Tuesday, May 27, 2014

What is the best topical antifungal for treating tinea pedis?

- Jennifer Middleton, MD, MPH

A section in this month's Prescriber's Letter regarding a new topical antifungal medication stated that a 2012 systematic review found no clinical difference among topical antifungals for treating dermatophyte infections. This statement contradicts what a clinical pharmacist once taught me: that topical terbinafine is superior to topical clotrimazole for treating tinea pedis. Given how frequently I treat tinea pedis, I have relied on this lesson countless times during my career to date. Thanks to the AFP By Topic on Skin Conditions I found an AFP article, "Dermatophyte Infections," citing the relevant randomized controlled trial (RCT) from 1993. Knowing from my Evidence-Based Medicine education that a well-done systematic review can trump a single RCT, I decided to check out both.

The 1993 study (that I assume my clinical pharmacist teacher referenced) was published in BMJ and divided 256 patients "with mycologically confirmed tinea pedis" into two groups; one group received 1% topical terbinafine twice daily for 1 week followed by 3 weeks of placebo, and the other group received 1% topical clotrimazole twice daily for 4 weeks.* The authors measured both microscopic and clinical cure rates, and terbinafine beat clotrimazole handily, with success rates of both measures combined of 89.7% vs 58.7% at week 4 and 89.7% vs 73.1% at week 6 (both p < 0.01).

The authors of the 2012 systematic review, published in the British Journal of Dermatology, looked at several comparisons among antifungal medications for multiple conditions. In one comparison, they reviewed 17 studies comparing allynes (medication class that includes terbinafine) and azoles (medication class that includes clotrimazole) for all topical dermatophyte infections and found no statistically significant difference.
The systematic review authors did not specifically single out studies comparing terbinafine and clotrimazole for tinea pedis, however.

For now, given that 1 week of therapy is probably preferable to most patients instead of 4, and given that the price difference between the two medications is negligible (around $10-16 for 30 grams of either), I will still favor terbinafine for treating tinea pedis. One option I will definitely not take is using the new brand new Luzu (luliconazole) referenced in this month's Prescriber's Letter for a reported $180 per 30 grams.

How do you choose which topical antifungal to prescribe for tinea pedis?

* According to Lexicomp, 1 week is a sufficient starting place for treating tinea pedis with terbinafine, but it recommends at least 4 weeks of clotrimazole.

Monday, May 19, 2014

Family physicians are natural health system leaders

- Kenny Lin, MD, MPH

Last week, the subtitle of a JAMA editorial on accountable care caught my attention: "the paradox of primary care physician leadership." The authors observed that although a typical family physician's or general internist's patient panel accounts for about $10 million in annual health care spending (of which only $500,000 is primary care revenue), primary care physicians have been "underused" as role players in health system reform. They further suggested that claiming leadership positions in accountable care organizations could be "a powerful opportunity [for family physicians] to retain their autonomy and make a positive difference for their patients - as well as their practices' bottom lines."

The American Academy of Family Physicians recently launched Family Medicine for America's Health, also known as Future of Family Medicine 2.0. One of the key questions considered by this ambitious initiative is "What are the core attributes of family medicine today?" Dr. Robert L. Phillips, Jr. and colleagues from seven U.S. family medicine organizations answer in a special article on the future role of the family physician in the current issue of Annals of Family Medicine:

Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.

This forward-looking definition of family physicians as natural health system leaders contrasts with the "foil definition" that the group envisioned family physicians becoming if they accept passive roles and allow themselves to be acted on by various forces that are changing American health care:

The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill-defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient panel management, community health, or collaboration with public health.

Are tomorrow's family physicians prepared to be leaders instead of followers? A research study published in Family Medicine explored relationships between specialty plans and clinical decision making in a national survey of 4,656 senior medical students. Students were asked to choose between management options in patient vignettes that exemplified principles of health reform: evidence-based care, cost-conscious care, and patient-centered care. Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle change counseling to starting medication for a mild chronic condition. Future family physicians were also more likely to prefer U.S. Preventive Services Task Force recommendations on preventive care to those from disease-oriented or patient advocacy groups, although this finding was not statistically significant.

Thursday, May 15, 2014

Neglected parasitic infections - what every family doc should know

- Jennifer Middleton, MD, MPH

The phrase "parasitic infections" probably brings to mind tropical locales and medical mission work, but the May 15th AFP article, "Neglected Parasitic Infections: What Every Family Physician Needs to Know," describes the Centers for Disease Control and Prevention's (CDC) effort to raise awareness of these infections in the United States. The authors review the 5 neglected parasitic infections (NPIs) that the CDC is focusing on:

Trypansoma cruzi is transmitted by triatomine bugs, which live in mud walls and thatched roofs in Central and South America. Infections in the US occur in persons who acquired the disease in those areas prior to entering the US. T. cruzi infection is asymptomatic for years but can later cause heart failure and gastrointestinal problems. Triatomine bugs have been found in the southern 1/2 of the US, and CDC researchers are working to determine if transmission is happening in the US as well.

Taenia solium, or pork tapeworms, are transmitted via the fecal-oral route. T. solium eggs travel to the brain and form cysts which can cause seizures. Approximately 1,000 persons are hospitalized with neurocysticercosis in the US every year, with most cases to date in New York state, Illinois, California, Oregon, and Texas.

Humans accidentally ingest Toxocara eggs from dog or cat feces. The two most severe forms of the disease, which typically affect children, can cause blindness and liver disease. According to the CDC, NHANES III data showed that 13.9% of the US population has antibodies to Toxocara. Deworming infected cats and dogs along with good hand hygiene can limit the spread of toxocariasis.

T. gondii is transmitted in cat feces and undercooked meat. Pregnant women who contract it are at risk of miscarrying. The CDC is working to improve diagnostic tests and also to develop a vaccine for cats against T. gondii.

The most common STD in the US, trichomoniasis is asymptomatic in 70% of cases. Infection with T. vaginalis increases the risk of infection by subsequent STDs (including HIV) and can also contribute to pre-term births. 

The CDC's webpage, "Neglected Parasitic Infections (NPIs) in the United States," describes the CDC's efforts to educate physicians and the public, provide testing and treatment recommendations, and bolster research to better understand these diseases. There is a wealth of information there, as well as at this hyperlink to the American Journal of Tropical Medicine and Hygiene's special section on NPIs in their May 2014 issue.

Has your practice seen any of these parasitic infections?

Wednesday, May 7, 2014

Improving patient handoffs and transitions of care

- Kenny Lin, MD, MPH

As a long distance runner on my high school track team, I won few accolades in individual events, but shone in relays. My teammates and I spent hours perfecting our baton exchanges, which must occur within a limited area of the track, until these handoffs felt smooth and effortless. In contrast, world class athletes focused on individual performances are often assigned to relay teams at the last minute, a practice that led to stunning disqualifications for dropped batons of both the U.S. men's and women's 4 X 100 meter relay teams at the Beijing Summer Olympics.

Dropped handoffs in medicine can expose patients to harm, too, even if individual clinicians are exceptionally skilled. An editorial in the May 1st issue of AFP reviewed studies of programs designed to improve care transitions from hospital to home and found mixed evidence that such programs improve health outcomes:

Although some programs reduced 30-day rehospitalization rates, a systematic review found that no single intervention is reliably helpful, and successful readmission reduction programs generally occur only in single institutions.However, it seems that programs that focus on the whole patient rather than a specific diagnosis are more successful in reducing readmissions. This concept is in keeping with the focus of primary care physicians. To solve the challenge of care transitions, the primary care physician should have a prominent role at three times: at admission, immediately after discharge, and at the postdischarge follow-up visit.

Research on improving inpatient handoffs has evaluated the varying effectiveness of electronic handoff tools, standardized communication training, verbal mnemonics, structural changes, and "handoff bundles" that include one or more interventions. Several residency programs at my institution recently found that an electronic template for graduating residents to hand off their "high risk" outpatients to other clinicians did not improve handoff quality or clinician satisfaction compared with free-text handoff notes.

What tools have you or your colleagues found useful to assure uninterrupted transitions of patient care from hospital to home, between clinicians in inpatient and outpatient settings, or between primary care physicians and subspecialists?