Monday, December 22, 2014

Screening for developmental dysplasia of the hip: when organizations disagree

- Jennifer Middleton, MD, MPH

If your medical education was anything like mine, chances are you learned to incorporate hip testing into every newborn exam, but the evidence base to support that common practice is uncertain. "Common Questions About Developmental Dysplasia of the Hip," an article in the December 15 issue of AFP, includes a discussion about the varied hip dysplasia screening recommendations by the United States Preventive Service Task Force (USPSTF), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the Pediatric Orthopaedic Society of North America (POSNA).

The USPSTF gives screening for developmental dysplasia of the hip (DDH) an "I" recommendation:
There is poor evidence (poor quality studies) of the effectiveness of both surgical and non-surgical interventions; avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and harms of screening for DDH but was concerned about the potential harms associated with treatment of infants identified by routine screening.
The AAFP concurs with the USPSTF:
The AAFP concludes that the evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. 
Although the AAP agrees that the quality of available studies was low, they came to a different conclusion:
There were few controlled trials and few studies of the follow-up of infants for whom the results of newborn examinations were negative. When the evidence was poor or lacking entirely, extensive discussions among members of the committee and the expert opinion of outside consultants were used to arrive at a consensus....All newborns are to be screened by physical examination. [emphasis in original]
And, the POSNA aligns with the AAP:
The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. 
When medical organizations' recommendations differ, family physicians can be left wondering who to follow and what to do. Considering each organization's goals and process for developing recommendations can help. The USPSTF and AAFP typically will not make a recommendation in the absence of high-quality studies, therefore setting the bar high to receive anything but an "I" (insufficient evidence) recommendation. The AAP and Pediatric Orthopaedic Society, however, are more comfortable providing a recommendation based on expert opinion and lower-quality studies.

We strive, in this age of evidence based medicine (EBM), to base our clinical decisions on high-quality evidence. When high-quality evidence is lacking, however, we must rely on what we do have to make decisions; in this case, on expert opinion and lower-quality studies. In the absence of high-quality studies, reasonable physicians may also be expected to disagree about how to interpret what is available. The practice of EBM does not seek to eliminate individual clinician judgment, and each of us is left to determine how to put into practice what evidence and expert opinion currently exists. There's an AFP By Topic on Neonatology/Newborn Issues if you'd like to read more.

What is your practice regarding screening infants for DDH?

Tuesday, December 16, 2014

What should doctors do at well-child visits?

- Kenny Lin, MD, MPH

As a family physician who provides care to children, and as a father of four ranging in age from 6 months to 8 years, I have a professional and personal interest in the content of well-child visits beyond childhood immunizations. Not only can health maintenance and counseling vary from practice to practice, previous reviews have found large gaps in the evidence to support preventive services recommended by government health agencies and medical groups. Also, clinicians who compare the Bright Futures / American Academy of Pediatrics "Recommendations for Preventive Pediatric Health Care" to the clinical recommendations for children published by the American Academy of Family Physicians (AAFP) will find that groups sometimes disagree about which services should be offered at well-child visits.

To provide perspective on how the AAFP evaluates evidence regarding the net benefit of individual preventive services in children, I recently wrote an editorial in American Family Physician that reviewed the guideline process and discussed why there is insufficient evidence to recommend screening children for autism spectrum disorders, high blood pressure, and cholesterol levels. (Note to readers: although I am a member of the Commission on the Health of the Public and Science and verified that this editorial reflects current AAFP recommendations, it should not be considered an official statement of the AAFP.) Here is the bottom line:

Time is a precious clinical resource. Clinicians who spend time delivering unproven or ineffective interventions at health maintenance visits risk “crowding out” effective services. For example, a national survey of family and internal medicine physicians regarding adult well-male examination practices found that physicians spent an average of five minutes discussing prostate-specific antigen screening, but one minute or less each on nutrition and smoking cessation counseling. Similarly, family physicians have limited time at well-child visits and therefore should prioritize preventive services that have strong evidence of net benefit.

Monday, December 8, 2014

Desmopressin works for adults with nocturia, too

- Jennifer Middleton, MD, MPH

Desmopressin has been a staple in the treatment of pediatric nocturia for years, and the December 1 issue of AFP reviews a recent systematic review describing desmopressin's effectiveness for adults as well.

The systematic review examined 10 randomized controlled trials (RCTs) of varied quality with approximately 2200 patients in total. The average age of participants ranged from 55-74 years, and men and women were both represented. All of the RCTs compared desmopression to placebo (1 compared desmopression plus furosemide to placebo).

Here is the decrease in the mean number of voids for each dose:

25 mcg = 0.38 [95% CI 0.09, 0.48] fewer voids/night
50 mcg = 0.44 [95% CI 0.16, 0.72] fewer voids/night
100 mcg = 0.72 [95% CI 0.48, 0.96] fewer voids/night

And, here is the increase in time until first waking to void:
"low dose" (less than 100 mcg) = 42.18 more minutes [95% CI 19.94, 64.42]
"high dose" (100 mg or higher) = 68.30 more minutes  [95% CI 39.42, 97.17]

Desmopressin does reduce nocturia, and it is a reasonable option to offer adult patients. The included RCTs did not, however, assess participant satisfaction. Did participants feel more rested the next morning? Was their quality of sleep better? How about their quality of life? Is an extra 42-68 minutes of sleep before waking up to go to the bathroom meaningful to patients? Without participant satisfaction studies, physicians are left to interpret for themselves the clinical significance of this data.

After all, statistical significance doesn't always equal clinical significance. To the authors' credit, they broach these same questions in their discussion section. Studies looking specifically at participant satisfaction could aid patient-physician decision making. Using desmopression may involve some patient-centered decision making; physicians may choose to share the above data with patients, perhaps also with the number needed to harm (NNH) of 20 for the side effect of hyponatremia, and let patients decide if it is worthwhile to give desmopressin a try.

Evidence-based medicine is the intersection of evidence, clinician expertise, and patient preference. Desmopressin decreases nocturia, but will patients be happy with the difference?  The answer will likely vary from patient to patient and from clinician to clinician. There's an AFP article on "Sleep Problems in the Elderly" if you'd like to read more broadly about this topic.

How does your office care for adults with nocturia?

Monday, December 1, 2014

Right-sizing care of patients with serious illnesses

- Kenny Lin, MD, MPH

Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Value Task Force of the American College of Physicians (ACP) recently published a synthesis of best practices on patient-centered communication about serious illness care goals. Although these conversations can sometimes be uncomfortable for clinicians or patients, the authors offered several reasons that they should occur early and often:

An understanding of patients’ care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress.

What clinical situations should trigger discussions about end-of-life preferences? The authors recommended making time for a conversation in the setting of worsening symptoms or frequent hospitalizations in patients with COPD, congestive heart failure, and end-stage renal disease; in all patients with non-small cell lung cancer, pancreatic cancer, and glioblastoma; in patients older than 70 years with acute myelogenous leukemia; in patients receiving third-line chemotherapy; and in hospitalized patients older than 80 years. The ePrognosis website offers useful tools for clinicians to estimate prognoses in older persons with serious illnesses.

According to the ACP, key elements to address in these conversations include understanding of prognosis; decision making and information preferences; prognostic disclosure; patient goals; patient fears; acceptable function; trade-offs; and family involvement. Additional guidance for discussing end-of-life care and eliciting patient preferences has been published in American Family Physician and Family Practice Management. Previous AFP Community Blog posts have also discussed misconceptions about palliative careprogressive disability in older adults, and gaps in end-of-life planning.