendations," Lawrence Leeman, MD, MPH and Valerie King, MD, MPH write:

We encourage maternity care providers and hospitals that do not currently offer TOLAC to use the NIH statement and revised ACOG guidelines as an opportunity to reevaluate their policies on TOLAC. The Northern New England Perinatal Quality Improvement Network's VBAC project is an example of a collaborative effort between community hospitals and maternity care providers to develop risk-stratification guidelines and to facilitate planning for emergent cesarean delivery. Counseling patients about delivery options involves consideration of maternal and perinatal risks and benefits, future childbearing plans, and the likelihood of successful VBAC. Most women who have had a previous cesarean delivery are candidates for TOLAC and should be offered that option.

Tuesday, January 18, 2011

Dabigatran for stroke prevention in atrial fibrillation: is it worth it?

For most patients with paroxysmal or persistent atrial fibrillation, anticoagulation with warfarin is recommended to reduce the risk of thromboembolic stroke. This recommendation generally requires that a patient come in for frequent International Normalized Ratio (INR) measurements, adjusting the dose of warfarin as needed to keep him or her in a narrow therapeutic range, and avoiding a long list of medications that alter warfarin metabolism. However, a review of diagnosis and treatment of atrial fibrillation in the January 1st issue of AFP describes an alternative:

The anticoagulation agent dabigatran, a direct thrombin inhibitor, was recently approved by the U.S. Food and Drug Administration for the prevention of stroke and systemic embolism with atrial fibrillation. In a randomized trial, 150 mg of dabigatran twice per day was shown to be superior to warfarin in decreasing the incidence of ischemic and hemorrhagic strokes. Patients assigned to dabigatran had a higher incidence of myocardial infarction than those assigned to warfarin, but the difference was not statistically significant.

As we will describe in a future STEPS article, clinical trials have shown dabigatran to be at least as effective at preventing strokes in patients with atrial fibrillation compared to warfarin, with a similar side effect profile. Its advantages over warfarin are that laboratory monitoring and dose adjustment are not required, and that dabigatran appears to have far fewer drug-drug interactions. That being said, a month's supply of dabigatran costs about $200, compared to $10 for warfarin. So is the increased cost worth it?

There are at least three approaches to answering this question:

1) Can the patient afford the drug? Does his or her health insurance cover it? If so, prescribe. If not, don't.

2) A cost-effectiveness analysis recently published in the Annals of Internal Medicine suggested that "dabigatran may be a cost-effective alternative to warfarin depending on pricing," although this analysis was based on a number of assumptions and data from a single industry-sponsored randomized trial with only two years of follow-up.

3) As is the case for many evidence-based interventions, many patients with atrial fibrillation who should be taking warfarin are not. In a study that AFP previously summarized in Tips From Other Journals, researchers described a "break-even point" at which "as many lives are saved by creating a new drug as by maximizing the delivery of established drugs." Would increasing the proportion of eligible patients taking any anticoagulant drug lead to a greater population-level benefit than switching every patient who is already using warfarin to dabigatran?

Primary care physicians may not be used to examining individual medical problems from a population health perspective, and in deciding whether to prescribe dabigatran or warfarin in day-to-day practice, option #1 is likely to be the most practical and widely used. But in an era in which the annual rise in U.S. prescription drug costs consistently outpaces inflation, ignoring the broader view is no longer an option.

Thursday, January 6, 2011

Consequences of judicious antibiotic use

A physician reader of AFP submitted the following post.


I appreciated the article in the December 1, 2010 issue, "Diagnosis and Treatment of Acute Bronchitis," especially its discussion of the preponderance of viral versus bacterial infections and the need to be more judicious in our use of antibiotics for bronchitis. I strive to practice evidence-based medicine and spend a lot of time explaining my decision to not prescribe antibiotics for viral conditions. However, this practice comes at a cost.

My colleagues and I have a busy group family practice in Des Moines, Iowa, and we take turns staffing the walk-in clinic. Recently, a father brought in his teenage son with an obvious viral condition that had lasted for three weeks. After a thorough history and physical exam, I told them that it appeared to be a viral syndrome, but I would go ahead and do a complete blood count with differential and rapid Strep screen just to be certain.

When the laboratory technician entered the room, the father told her that they didn’t need the lab work and she should tell the doctor to just give them some antibiotics. The lab tech appropriately told the patient that the doctor had ordered the tests to see if he needed them or not, and they allowed the specimens to be taken. The results showed a negative Strep screen and a low white blood cell count with a right shift in the differential. I spent some time going over the lab results and explaining why it was unnecessary to prescribe an antibiotic for a viral illness, and wrote a prescription for Robitussin with codeine for symptomatic relief. The patient and his father then stormed out of the exam room and through a crowded waiting room, with the father yelling, “This (expletive) clinic sucks!”

A little while later, I received the following message from the patient's mother on my office voice mail: “My son was just seen in the walk-in clinic. He has been sick for three weeks and we waited for three hours to get in, but the 'care' he got from you was ridiculous. Just take some Robitussin? This is exactly why we have stopped going to your clinic regularly, because the doctors there are no help whatsoever. I can tell you I am going to give you every bad review I can on the Internet and everybody I know, I will tell.”

We receive similar complaints fairly commonly. Although they will not dissuade me from "doing the right thing" regarding antibiotic prescriptions, I wonder how many other clinicians will continue to suffer the slings and arrows of a demanding public when it is a lot easier, less time consuming, and certainly less stressful to just give patients what they want. I would, however, encourage all of my primary care colleagues to stick to our guns in educating the public about the appropriate use of antibiotics, despite the occasional assaults on our professional integrity.

Steve R. Eckstat, DO
Medical Director
Mercy West Medical Clinic
Des Moines, Iowa

Monday, January 3, 2011

Geriatric assessment tools

The editors of AFP recognize the importance of providing family physicians with clinical information and tools relevant to the care of older patients. Our AFP By Topic collection on Geriatric Care contains links to content on general screening and prevention, as well as up-to-date guidance on managing specific issues such as elder abuse, falls, home care, and adverse drug events. Also, the inaugural print issue of 2011 features a review of the geriatric assessment by Drs. Bassem Elsawy and Kim Higgins. The authors explain why this type of structured evaluation is specific to older patients:

The geriatric assessment differs from a typical medical evaluation by including nonmedical domains; by emphasizing functional capacity and quality of life; and, often, by incorporating a multidisciplinary team including a physician, nutritionist, social worker, and physical and occupational therapists. This type of assessment often yields a more complete and relevant list of medical problems, functional problems, and psychosocial issues.

In addition to describing the essential components of the geriatric assessment, the article contains tools for assessing independence in activities of daily living, a nutritional health checklist, and brief instruments to detect hearing and cognitive impairment.

As more primary care practices transition to electronic medical record systems, we recognize that print may not necessarily be the most useful format for many readers. What do you think we could do to make point-of-care tools, tables, and figures more accessible in your practice setting? We invite you to submit comments or suggestions on this blog, our Facebook page, or by e-mail at