Monday, February 24, 2014

The family physician's role in HIV care

- Jennifer Middleton, MD, MPH

I read my AFP cover to cover most of the time, but I hesitated before reading this issue's "What Is New in HIV Infection?" I don't work in an area of the country with a high prevalence of HIV, and I admit to thinking that HIV care largely belongs with infectious disease (ID) specialists, not family doctors.

At least, that's what I thought before I read the article. I learned that the new fourth-generation assay for HIV turns results around in hours, that preexposure prophylaxis ("PrEP") is an option for high-risk individuals, and that early treatment for newly diagnosed HIV can help prevent the spread of HIV.

The new fourth-generation assay tests for both HIV antibodies and the p24 antigen. It's more expensive than third-generation tests (which my health system currently uses) but yields faster results; high-risk individuals can be retested three weeks later instead of six months later. Family physicians can advocate for their patients by encouraging their labs and health systems to adopt this improved test.

PrEP is another opportunity for family physicians. Using guidelines in this article, we can counsel on risk reduction behaviors, routinely check for STDs and pregnancy, test for HIV every three months, and prescribe emtricitabine/tenofovir (Truvada) to our patients at high risk of contracting HIV. Primary care is the right arena for prescribing PrEP; after all, we know our patients well, and we're in the perfect position within our Patient-Centered Medical Home practices to follow these patients.

Immediate treatment for newly diagnosed HIV has been standard for a while, but the article nicely summarizes the most up-to-date treatment guidelines. Given the complexity of these regimens, here I absolutely would partner with my ID colleagues. We family doctors, though, can still streamline the referral process for our patients and, perhaps, even get them started on HIV treatment while they await their first ID appointment; for patients in more remote areas, this timely care could make a big difference both to them and the community.

There's an AFP By Topic on HIV/AIDS if you'd like to read more.

Does this article change how you will prevent, test, and care for HIV in your practice?

Wednesday, February 19, 2014

Screening mammography: growing costs, shrinking benefits

- Kenny Lin, MD, MPH

Providing preventive services is a core responsibility of family medicine, and, consequently, AFP devotes many pages to keeping readers up-to-date with the latest studies and recommendations on breast cancer screening. There has been much news of note in the past few years, beginning with the U.S. Preventive Services Task Force's 2009 statement that clinicians should engage women in shared decision-making discussions about the relative benefits and harms of beginning screening mammography before age 50, and perform screening only every other year.

Other groups, such as the American College of Obstetricians and Gynecologists, recommend annual mammography starting at age 40. As reviewed in a recent AFP article, the conflicting USPSTF and ACOG guidelines agree that mammography appears to lower breast cancer mortality, but dispute how to value the harms: false positive results, anxiety, biopsies, overdiagnosis, and unnecessary treatment. To further complicate matters, as adjuvant therapies for breast cancer continue to improve, researchers have speculated (with some supporting data) that mammography may not be nearly as useful at preventing deaths from breast cancer today as it seemed to be a generation ago.

But could the mortality benefit of mammography in younger women actually be as low as zero? That was the startling conclusion of the Canadian National Breast Screening Study, which published its 25-year follow-up report last week in BMJ. Beginning in the early 1980s, this randomized trial evaluated the effect of 5 years of annual mammography in nearly 90,000 women between the ages of 40 and 59 and found no difference in breast cancer mortality between the intervention and control groups. (It's important to note that women age 50 and older in the control group received annual clinical breast examinations.) The study's findings also suggested that more than 1 in 5 breast cancers detected in the mammography group would not have become clinically evident during a patient's lifetime in the absence of screening.

The American College of Radiology immediately labeled the BMJ study "incredibly flawed and misleading" and advised that clinicians and patients disregard its findings. Others countered that this study's well-documented limitations (e.g., older mammography technology) were no more disqualifying than those of other (even older) studies that found screening reduced breast cancer deaths: "If you’re not going to be swayed at all by a randomized controlled trial of 90,000 women with 25 year follow up, excellent compliance, and damn good methods, it might be time to consider that there’s really no study at all that will make you change your mind [about the effectiveness of screening mammography]."

Researchers recently estimated in Annals of Internal Medicine that the total cost of mammography screening in the U.S. in 2010 was $7.8 billion, not including costs of missed work or subsequent treatments. If 85% of women between the ages of 40 and 85 were screened annually as recommended by ACOG, the cost would have been $10.1 billion. In contrast, if the same proportion of women adhered to USPSTF screening guidelines (biennial mammography between 50 and 74, with the option of starting earlier or ending later based on a woman's preferences and health status), the cost would have been $3.5 billion. Even though the Affordable Care Act requires insurers to cover annual screening mammography in women over 40 without any out-of-pocket costs, are patients really getting their money's worth in improved health?

Monday, February 10, 2014

Overcoming "noncompliance" with universal literacy precautions

- Jennifer Middleton, MD, MPH

I suspect that most family physicians try to provide health information to their patients in a lay-friendly way. Like them, I try to avoid jargon, give clear instructions, and use techniques like "teach-back" to maximize my patients' understanding.

Unfortunately, an article in the current issue of Family Practice Management highlights a common divide between physicians' perceptions of their patients' health literacy and their patients' true health literacy. The article defines health literacy as
the ability of patients to find, understand, and use health-related information to make good decisions about their medical care and personal health.
When patients are confused about how to take their medications or implement their physicians' instructions, they are much less likely to comply with these instructions.  Frustrated physicians may then label these patients as "noncompliant," and assign reasons for this noncompliance that have nothing to do with the true cause.

The article, written by AFP medical editor Dr. Barry Weiss, cites studies showing that 1/3 of US adults have low health literacy; and, in some population groups (older adults, African-Americans, Hispanics, American Indian/Alaska Natives), it can be 1/2 or more of adults. I know that, myself, I had not considered that such a high proportion of my patients might have difficulty understanding me.

Although there are screening instruments to identify low health literacy, the author argues that we should use "universal literacy precautions" for all patients instead. Words such as "benign," "cardiologist," and "bacteria" can confuse patients with even good health literacy; Dr. Weiss suggests using "not cancer," 'heart doctor," and "germs" instead.  (He provides multiple other examples and suggested changes in a table on page 16 of the article.) Speaking more slowly and limiting the information we provide to the essentials benefits all patients. And, yes, the "teach back" technique can also help. This 2005 article from AFP provides additional suggestions.

This article has changed my practice; as a naturally quick speaker who was liberally lacing my patient dialogues with some of these words, I now wonder how many of my "noncompliant" patients were struggling to understand me. I focus on slowing down and define an echocardiogram for patients as a "picture of your heart" instead of just handing them the order. I gently correct medical students when I hear them tell patients to take their medication orally instead of "by mouth," and I make sure that patients know that an MRI provides me with "pictures" of their body.

How are you doing with your patients with low health literacy? Will this article change your practice?