Monday, September 30, 2013

Health checks increase diagnoses, but do they improve health?

- Kenny Lin, MD, MPH

After moving into our current home nine years ago, my wife and I purchased a basic security system - the kind with a programmable keypad, multiple door alarms and a motion sensor. The alarm has sounded about a dozen times since then. None of these times was a burglary actually in progress. On several particularly windy days, one of us forgot to lock the back door after leaving, and it blew open. Two or three other times, departing early for work, I accidentally hit "Away" on the keypad (arming the motion detector at the foot of the stairs) rather than "Stay," causing the klaxon to sound when my unsuspecting son came down the stairs later in the morning. We've also set off the fire alarm a few times while cooking. Although our security system cost little to purchase, by now we've spent more money in monitoring fees than the value of what we might conceivably have lost in an actual burglary.

There are intangible benefits to having a home security system - peace of mind being the most important. But our peace of mind has been achieved at the cost of temporarily diverting multiple municipal police and fire units, disturbing our neighbors, receiving inconvenient cellular phone calls from the monitoring company, and terrifying a 5 year-old on his way to breakfast.

I think about my home security system every time I do a physical examination on an apparently healthy adult. Although the general health check is an established medical tradition, a Cochrane for Clinicians review in the October 1st issue of AFP concluded that health checks increase the number of diagnoses but don't reduce morbidity or mortality. So are these visits a waste of time? Not necessarily, argued Dr. Krishnan Narasimhan:

Although the general health check has not been shown to decrease morbidity or mortality, there is some evidence that designating a specific visit for the provision of preventive services may increase the likelihood that patients will receive them. ... Adding preventive services to other patient visits, sending reminders to patients to use these services, and using community linkages, such as screening at job sites or schools, could be potential avenues for effective delivery of preventive services. Evaluating better models for the delivery of evidence-based preventive services is an area for further research.

Unfortunately, a 2012 study in the Annals of Family Medicine found that patients often overestimate the benefits of preventive interventions that primary care physicians commonly provide at health checks: breast cancer screening, colorectal cancer screening, and medications to prevent hip fractures and cardiovascular disease. In most cases, patients' "minimum acceptable benefit" (the lowest level of benefit that in their mind was required to justify the preventive intervention) far exceeded the actual benefit of the service established in randomized trials. Further, the study considered only the benefits of these services, and not the false alarms, which occur, for example, in more than 60 percent of women receiving annual mammography after 10 years.

Monday, September 23, 2013

Small Effect of Inhaled Steroids on Height in Children with Asthma

- Jennifer Middleton, MD, MPH

Childhood asthma is a frequent diagnosis in many Family Medicine offices, and inhaled corticosteroids are often the mainstay of treatment for kids with moderate or severe persistent disease.  Previous retrospective studies were reassuring regarding how these inhaled medications might affect height; children may not grow quite as fast when they're using inhaled steroids for asthma - but these studies suggested that, once the steroids are stopped, children catch up without any lifelong loss of height.

A recent randomized controlled trial, reviewed in this month's Journal of Family Practice (JFP), challenges this notion. The researchers found that children (ages 5-13 years at the beginning of the study) on long-term budesonide treatments for moderate persistent asthma did lose about half-an-inch (actually 0.47 inches or 1.2 cm, to be precise) of height during the 4-6 year trial that was sustained when they were followed up in their mid-20s.

The JFP authors point out that the enrolled children were on the same dose of budesonide throughout this lengthy study, which may be a bit atypical. The Expert Panel Review 3 (EPR-3) recommends that physicians consider tapering down chronic asthma therapy for adults and children if their symptoms have been controlled for three months (see page 288 of this document). This trial does add a bit of additional weight to that recommendation; we don't know whether intermittent use of these medications would mitigate this height loss, but it's probably still reasonable to limit their use when possible.

On the flip side, I wouldn't like to see 0.47 inches of height get in the way of adequately treating a child with moderate persistent asthma, either. (The researchers intentionally didn't include children with severe persistent asthma, assuming that the benefit of inhaled steroids for them would absolutely outweigh the risk of a few millimeters of height.) Like so many things in medicine, our discussion of this trial's finding with parents and families should include both the risks and benefits of these medications.  But this trial is a good example of how important it is to follow-up assumptions from retrospective studies with more rigorous, prospective trials.

AFP By Topic has a rich collection of resources on asthma which includes several articles related to the care of children with asthma.

Will this trial affect how you prescribe inhaled corticosteroids to children and adolescents?

Sunday, September 15, 2013

Managing progressive disability in older adults

- Kenny Lin, MD, MPH

One in seven Americans suffer from disability, which an article by Dr. Cathleen Colon-Emeric and colleagues in the September 15th issue of AFP defines as "limitation in the ability to carry out basic functional activities." Progressive disability, or functional decline, commonly affects older adults with multiple chronic health conditions. First steps in the evaluation of an older adult with a new or progressive disability include characterizing the time course, associated symptoms, effects on specific tasks (including activities of daily living), and compensatory strategies. The authors then recommend that clinicians identify potentially modifiable health conditions, comorbid impairments, and contextual factors. All of this information should be considered and integrated into a treatment plan that enhances the patient's capacity and/or reduces task demands.

A Close Ups in the same issue of the journal provides insight on the perspective of a patient and family member who benefited from a comprehensive evaluation for functional decline. C.W. writes about her late mother's positive experience:

Twenty-minute visits were inadequate to address all of the diagnoses and medications, let alone her falls, constipation, insomnia, and cognitive decline. It seemed no one was appreciating the big picture. ... With full support from her family physician at home, we arranged for her to undergo a comprehensive assessment [that] focused on mom's primary goal—the ability to continue the activities she loved. She was evaluated by a geriatrician, a nurse, and a social worker. My family was also interviewed, and the appointment concluded with a meeting involving the whole team. We were given recommendations to consolidate and simplify her regimens for pain, insomnia, and constipation; initiate medication for depression; and make sure she exercised and socialized regularly, with concrete recommendations for overcoming barriers to these goals, such as transportation. Additionally, we received referrals for physical therapy and low vision rehabilitation.

In a related editorial, Dr. V.S. Periyakoil observes that progressive frailty that does not respond to optimal management of reversible conditions is in fact a terminal illness, even if it is often not recognized as such. He criticizes a recent decision by the Centers for Medicare and Medicaid Services to stop accepting the ICD codes for "debility not otherwise specified" and "adult failure to thrive" as principal hospice diagnoses, arguing that "these older adults may be subjected to ineffective interventions, including repeated emergency department visits and hospitalizations that are burdensome and expensive, and erode their quality of life."

Do you have the time and resources to evaluate functional decline in older adults in your practice, or do you refer these patients to other health professionals? How do you recognize when a patient is transitioning from a reversible state of frailty to a potentially terminal one? Will the information in these articles change your approaches to disability and end-of-life care, and if so, how?

Tuesday, September 10, 2013

Ruling out DVT: doppler or D-dimer?

- Jennifer Middleton, MD, MPH

Yesterday I saw an older patient with a swollen leg. Although I was reasonably confident that the swelling and pain was due to an early cellulitis, I still felt compelled to rule out a deep venous thrombosis (DVT). I ordered a stat ultrasound doppler of the leg, which was negative for DVT. I was left wondering if I shouldn't have wasted the patient's time and his insurance dollars on this test; I wasn't terribly worried about a DVT, but I also knew that I couldn't afford to miss one.

One of the POEMs in AFP last week reviewed a recent article from the Annals of Internal Medicine regarding testing for DVT.  The researchers evaluated the use of Wells' criteria to determine whether ultrasound (doppler) or a D-dimer was used first to evaluate for possible DVT.  The researchers divided the patients into two groups; one group consisted of outpatients with a low or moderate pre-test probability according to their Wells' score, and one group consisted of outpatients with a high pre-test score along with inpatients.  The patients in the first group with a positive D-dimer went on to ultrasound.  They found that stratifying patients by pre-test probability decreased the use of both D-dimer and ultrasound but did not negatively affect patient outcomes.

I know I should use clinical decision rules like the Wells criteria more often to help me eliminate unnecessary testing; there are a few rules that I do use regularly, but for less frequent diagnoses like this one, I often forget to look for an applicable rule.  There are many inexpensive smartphone apps that can make this process easier for clinicians, too.  I suspect that my patient yesterday would have preferred a quick blood test in the office instead of having to trek over to the hospital's vascular lab.  It seems, though, when I'm in the middle of a busy office session, that I often only think about using these tools after the day is done.  This POEM was an excellent reminder to me to think about incorporating these tools more into my everyday decision-making process.

There is a useful AFP by Topic about DVT and Pulmonary Embolism if you'd like more information about this topic.  And, here's the original study that validated Wells' criteria for DVT.

How are you currently working up possible DVTs?  Is it realistic to integrate the use of clinical calculators into your day-to-day practice?

Tuesday, September 3, 2013

Why do clinical questions go unanswered?

- Kenny Lin, MD, MPH

What do you do when you have a clinical question that ideally requires an answer before the patient leaves your office? Do you flip through a textbook or a back issue of American Family Physician? Look up the topic in a online reference? Consult an smartphone app? Ask a colleague in the office or curbside a specialist by telephone?

Family physicians take many approaches to answering clinical questions, some more efficient and effective than others. For example, using AFP By Topic or the journal website search function is more likely to yield relevant results than hunting through a stack of print issues for that article on community-acquired pneumonia that you remembered reading at some point. Unfortunately, Deputy Editor Mark Ebell, MD, MS reported in a 2009 article that on average, 15-20 clinical questions come up each day, and most of these go unanswered.

A recent study published in JAMA Internal Medicine examined barriers to answering clinical questions at the point of care. Researchers affiliated with the Mayo Clinic conducted several focus groups with a total of 50 family and internal medicine physicians in academic medical center and community settings. Not surprisingly, the barrier most commonly mentioned by physicians was insufficient time. Some physicians with convenient access to computers and online references complained of not knowing which resource to search, and having doubts about whether the search was likely to yield an answer. Others were concerned that looking up information while in the examination room might diminish a patient's confidence in them. Finally, some physicians found that available resources simply did not contain the answers they needed.

The editors of AFP are interested in learning more about how you use our journal - in its print, online, and mobile versions - to answer your clinical questions. Are you able to find current, relevant answers at the point of care, or do you prefer to browse AFP at home and subsequently incorporate what you learn into practice? What could we do to improve your searching and reading experiences?