Sunday, December 27, 2015

The top ten AFP Community Blog posts of 2015

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

Some themes that emerged from this year's list of most-read posts included avoiding overtreatment, challenging medical dogma in management of low back pain and myocardial infarction, and estimating efficacy and adverse effects of depression therapies in primary care settings. Happy holidays and best wishes for the New Year!

1. Advise patients to steer clear of these six orthopedic procedures (March 16) - 1804 views

What accounts for the continued popularity of ineffective orthopedic procedures? Excessive magnetic resonance imaging (MRI) plays a role. Patients who perceive surgery to be a "quick fix" may not have the patience to stick with physical therapy and rehabilitation. And there is the inescapable reality that, necessary or not, these procedures pay well.

2. Can treating mild hypertension be too much medicine? (January 2) - 935 views

Key take-home points are that the absolute benefits of treating otherwise healthy persons with mild hypertension are relatively small; lifestyle modification should generally precede medication; and blood pressure measurement should be performed and repeated carefully to ensure accurate identification of hypertensive patients.

3. ACC/AHA and Framingham calculators overestimate cardiovascular risk (March 3) - 841 views

Men in the Multi-Ethnic Study of Atherosclerosis cohort with a calculated ACC/AHA risk score of 7.5 to 10 percent had an actual event rate of only 3 percent; and just over 5 percent of women with a similar risk score experienced cardiovascular events.

4. Acetaminophen ineffective for chronic low back pain - now what? (April 6) - 826 views

Intuitively, acetaminophen seems like a reasonable choice for treating chronic LBP. It's inexpensive and relatively safe when used at recommended doses. This 2015 meta-analysis overturns that recommendation and should prompt a change in the clinical guidelines.

5. Stop beta-blockers 30 days after acute MI? (March 23) - 794 views

The greatest challenge for family physicians managing patients following up after an AMI admission may be the decision to stop a beta-blocker. Discontinuing therapies may be difficult for physicians.

6. Guest post: quality medical care makes patients feel at home (Sept. 7) - 766 views

In my view, the definition of good care includes communication, patience, concern, and perseverance. A high quality, "patient-centered" medical home is based on these human characteristics and not on outcome criteria, EHR meaningful use, or other measures.

7. Announcing the #AFPTop20 Tweet Chat on August 26th (August 17) - 760 views

On Wednesday, August 26th at 4 PM Eastern, @AFPJournal held its first #AFPTop20 Tweet Chat to take a deeper dive into the findings of some of the top POEMs of the year and their ramifications for family physicians.

8. Which antidepressants have the highest suicide risk? (July 6) - 748 views

In a United Kingdom cohort of 240,000 adult patients with depression, the adjusted hazard ratios for venlafaxine and mirtazapine for suicidal behavior were 1.70 (1.44 to 2.02) and 1.85 (1.61 to 2.13), respectively, compared with citalopram.

9. How to make sure your patients understand health information (July 15) - 713 views

A large body of evidence demonstrates strong associations between low health literacy and poorer health outcomes; compared to patients with high health literacy, patients with low literacy have more hospitalizations, more emergency department visits, and are less likely to receive appropriate preventive and chronic care services.

10. Depression treatment: the evidence base from a primary care perspective (Feb. 23) - 695 views

This systematic review provides guidance for family physicians treating patients with mild to moderate depression as well as severe depression; it provides reassurance to patients unable to attend multiple psychotherapy sessions that even a few sessions can provide benefit.

Monday, December 21, 2015

Link to your favorite references from the AFP home page!

- Jennifer Middleton, MD, MPH

When I was a resident 10 years ago, I carried several references in the pockets of my white coat. My Palm pilot was useful for referencing medical equations but little else, so I carried everything else in paperback: a drug reference guide, an antibiotic guide, a book on common on-call patient situations. Online reference tools were in their infancy, and by the end of my intern year several pages in those books were dog-eared and memorized.

Fast forward to 2015: my smartphone contains all of those resources and more - I don't even have to carry a printed patient census in my pocket anymore when I round in the hospital. But as nice as smartphones are, nothing beats the full view of a webpage on a computer screen, and we have endless options of medical reference websites at our fingers. Answering clinical questions at the point-of-care is easier than it's ever been, but keeping track of those websites can be difficult. Sure, you can add bookmarks to your web browser, but some health systems limit the ability to access those behind their firewalls. Plus, it takes time to bring those up and log in.

What if you could pull up a trusted website and access all of your favorite references right there? AFP recently added the ability to do precisely that - on the right side of the top banner with a gold star is the new "Favorites" section. If you're logged in to the AFP website (which you can do once and leave it if you're working on a trusted computer), clicking on "Favorites" will bring you to a page where you can quickly paste in the hyperlinks of whatever references you'd like to include - be they AFP sites or others.

AFP By Topic and the Choosing Wisely tool are available from the AFP homepage, so I decided not to add those to my Favorites list. I did add AFP's Medicine by the Numbers webpage, along with our new Podcasts. I suspect that the CME Quiz and Photo Quiz department pages will be popular on many AFP subscribers' Favorites. I've also added my prescription drug database of choice and a couple of subscription online clinical information resources to round out my list.

Answering questions quickly at the point-of-care is easier than ever with the AFP Favorites feature, as is accessing your favorite medical content when you have a little more time to peruse it. If you'd like a full tour of all of the updates to the AFP website, including the Favorites feature, you can find it here.

Monday, December 14, 2015

Pharma industry free speech is anything but free

- Kenny Lin, MD, MPH

Last month, the American Medical Association (AMA) called for a ban on direct-to-consumer (DTC) advertising of prescription drugs and medical devices, arguing that this type of advertising drives the nation's escalating drug bill by creating demand for new, expensive medications that are often no more effective than older ones. Since the first televised prescription drug ad aired in the U.S. in 1983, pharmaceutical companies have spent billions of dollars on DTC advertising, including $4.8 billion in 2014. The ads are worth every penny. According to Kantar Media, 76% of Americans have seen at least one DTC ad on television in the past 12 months, and 1 of 3 who viewed these ads took some action as a result.

The AMA's call comes at a time of increasing public concern about the potentially harmful impact of loosening restrictions on marketing and promotion of off-label use of drugs. Although the U.S. Food and Drug Administration (FDA) has historically prohibited this practice, earlier this year a federal District Court judge blocked the FDA from enforcing restrictions on promoting a prescription fish oil product for an unapproved indication. The judge determined that if the FDA refused permission to distribute the promotional materials, it would violate the company's First Amendment right to freedom of speech.

Although recent Supreme Court decisions have established that for some purposes, corporations have the same rights as people, there are real dangers to allowing the pharmaceutical industry to claim anything they want about their products to physicians or consumers under the guise of free speech. A Canadian cohort study published in JAMA Internal Medicine found that off-label drug use was 44 percent more likely to be associated with adverse drug events than on-label use, a difference driven almost entirely by the prescription of drugs without strong supporting scientific evidence (about 80 percent of all off-label prescriptions). The top five drugs used off-label were quinine, gabapentin, quetipine, amitriptyline, and risperidone.

A 2014 American Family Physician editorial by Drs. April Fitzgerald and Patrick O'Malley discussed how family physicians can "stay on track when prescribing off-label." The authors noted that the toughest calls occur when evidence suggests potential benefits but the harms are not well described:

The ethics surrounding off-label use become more complicated when considering medications with less clear-cut positive or negative risk-benefit ratios. This is the gray area where physicians individually weigh the translational gaps in evidence between effectiveness, available research, and the complexities of real-world clinical practice. Particular scrutiny is suggested when using off-label medications with red flags, such as new medications, medications with known serious adverse effects, or high-cost medications, or when considering novel off-label use.

Pharmaceutical free speech is actually anything but free. By directly encouraging patients to request new medications from physicians, and by promoting drugs for unapproved uses, the industry will not only continue to increase national spending on prescription drugs, but expose even more patients to an unacceptable risk of iatrogenic harm.

Monday, December 7, 2015

What is the best diuretic for treating hypertension?

- Jennifer Middleton, MD, MPH

Even though hydrochlorothiazide (HCTZ) was the 10th most commonly prescribed drug in the US in 2010, an FPIN Help Desk Answers article in the current issue of AFP argues in favor of chlorthalidone over HCTZ, as does a 2008 AFP editorialAlthough some studies have found HCTZ and chlorthalidone's effects on cardiovascular mortality to be equivalent, some studies have found chlorthalidone to be more effective. 

The AFP FPIN Help Desk article reviews two systematic reviews and one randomized controlled trial (RCT) comparing HCTZ and chlorthalidone for reduction of coronary heart disease (CHD) events. The first systematic review and the RCT both showed greater blood pressure lowering with chlorthalidone compared with HCTZ, but neither measured cardiovascular outcomes. The second systematic review included a network analysis comparing outcomes from studies that used chlorthalidone to studies that used HCTZ. Those researchers found that the number needed to treat (NNT) with chlorthalidone instead of HCTZ to prevent 1 additional cardiovascular death over 5 years was 27.

Some cohort studies have found chlorthalidone non-inferior to – and potentially more hazardous than – HCTZ. A 2013 prospective cohort study conducted in Canada found no difference in cardiovascular outcomes but a higher risk of hospitalization for hypokalemia; interestingly, patients on chlorthalidone were more likely to be on a beta-blocker than those on HCTZ because of a combination pill on the Canadian formulary. A retrospective cohort study reviewed by AFP in 2013 found equivalent outcomes between patients treated with chlorthalidone versus those treated with HCTZ.

These cohort studies showing equivalence between chlorthalidone and HCTZ, along with concern for more hypokalemia with chlorthalidone, may explain why HCTZ is the diuretic of choice in treating hypertension in the US.  In the level of evidence hierarchy, cohort studies sit below randomized controlled trials (RCTs) and systematic reviews because they are more prone to bias. On the flip side, however, cohort studies can sometimes provide better information about "real life" conditions; in an RCT, participants follow strict protocols, but in cohort studies, we can measure the effect of interventions as they play out in practice.  

So, overall, some cohort studies have found HCTZ and chlorthalidone to be equivalent, but some RCTs and systematic reviews have found differently. Some studies have shown increased hypokalemia with chlorthalidone use, but several large hypertension treatment trials, including the 2015 SPRINT, preferentially used chlorthalidone in their treatment protocols.  If you’d like to read more, there’s an AFP By Topic on Hypertension.

When the evidence base is conflicting, it can be challenging to decide what to do in practice. How do you decide which diuretic to prescribe for patients with hypertension?

Monday, November 30, 2015

Guest Post: Primary care lifeline

- Sarah E. Stumbar, MD, MPH

In March, the Association of American Medical Colleges (AAMC) released a report estimating that there would be a shortage of between 12,500 and 31,100 primary care physicians by 2025. These projections are not news to anyone in medicine, but in the uproar following Columbia University/New York-Presbyterian’s unilateral decision to close its family medicine residency program (and the subsequent quick reversal of that decision), it became obvious that most people still do not understand the complex and integral roles that primary care physicians play in their patients’ lives.

During my Family Medicine residency, I provided prenatal care, delivered babies, provided postpartum contraception, performed options counseling and abortions, and saw the infants I delivered grow into toddlers. I went on home visits to provide emotional support and end-of-life care to a magnificent woman dying of esophageal cancer. I followed my patients from the clinic to the inpatient setting and back to the clinic again. I worked to forge relationships that would hopefully keep my patients out of the hospital. I gave out my cell phone number and my e-mail address, and I welcomed phone calls and clinic walk-ins whenever there was a question or concern. I made countless calls to specialists, begging them to see my patients sooner than the next available appointment in six months. Once, for a patient with possible lung cancer on a CT scan, I made twelve phone calls to a pulmonologist before I was able to get her an appointment within an acceptable amount of time. In the Bronx community where I trained, I made certain that I was the strongest advocate for my patients, many of whom had never had anyone advocate for them before.

Now seeing uninsured patients in a mobile health clinic in Miami-Dade County, I am the safety net that wouldn’t otherwise exist. My new patients are quickly learning that I believe in their right to health care, and I will do anything to help them navigate our struggling medical system. The Washington Heights Community served by Columbia’s deeply invested residents—and this nation as a whole—needs more family physicians, not more medical administrators who have forgotten the daily realities of our patients.


Dr. Stumbar is a 2015 graduate of Montefiore Medical Center’s Residency Program in Social and Family Medicine. She is now an Assistant Professor of Family Medicine at Florida International University in Miami.

Monday, November 23, 2015

Which patients should SPRINT to a systolic goal of 120?

- Jennifer Middleton, MD, MPH

Two weeks ago, I wrote about the controversy surrounding the early closure of SPRINT. That same day, the SPRINT research group published the results of their study; for SPRINT participants, a systolic blood pressure (SBP) goal of 120, compared to 140, resulted in lower risk of several cardiovascular events including mortality, but we should proceed with caution before applying these findings to our patients.

SPRINT was a randomized controlled trial that enrolled over 9000 community-dwelling participants across 102 clinical sites in the United States. Participants had to be at least 50 years old, have a SBP between 130 and 180, and had to have "an increased risk of cardiovascular events," which the research group defined as prior cardiovascular disease (CVD) excluding stroke, chronic kidney disease (CKD), a 10-year Framingham risk score of at least 15%, or age of at least 75 years. Participants were excluded if they had diabetes or a history of a stroke. The research group provided a suggested protocol for antihypertensive medications. Participants in the intensive group had a mean SBP of 121.4 mmHg, and participants in the control group had a mean SBP of 136.2 mmHg.

The researchers' primary outcome was a composite of myocardial infarction, acute coronary syndrome, stroke, heart failure, or death from CVD, and the rate of the composite outcome was lower in the intensive group (hazard ratio 0.75 [0.64-0.89]). The number needed to treat to prevent a primary outcome event was 61. The intensive treatment group also had a higher likelihood of worsening renal function, and since the study was stopped early, it's impossible to know how likely it is that those renal effects would be irreversible. Other adverse events more common in the intensive treatment group: hypotension, syncope, and electrolyte abnormalities.

The study population may not be generalizable to your practice; it's important to note that these findings should not be extrapolated to suggest that all of our adult patients should aim for SBPs below 120. Certainly, that may be a reasonable goal for patients over the age of 50 with "an increased risk of cardiovascular events," but I suspect that many of our patients over the age of fifty with hypertension (and without diabetes) do not have those risk factors. Those patients who do meet the study parameters should still engage in patient-centered decision making regarding the risks of intensive treatment.

Dr. Lin commented on other challenges of applying this study to our patients; office blood pressure measurements, for example, are rarely done with the level of precision they were measured with in SPRINT. Aggressively adjusting medication doses based on what may be inaccurate office BP readings could potentially cause patients significant harm. Most of the time, the JNC 8 guidelines are likely to be more applicable to the patients in our offices than SPRINT's narrowly defined parameters.

Has SPRINT changed how you treat hypertension?

Tuesday, November 17, 2015

Two perspectives on the PSA screening pendulum

- Kenny Lin, MD, MPH

Two research studies published today in JAMA presented compelling evidence that the 2012 U.S. Preventive Services Task Force recommendation statement that discouraged prostate specific antigen (PSA)-based screening for prostate cancer has had a significant impact on clinical practice. In one study, researchers from the American Cancer Society used data from the Surveillance, Epidemiology, and End Results registries to document an 18% relative decrease (from 37.8% to 30.8%) from 2010 to 2013 in the percentage of men age 50 years and older who reported PSA screening in the previous 12 months. In another study, a separate team of investigators found a similar decline in the prevalence of PSA screening reported in the National Health Interview Survey in men age 50 to 74 years.

For me, and for other proponents of the view that PSA screening is not effective in reducing mortality from prostate cancer and instead leads to substantial psychological and physical harms, this reversal in practice is good news. In an editorial published in the October 15th issue of American Family Physician, Dr. Vinay Prasad argued that family physicians who reduce or discontinue their use of the PSA test for screening are on solid ground:

When it comes to PSA screening, the pendulum has swung. Not only has our understanding of the benefits and harms shifted, as reflected by a continual change in guidelines away from testing, but the burden to justify screening has also swung. For decades, critics of PSA testing have shown the many unintended repercussions of the test, cautioning that our initial widespread adoption was not justified. Moving forward, it must be the proponents of screening who shoulder the burden of proof. Their task will be to show in a future randomized study whether any PSA screening algorithm can improve survival or quality of life compared with what is now the standard of care—no routine screening. Before primary care physicians consider reintroducing the PSA test, they must have proof that it improves outcomes.

In another editorial that accompanied the JAMA studies, Dr. David Penson also described the shift in practice as a "pendulum," but took the position that until a better screening test is developed, "the PSA test can be deployed more effectively (or strategically), maximizing benefit while minimizing harm." If PSA screening does in fact save some lives, Dr. Penson argued, then extending screening intervals and focusing on men who are more likely to develop "high-risk" prostate cancer could be a better approach than not screening at all:

Certainly, physicians have been overly aggressive in their approach to prostate cancer screening and treatment during the past 2 decades, but the pendulum may be swinging back the other way. It is time to accept that prostate cancer screening is not an “all-or-none” proposition and to accelerate development of personalized screening strategies that are tailored to a man’s individual risk and preferences. By doing this, it should be possible to reach some consensus around this vexing problem and ultimately help men by stopping the swinging pendulum somewhere in the middle.

Where is your practice on the pendulum of PSA screening?

Monday, November 9, 2015

Should we SPRINT to lower blood pressure goals?

- Jennifer Middleton, MD, MPH

Just as we were all adjusting to JNC 8's blood pressure goal recommendations this past December (140/90 for most and 150/90 for adults over 60 without co-morbidities), in September the National Institutes of Health (NIH) issued a press release stating that they were halting SPRINT early due to preliminary findings that the benefits of a systolic blood pressure goal of 120 reduced the risk of cardiovascular events and mortality compared to a systolic blood pressure goal of 140.

SPRINT, the Systolic Blood Pressure Intervention Trial, aimed to prospectively enroll and then follow over 9000 patients during a four- to six-year time period to definitely answer that age-old blood pressure treatment question - how low should we go? Participants were at least 50 years of age, had a systolic blood pressure of at least 130, and had at least one additional risk factor for cardiovascular disease (chronic kidney disease, a Framingham score of at least 15%, and/or age of at least 75 years) but no prior history of cardiovascular disease. Patients with diabetes were excluded. The primary outcomes of interest were incidence of myocardial infarction (MI), acute coronary syndrome (ACS), stroke, heart failure, or cardiovascular death; they examined several other secondary outcome measures as well, including all-cause mortality and worsening chronic kidney disease.

Prior studies examining this question found no benefit for keeping systolic blood pressure under 120 but possible harm from doing so; Dr. Lin has reviewed this evidence base twice on the AFP Community Blog, in 2013 and again earlier this year. (There's also an AFP By Topic on Hypertension if you'd like to read more.) So, if the SPRINT findings are legitimate, significant changes may be quickly coming about blood pressure treatment recommendations, including the possible early retirement of JNC 8. The stakes are high.

Stopping a study early isn't necessarily a bad thing. If it's clear, for example, that one arm of the trial is causing harm, then researchers are ethically obligated to stop the study. Similarly, it can be questionable to continue a study when it's clear one treatment is far superior to the other. But stopping studies early also has risks; for example, a smaller number of participants, and/or a decreased amount of time following them, can skew results to look more impressive than they might otherwise have been.

The NIH has faced significant backlash on social media, but for more than just stopping the study early:

From Health News Review:
The big announcement about these “landmark” results doesn’t actually include any “results” from the SPRINT study. You can search the news release high and low but you’ll find nary a single statistic from the study or a number related to what the researchers found.
From The Incidental Economist:
[T]his is basically the release of conclusions without methods or even results. It hasn’t been peer reviewed. I don’t know the details....Those who conducted and funded the study can’t be the ones to judge its merit. 

From Scientific American:
Doctors and reporters only had the slick NIH press release, which glistened with words such as “landmark” and “life-changing” and provided hype but little substance. It did not emphasize that the findings may only apply to a limited segment of the population...and it did not mention potential risks associated with taking multiple blood pressure drugs...
From the PLOS blog:
If the primary outcome turns out to be rock solid and confirmed in the future, other aspects of the study...are vulnerable to the shorter intervention period. That includes knowledge about longer term and less common adverse events, and the impact on subgroups of sicker people.

When it comes to data release of clinical trial results, the NIH should set the standards. It shouldn’t be moving the bar. In this case, one could imagine some overly pushy drug company using this data release to justify releasing more data on its own product. That leads us even further into a world where science is conducted by press release. That shouldn’t be an outcome anyone wants.
Your patients may already be reading and asking about SPRINT; how are you responding? What do you want to see from SPRINT before considering a change in how you manage patients with high blood pressure?

SPRINT was just published today, and no doubt there will be a lot of discussion in the coming weeks dissecting its findings. Watch for more on this topic from the AFP Community Blog, too!

Monday, November 2, 2015

If CBT came in a pill, how much would it cost?

- Kenny Lin, MD, MPH

Family physicians commonly treat patients with depression, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), sleep disorders, and other psychiatric conditions. Although some patients respond to medication, prescribing has significant downsides. Antidepressants can increase suicide risk, and a study that once declared medications to be superior to behavioral therapy for ADHD is now receiving a second look. In contrast, an article by Drs. Scott Coffey, Anne Banducci, and Christine Vinci in the November 1st issue of American Family Physician reported that cognitive behavior therapy (CBT) effectively relieves symptoms of all of these conditions, plus those from post-traumatic stress disorder, autism, obsessive-compulsive and tic disorders, personality disorders, and eating disorders. The article answered several common questions about CBT, including how it works:

The aim of CBT is to help patients adopt more adaptive patterns of thinking and behavior to improve function and quality of life. Treatment goals are selected collaboratively with patients to determine whether progress is being made. CBT involves three core strategies applied alone or in combination, depending on the patients' needs: (1) identifying and challenging problematic thoughts and beliefs, with the goal of helping patients develop more realistic and adaptive thoughts and beliefs, (2) scheduling pleasant activities to increase environmental reinforcement, and (3) extended exposure to unpleasant thoughts, situations, or physiologic sensations to decrease avoidance and arousal associated with anxiety-eliciting stimuli.

Finding a qualified therapist many be a challenge in some communities, and CBT usually doesn't come cheaply. However, CBT for most conditions is time-limited: one session per week for 8 to 12 weeks. At $150 to 200 per session, the typical cost for a treatment course would be between $1200 and $2400.

In comparison, a one-month supply of the newer antidepressants levomilnacipran, vortioxetine, and vilazodone (which are labeled only for treatment of major depressive disorder in adults, and are often prescribed indefinitely) cost $286, $254, and $149, respectively, at the time each drug was reviewed in AFP's STEPS (Safety, Tolerability, Effectiveness, Price, and Simplicity) department. So a newer antidepressant could cost as much or more than a course of CBT in as little as 4 to 8 months.

If CBT could somehow be packaged into a pill and patented, though, it would likely cost a lot more, given its versatility and enormous potential market share. It might become the next big blockbuster drug, like newer antiviral treatments for hepatitis C that cost between $84,000 and $156,000 for a 12-week course of treatment, or $1000 or more for a single pill. Or, since CBT has been around since the 1960s, perhaps a better benchmark would be the infamous recent example of the 62 year-old drug pyrimethamine (Daraprim), whose manufacturer raised the per-tablet price from $13.50 to $750, literally overnight.

Monday, October 26, 2015

Thickened feeds may help infant GERD but may also cause excess weight gain

- Jennifer Middleton, MD, MPH

Thickening infant feeds with rice cereal is not a new practice; my mother has told me more than once that doing so "cured" my belly woes as an infant, and she frequently recommends the same to new mothers whose babies are struggling with frequent spit-ups and fussiness. As discussed in an article in the current issue of AFP, thickening feeds is one of many remedies often tried for symptomatic gastroesophageal reflux disease (GERD) in infants prior to treating with medication, but this common remedy can be associated with excess weight gain.

This finding comes from a 2008 systematic review, cited by the AFP authorsThe included studies also demonstrated mixed results regarding the efficacy of thickening feeds, and the systematic review authors, citing a 2002 guideline, assert that "thickening agents and infant diets containing thickening agents should be used only for selected infants with failure to thrive caused by excessive nutrient losses associated with regurgitation and used only in conjunction with appropriate medical treatment and supervision."

Although the connection between excess weight gain from thickening agents in formula and weight later in life has not been studied, another 2008 systematic review did find that overweight children tend to remain overweight into adulthood. This study, recently featured in the Journal of Family Practice, included 13 studies dating back to 2001 deemed to be of high quality and looking at children's weights as far back as 1 year of age; one study also included birth weights in its cohort. Although there was significant variability in study findings, in general, children with BMIs greater than the 85th percentile were at least twice as likely to be overweight as adults. It's perhaps not an impossible stretch that minimizing infants' excess calories may benefit them later in life, especially since even what our mothers ate while pregnant can affect our risk for obesity. 

There are several other conservative measures to recommend first for infants with GERD. If you'd like to read more, there's also an AFP article from 2009 on infant formula as well as an AFP by Topic on nutrition.

Monday, October 19, 2015

RightCare Action Week and Choosing un-Wisely

- Kenny Lin, MD, MPH

This week, American Family Physician is joining clinicians, patients and organizations all over the country in supporting the Lown Institute's RightCare Action Week (#RCAW), which aims to re-focus the U.S. health system on care that is "effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations." This goal is more far-reaching than the three year-old Choosing Wisely campaign objective of encouraging conversations between physicians and patients about potentially unnecessary care. As Dr. Jennifer Middleton mentioned in last week's post, AFP has developed several resources to help family physicians implement Choosing Wisely in their practices. On the patient side, Consumer Reports has worked with more than 20 physician groups to create and distribute educational content about specific items in the campaign.

Are these efforts to reduce unnecessary care making a measurable difference? JAMA Internal Medicine recently published a study of national insurance claims data by Dr. Alan Rosenberg and colleagues that analyzed trends among seven of the earliest Choosing Wisely "don't do" recommendations from 2010 through 2013. Although there were statistically significant declines in CT and MRI for uncomplicated headaches and cardiac testing in patients without heart conditions, use of two other inappropriate services increased (NSAID prescriptions in patients with hypertension, heart failure, or chronic kidney disease; and primary HPV testing in women younger than age 30). Since the study didn't include data from 2014 or 2015, the results could either mean that the campaign isn't working or that it was just too early to tell.

Family physicians and patients should keep in mind that even care that is recommended by evidence-based guidelines and incentivized by pay-for-performance programs can be harmful if provided to patients without regard to their individual circumstances. In an Annals of Internal Medicine essay titled "The Tyranny of Guidelines," Dr. George Sarosi described the six-year saga of Mr. O, an independent octogenarian with mild hypertension and diabetes who suffered a hip fracture and subsequent stroke as the unfortunate end result of a "relentless downhill medical care spiral fueled by interventions ... to tightly control both the blood sugar and the blood pressure."

The pitfall in this case wasn't the guidelines themselves as much as the one-size-fits-all way they were applied by "the system" to the patient. Dr. Sarosi concluded, "We need a system that rewards the physician who understands the limitations of guidelines." Indeed, a Right Care system would reward physicians who prevent patients from receiving too much medicine.

Monday, October 12, 2015

RightCare Action Week is next week!

- Jennifer Middleton, MD, MPH

Overuse of medical services - unnecessary prescribing, testing, and hospital care - may represent as much as 30% of the medical services we provide in the United States. Besides wasting resources, these unnecessary medical services can also cause patient harm and even death. Led by the Lown Institute's RightCare Alliance, several leading patient care advocacy organizations have declared October 18-22 RightCare Action Week:
RightCare Action Week is a grassroots initiative for clinicians and others who want to take action that demonstrates how much better our healthcare system can be.Our healthcare system has strayed from its mission: Healthcare that is effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations. (
RightCare Action Week is an opportunity for all of us to show our patients that they deserve better than to be harmed by unnecessary medical services. You may feel, as a busy family doctor, that participating in such initiatives is unrealistically time consuming, but this week provides plenty of opportunities to get involved on even a very small scale - and when those small actions are added up across the country, they can make a very powerful voice.

The RightCare Action Week Guide to Taking Action describes easy ways to get involved. First, consider participating in an overuse count; simply observe how many unnecessary medical services you see during all or part of the week and share your tally at Second, look for or organize a story slam, a time when healthcare workers can come together and share stories of overuse - and possibly associated harms - they've seen. Third, and perhaps the quickest of all, consider participating in their photo campaign - a pic of you holding a sign describing what "right care" means to you, tweeted or e-mailed to the Lown Institute. You can find more details about each of these initiatives here.

You can also count on AFP to provide you with the point-of-care resources you need to avoid overuse. If you haven't checked out our Choosing Wisely search tool, it's a great way to quickly access those evidence-based guidelines. Under the Department Collections tab on the AFP home page (hyperlink), you can find AFP Journal Club, where AFP editors critically assess recent studies, Medicine by the Numbers, which provides clear-cut summaries of the harms and benefits of various interventions, and a POEMs (Patient Oriented Evidence that Matters) archive which includes the top 20 POEMs by calendar year. Each of these resources has interactive search tools and provide quick answers intended to enhance the care you provide to your patients every day.

If you'd like to read more about overuse, AFP ran a series of editorials on overscreeningoverdiagnosis, and overtreatment by Dr. Mark Ebell, AFP Deputy Editor for Evidence-Based Medicine, earlier this year along with an accompanying editorial by AFP Editor Dr. Jay Siwek. 

RightCare Action Week starts in just 7 days; please consider taking part in at least some small way! Maybe you'll commit to trying one of the AFP resources above that is new to you, or maybe you'll try an overuse count, story slam, or photo campaign. Share your involvement on social media with #rightcare and watch for RightCare Action Week updates from @AFPjournal and myself, @SingingPenDrJen, too.

Wednesday, October 7, 2015

How can tech help Family Medicine for America's Health?

- Kenny Lin, MD, MPH

A randomized trial published last month in JAMA found that sending lifestyle change text messages to patients with coronary artery disease improved smoking cessation rates, increased physical activity, and reduced other cardiovascular risk factors. After only 6 months, the texted group had lower low-density lipoprotein, systolic blood pressure, and body mass index measurements than the usual care group. This was an impressive finding, but an unsettling one, since I had just finished reading an American College of Physicians position paper on the use of telemedicine in primary care settings. Taken together, these publications suggest that virtual care technologies, broadly defined, could make many in-person clinical encounters unnecessary. That's good for patient convenience, but potentially threatens one of the best parts about practicing family medicine: seeing patients in person.

Health information technology (IT), as embodied in electronic medical record systems that have replaced paper charts in most family practices, has thus far been a mixed blessing for our specialty. But what about tech beyond traditional health IT? The technology "tactic team" of Family Medicine for America's Health published a special article in Family Medicine that described strategies for family physicians to utilize an array of evolving technologies to strengthen therapeutic relationships and improve outcomes:

1) Smartphone apps and wearable devices that capture data about patients' health habits and give feedback to influence their behavior

2) Point-of-care musculoskeletal ultrasound

3) Web-based communication for "virtual" hospital rounding and specialist consultations

4) Web-based videos to provide patient and professional education

Although all of these initiatives have great potential to benefit patients, many are being developed in silos without leadership or input from family physicians. Therefore, the paper's authors proposed that Family Medicine for America's Health work to integrate these overlapping efforts into "a united front improving health IT and other technologies for the specialty."

Key opportunities for family physicians "to capitalize on our collective strengths" in the near future include partnering with developers to create health IT tools that improve clinical outcomes (rather than merely serving administrative or billing functions); supporting primary care-centric data models; participating in the development of primary care quality measures; and collaborating with patient and consumer organizations locally and nationally to identify and promote patient- and family-centered technology solutions that complement the vital functions of family medicine.

Monday, September 28, 2015

Peer review benefits journals, readers, and reviewers #peerrevwk15

- Jennifer L. Middleton, MD, MPH

Today kicks off the first-ever Peer Review Week, a time to both celebrate and debate peer review in scientific publications. A group of 4 publishing organizations came up with this idea as a way to "honor...thcentral role peer review plays – and, we believe, will continue to play – in scholarly communications." You can follow the conversation on twitter with #peerrevwk15.

But what is peer review, exactly? Here's one definition from
Peer review is the system used to assess the quality of scientific research before it is published. Independent researchers in the same field scrutinise [sic] research papers for validity, significance and originality to help editors assess whether research papers should be published in their journal. 
Peer review furthers journals' credibility by ensuring that external reviewers with no stake in the journal (monetary or otherwise) have deemed their content of sufficient quality and interest to disseminate.

Before each crisp new issue of AFP hits your mailbox or your tablet, peer review volunteers have examined every single clinical article it contains. The peer review process at AFP is similar to many other medical journals. Once we receive a manuscript, AFP staff assigns it to 3-4 peer reviewers. Reviewers receive a copy of the manuscript and provide feedback on both the manuscript's content and quality using an online form, which includes an assessment of whether the manuscript is, or could be, publication-worthy. The assigned AFP medical editor collates the feedback and provides it back to the manuscript authors. Most of the time, authors are asked to respond to the feedback with an improved manuscript. The result is a final article that has been made better by peer reviewers' feedback and ideas.

AFP is grateful to its peer reviewers for their contributions. AAFP members may claim CME credit for each manuscript they review, which is easy to do at the AAFP "Your CME Report" website. Additionally, peer reviewing can help writers strengthen their writing and reading skills. Reading a manuscript for peer review requires careful attention to each word, phrase, and sentence, scrutinizing each one for accuracy, clarity, and any possible bias. Being "sensitized" to "common writing mistakes," as AFP Editor Dr. Jay Siwek has said, can improve the quality of writers' own manuscripts, and I would argue that learning how to read carefully benefits peer reviewers every time they read pretty much anything else.

I've been a peer reviewer for a handful of journals since I was a fellow, and I have immensely enjoyed the opportunity to develop my writing and editing skills along the way. Interacting with journal editors and discovering if they concurred with your assessment has been a great learning process and quite a privilege. Anyone can apply to be a peer reviewer, and journals always seem to be looking for them. If you'd like to learn more about the peer review process at AFP, check out our online reviewer's guide, which includes both this handy reference list of peer review resources and the link to apply to be an AFP peer reviewer (click "Fill out the reviewer profile" and you can download a pdf with further instructions). Remember - AAFP members can get CME credit for each manuscript, and you'll help us continue to produce the high-quality work you've come to expect from AFP.

AFP peer reviewers, please chime in - what do you value about being a peer reviewer?

Monday, September 21, 2015

Ready or not, ICD-10 has arrived at last

- Kenny Lin, MD, MPH

After two separate one-year delays, the U.S. implementation of the International Classification of Diseases, Tenth Revision (ICD-10) code sets for medical diagnoses and inpatient procedures is now just 9 days away. If you are an employed family physician like me, you have probably been required by your employer to familiarize yourself with the new codes through face-to-face training or online modules. If you own your own practice, hopefully you have already confirmed with your electronic health record vendor that the switch to the new code sets will happen seamlessly on October 1st.

But if for some reason you have procrastinated, there is still time to get up to speed on the changes. To make this process as painless as possible, the editors of Family Practice Management have assembled a timely collection of links to articles on the ins and outs of ICD-10 coding, including their latest piece about documentation elements to support coding five common conditions in family medicine (asthma, otitis media, diabetes, well-child examinations, and hypertension). If you want to have all of this information in one place, you can purchase an e-book anthology available for iOS, Kindle Fire, Google Play, or Nook.

Although the increased diagnostic specificity that ICD-10 permits compared to ICD-9 can and should benefit the health system, FPM medical editor Ken Adler, MD, MMM warned in a recent editorial that doctors could lose in the short term:

We are told that we need ICD-10 for better quality reporting, public health research, health policy planning, fraud detection, and risk adjustment for quality based payments. That all sounds reasonable. But will the primary beneficiaries of ICD-10 turn out to be payers rather than patients? Will ICD-10 be used as just one more tool to delay or deny payment to physicians? ... There are plenty of reasons to be reasonably specific with our coding, ... but fear of not being paid should not be one of them. As physicians, we need to continue to make that point loud and clear.

Hear, hear.

Monday, September 14, 2015

When "drink plenty of fluids" isn't enough

- Jennifer Middleton, MD, MPH

Treating the dehydration that can accompany foodborne illness may seem straightforward, and many physicians advise little more than "drink plenty of fluids" to patients who are only mildly ill. In the current issue of AFP, though, the authors of "Diagnosis and Management of Foodborne Illness" recommend making specific recommendations about oral rehydration therapy, especially for younger patients.

Without specific guidance, many parents will use soft drinks and juices to prevent and treat their children's dehydration. These sugar-rich and electrolyte-poor beverages can exacerbate diarrhea and cause hyponatremia. Sports beverages that tout electrolyte replacement are also not appropriate as they typically contain excessive sugar. Physicians should instead recommend oral rehydration solutions with an appropriate balance of carbohydrate and electrolytes; in the US, Pedialyte and Enfalyte are options. These commercially available solutions eliminate the risk of preparation error (and possible electrolyte imbalances and/or worsening diarrhea) of homemade oral rehydration solutions.

Physicians may wish to counsel families of infants and young children to keep these solutions on hand at well visits, so that they are immediately available should their child become ill. For outpatient treatment of mild dehydration, parents may give 1 mL per kg every 5 minutes over a 4-hour period. For maintenance after that time, parents should aim for 1 oz of oral rehydration per hour for infants, 2 oz per hour for toddlers, and 3 oz per hour for older children for as long as illness symptoms persist. As they recover, patients will experience decreased thirst, which inherently protects against over-hydration. If you'd like more information, check out the AFP By Topic on Gastroenteritis and Diarrhea in Children, which includes this 2012 article with more detail about using oral rehydration solutions.

Physicians may find it helpful to have patient information handouts (either on paper and/or integrated into electronic health records) for patients to refer to at home like this one from or this Information from Your Family Doctor on treating dehydration. Either way, providing specific recommendations about oral hydration can help our younger patients better recover from foodborne illness.

Monday, September 7, 2015

Guest Post: Quality medical care makes patients feel at home

- William Gilkison, MD

For decades, health care analysts, policy makers, administrators, and pundits have talked and written about “good quality health care.” But has anyone ever defined just what good care means? Does it mean the patient got well? That the physician met all the quality measures criteria? What defines quality medical care for patients? What is it that gives them reassurance and the knowledge that they are being well-cared for? After all, it’s the patient's definition that really matters.

Now that I’m retired from family medicine, I frequently hear from friends and former patients stories about how their doctor doesn’t seem to listen to them, how they can’t get through on the phone, how he doesn’t return their calls, how she doesn’t get back to them with lab or x-ray results, and how their staff doesn’t seem to care. These perceptions all play a role in how the patient (an anxious human being) defines quality care.

They say first impressions define the situation, so it is imperative that the first contact patients have with the doctor’s office does not result in frustration. The individual who answers the phone sets the tone for the whole encounter. If this person is surly or curt, could the doctor be like that, too? How comforting it is to a patient when the person on the other end of the line recognizes their concern, anxiety, or voice and treats him or her as one would a friend.

Many other seemingly minor issues determine the patient’s perception of good medical care. Was the patient allowed time to relate the history and symptoms? Did the doctor listen, not interrupt, and seem interested? Were appropriate follow-up questions asked? Were all the patient’s concerns addressed and questions answered before he left the exam room?

Anxiety is made worse by fear of the unknown. It drives people nuts to have to wait a week or longer for important, sometimes life-changing results when they’re in pain or worried they may have cancer. Results of blood work, the abdominal CT for that belly pain, the MRI for that headache, or the biopsy of the breast or prostate mass - all of these normal and abnormal test results should be reviewed by the physician as soon as they are available, and a disposition made immediately. Patients appreciate this more than one can imagine.

In my view, then, the definition of good care includes communication, patience, concern, and perseverance. A high quality, "patient-centered" medical home is based on these human characteristics and not on outcome criteria, EHR meaningful use, or other measures. To the patient, good care means this: the doctor saw me when I needed him, diagnosed my problem correctly, treated it appropriately and effectively, gave me my test results without my having to ask, communicated permitted pertinent information to my loved ones, and asked how I was doing the next time we met. And better yet, his office staff knew my name when I came in. Isn’t that just like being at home?

Monday, August 31, 2015

Identifying female patients' sexual health concerns

- Jennifer Middleton, MD, MPH

Talking with patients about sex can be uncomfortable for physicians, yet many of our patients have concerns about their sexual functioning. "Sexual Dysfunction in Women: A Practical Approach" in the current issue of AFP provides pragmatic advice to enable family physicians to assist these women.

The authors differentiate between sexual health concerns and dysfunction, discuss three categories of sexual dysfunction, and describe treatment options. They suggest using the PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model when discussing sexual health with women and give examples of supportive, normalizing statements to use with patients (Table 5).

All of this excellent advice is of little use, though, if female patients' concerns are not voiced. Few women will initiate a discussion about sexual concerns with a physician, and many women will not seek care at all for sexual concerns due to embarrassment. Also, the greater the age difference between female patient and clinician, the less likely female patients will bring up sexual health issues. Most women will not ask questions about sex to physicians.

Physicians, then, need to directly solicit concerns. Most women, regardless of age, are willing to answer questions about their sexual functioning, and many would like for their physicians to ask them questions about this area of their health. A multi-specialty survey of physicians, however, found that few physicians initiate conversations about sexual health. We must overcome our reticence to discuss sex with our female patients; the questions in Table 3 of the AFP article referenced above provide a starting point for these conversations. Automated patient history software is another potential solution; in one study, patients were more comfortable disclosing sexual health concerns when giving their history on an electronic tablet compared to verbally giving their history to a physician.

Regardless of how we do so, inquiring about sexual functioning is important for women of all ages. A study in the current issue of Annals of Family Medicine examines the factors associated with sexual activity and satisfaction in older women; those authors found that the majority of partnered women remain sexually active throughout the life span. As a healthy sex life correlates highly with quality of life measures, especially as people age, family physicians need to be willing to discuss sexual issues with their patients.

Monday, August 24, 2015

Interacting with the arts in medicine: a web-based repository for teaching and learning

- Caroline Wellbery, MD, PhD

A cadre of physicians and other health practitioners, mostly educators in medical schools, believe in the healing power of the arts. Many of these clinicians find ways of incorporating the arts into their practice. Although hard evidence is lacking, the arts can be used to improve clinical observation, deepen the doctor-patient relationship and prevent physician burnout. Playing music for and with patients, listening to and re-telling stories, and spending time looking at art all have a role in teaching medical trainees and caring for patients.

Over the years, I have developed a rich web-based resource from which physicians and students can draw—the website “Interacting with the arts in medicine.” This repository of visual, auditory and narrative art covers many relevant topics—from learning anatomy to patients’ experience of illness to challenges faced at the end of life.

Winthrop Chandler - Dr. William Gleason, 1785 Oil Ohio Historical Society

Many of the works included in the site are the result of personal relationships I’ve cultivated with artists around a mutual interest in medicine. Once while reading the newspaper, I came across an article about a dancer, Ciao-Ping Li, who had choreographed a work entitled “Painkillers.” The article described how Ciao-Ping Li created this work in response to a serious car accident that had among other injuries crushed her foot. The performance chronicles her ordeal as she tried unsuccessfully to return to dance. Seeing that Ciao-Ping was in town to premiere this work, I attended her event and afterwards introduced myself. I asked if I could post her story on my website and she graciously agreed. She not only sent me pictures of her surgeries, but included clips from her choreographic work as well. In a similar way, I have connected with musicians, photographers, poets and storytellers, all of whom have generously allowed me to share their work on the site. I have always joked that my greatest talent is recognizing the talent of others and indeed, the website casts me as a kind of impresario of the arts-in-medicine.

Many of the features on the website address common clinical scenarios. In that, they complement the humanities features we publish in American Family Physician, notably Curbside Consultation, which addresses clinical dilemmas, and Close-ups, a patient page which gives patients a forum in which to tell their stories. So, for example, I’ve included in my website my colleague Heike Bailin’s humorous ruminations on caring for challenging patients, which complements many of Curbside’s themes. Or, as mentioned on the website’s page on social isolation featuring Anne Sexton’s poem, “The Touch,” I include as an additional resource one of our earliest Close-ups on the patient-physician contact during the physical exam as described in a patient’s reflection on “The Importance of Touch.”

While most medical journals provide a space for reflective writing, and some feature visual art, the pieces they publish must conform to each journal’s didactic agenda. The “Interacting with the arts in medicine” website celebrates a more open-ended approach to the arts and their application. Most features begin with a series of questions I have asked to challenge the user. Each visitor must decide how he or she wishes to engage with the site’s resources: for entertainment, to share with a patient, to pass on to a student, or to help mend a personal wound.

Some sections of the site are still being built. The visitor is invited to offer feedback, connections and additional materials or ideas. I hope you will enjoy browsing the site and finding stories, poems or images that resonate with you.


Note: Dr. Wellbery is Associate Deputy Editor of AFP.

Monday, August 17, 2015

Announcing the #AFPTop20 Tweet Chat on August 26th

- Kenny Lin, MD, MPH

For the past four years, American Family Physician has published a summary review of the top 20 clinically relevant research articles of the preceding year, as selected by a survey of Canadian Medical Association members using a validated tool. Each of these summary articles draws on material from POEMs (patient-oriented evidence that matters) written by experts in primary care and evidence appraisal at Essential Evidence Plus. This year's compilation, authored by AFP deputy medical editor Mark Ebell and McGill University family physician Roland Grad, features the top 20 research studies published in 2014 judged to be most likely to change primary care practice.

On Wednesday, August 26th at 4 PM Eastern, @AFPJournal will hold its first #AFPTop20 Tweet Chat to take a deeper dive into the findings of some of these POEMs and their ramifications for family physicians. Contributing medical editor Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will serve as moderators, and we will be joined by Dr. Ebell (@markebell). To focus the discussion, we have selected three studies that we found to be the most challenging and/or potentially controversial. If you want to read the POEMs ahead of time (helpful, but definitely not essential), they are available at the links below:

Opioids for Chronic Back Pain: Short-Term Effectiveness, Long-Term Uncertain

Low-Carb Diet Better Than Low-Fat Diet to Reduce CV Risk Factors and Cause Weight Loss (or, listen to the podcast)

New Anticoagulants vs Warfarin in A Fib: No Clear Winner

For those who can't tune in to #AFPTop20 live, we plan to make the highlights available on Storify. Either way, please follow us at @AFPJournal and re-tweet this announcement (with the #AFPTop20 hashtag) far and wide!

Monday, August 10, 2015

Ruling out acute MI in 2 hours, not 2 days

- Jennifer Middleton, MD, MPH

Since the current troponin assay used in the U.S. may not be positive until several hours after myocardial damage has occurred, many patients presenting to emergency departments (EDs) with chest pain will spend a night in the hospital to obtain serial troponin measurements. A POEM in the current issue of AFP, however, demonstrates that ruling out acute MI can be done in only 2 hours with a new high-sensitivity cardiac troponin assay.

The high-sensitivity cardiac troponin assay has several advantages over the troponin assay currently used in the United States. It detects myocardial damage within 90 to 180 minutes after an acute MI, allowing for both faster diagnosis and treatment along with faster rule out, allowing for quicker discharge home. The high sensitivity assay is also more specific for myocardium cell death compared with the current assay.

The researchers for this POEM's study enrolled approximately 1600 patients from participating hospitals in Europe and Australia who presented to EDs complaining of chest pain. Included participants had normal electrocardiograms (ECG) that did not show ST-segment elevation. They had routine serial troponins followed but also had high-sensitivity troponins drawn at 0 and 2 hours of presentation. Participants were managed independently according to their clinical presentations. After discharge, blinded cardiologists reviewed the lab work and patient courses to determine which patients did and did not have acute MI. Comparing the high-sensitivity assay against the current gold standard troponin test, the researchers found a specificity of 99% for the high-sensitivity assay with a negative predictive value of 99.5%.

This study is predated by several others seeking to improve the efficiency of ED chest pain evaluation. A 2002 study found that a 6 to 12 hour observation in the ED, with stress tests in higher risk patients, was equivalent to care with hospital admission for patients at lower risk of acute MI. A 2007 study suggested that low risk patients with normal ECGs can reasonably be discharged home. A 2009 study found that, in patients with normal ECGs, the presence of active chest pain did not confer additional risk of acute MI. Even the idea of a two-hour window is not new; in 2002, a group of researchers studied an "accelerated evaluation protocol" and found that they could rule out acute MI in 2 hours for low risk patients. Despite these studies, though, an overnight stay to rule out MI remains the standard of care in many hospitals across the U.S. in 2015, perhaps partially due to high rates of malpractice suits against ED physicians for missed MI diagnoses, but perhaps also due to the significant risk of missed MI given the limitations of the current troponin assay.

Challenges exist with the new assay as well, though. The high sensitivity of the test may lead to false positives, especially in patients with a prior history of coronary artery disease. Clinicians currently disagree about what cut-off levels to use with the high-sensitivity assay to rule in MI. And, although cost-effectiveness models in Europe suggest overall savings with use of the new assay, it's unclear how expensive it will be in the United States. It's possible that we won't realize any cost savings if the new assay is significantly more expensive than the current one.

If U.S. EDs adopt this new test, outpatient family doctors will need to complete the evaluations for these patients after they are discharged. This 2013 AFP article discusses outpatient chest pain evaluation. You can also find several resources regarding acute coronary syndrome diagnosis in the AFP By Topic on Coronary Artery Disease/Coronary Heart Disease.

Sunday, August 2, 2015

Improving the likelihood of a successful vaginal delivery

- Kenny Lin, MD, MPH

Two of the most important questions that pregnant women have are: 1) How can I improve my chances of having a normal (vaginal) delivery? and 2) Does where I plan to have my baby make a difference in birth outcomes? In the August 1st issue of AFP, Drs. Lee Dresang and Nicole Yonke review the management of spontaneous vaginal delivery by family physicians. The authors note that the following practices are associated with positive maternal and neonatal birth outcomes:

1) Encouraging patients to walk and stay in upright positions
2) Waiting until at least 6 cm dilation to diagnose active stage arrest
3) Providing continuous labor support (e.g., doulas)
4) Using intermittent auscultation in low-risk deliveries
5) Group B streptococcus prophylaxis
6) Active management of the third stage of labor

Guidelines from the American Academy of Family Physicians and American College of Obstetricians and Gynecologists encourage women with a previous low transverse uterine incision to consider a trial of labor after cesarean delivery, as most will be able to deliver vaginally.

Although obstetricians and family physicians remain the most common birth attendants in the U.S., pregnant women at low risk of complications have been increasingly turning to midwives practicing in birth centers or other out-of-hospital settings. A United Kingdom prospective cohort study that examined perinatal and maternal outcomes by planned place of birth in 64,000 healthy women with low-risk pregnancies found no differences in the odds of a composite outcome of perinatal mortality and intrapartum neonatal morbidities in freestanding midwifery centers compared to obstetric hospital units. Planned home births were associated with worse neonatal outcomes for women delivering for the first time, but not for women in subsequent pregnancies. As one might expect, labor interventions occurred most frequently in hospital settings.

Monday, July 27, 2015

Did eliminating annual pap tests worsen chlamydia screening rates?

- Jennifer Middleton, MD, MPH

Despite the USPSTF's recommendation to screen all sexually active women aged 15-24 for chlamydia annually (along with women over age 24 at increased risk), many women do not receive this testing. Even worse, a recent study in the Annals of Family Medicine found that the rate of annual chlamydia screening in young women in one health care system decreased after 2009, the year the American College of Obstetrics and Gynecology (ACOG) updated their cervical cancer screening recommendations and increased both the initial age of screening and the recommended screening interval for cervical cancer (which is consistent with the United States Preventive Services Task Force [USPSTF]'s current recommendations). Given that asymptomatic chlamydia infections can cause serious, potentially permanent complications in women, this study should prompt each of us to examine how and when we are screening for chlamydia in our offices.

The study researchers obtained data from 5 outpatient family medicine offices in a university-based health care system. They looked at the number of visits made by women aged 15-21 for any reason and calculated the percentage of women who had received chlamydia screening during two 13-month intervals, the first spanning 2008-2009 and the second 2011-2012. The total number of office visits for each cohort was similar. The odds ratio for having chlamydia screening done in the 2008-2009 group compared to the 2011-2012 group was 13.97 (95% confidence interval 9.17-21.29); in these offices, at least, chlamydia screening happened significantly more often when annual gyn exams were still the norm.

As discussed in the current issue of Family Practice Management, the Choosing Wisely campaign's goal is to eliminate medical overuse - unnecessary, potentially harmful care. Annual cervical cancer screening certainly falls into this category, as do annual screening pelvic examinations. Many of us family physicians currently practicing, however, learned to associate sexually transmitted disease (STD) screening with these no-longer annual visits; a decrease in chlamydia screening may be an unintended consequence of scaling back on cervical cancer screening.

The importance of this screening regarding our female patients' reproductive health cannot be overstated; the Centers for Disease Control (CDC) estimates that 60% of female infertility could be eliminated with appropriate chlamydia screening. Family physicians may find it helpful to measure the rate of chlamydia screening in their own practices, and, if suboptimal, consider implementing an office quality improvement initiative to increase screening. Using a urine sample to screen, which is as accurate as a cervical sample, may be one way to reduce barriers for both patients and clinicians. The National Committee for Quality Assurance (NCQA) has a publication addressing chlamydia screening which includes several additional strategies to try.

There's an AFP By Topic on STDs if you'd like to read more, and the collection contains this 2012 article on chlamydia infection screening, diagnosis, and management.

How is your office screening women for chlamydia?

Wednesday, July 15, 2015

How to make sure your patients understand health information

- Kenny Lin, MD, MPH

In the July 15th issue of AFP, associate medical editor Barry Weiss, MD shares an anecdote about a hospitalized patient's confusion about a conversation between himself and a consultant who said that it was okay to move her from the intensive care unit to the floor. The perplexed patient interpreted "floor" literally to mean that the hospital was so overcrowded that she would not be able to sleep in a bed! Although this mildly comical story might elicit chuckles at health professional gatherings, it also highlights the serious potential for limited health literacy to lead to misunderstandings between doctors and patients.

Health literacy encompasses essential skills that patients need to access health services, understand and apply health information, and make good decisions: reading, writing, numeracy, and communication. A large body of evidence demonstrates strong associations between low health literacy and poorer health outcomes; compared to patients with high health literacy, patients with low literacy have more hospitalizations, more emergency department visits, and are less likely to receive appropriate preventive and chronic care services. According to a clinical review by Dr. Lauren Hersh and colleagues, "More than one-third of U.S. adults, an estimated 80 million persons, have limited health literacy, making it more difficult for them to read, understand, and apply health information. ... Although U.S. adults on average read at an eighth-grade level, more than 75% of patient education materials are written at a high school or college reading level." Limited health literacy is more common in patients age 65 years and older and in minority populations.

How can family physicians make sure their patients understand health information? Rather than routinely screening for low health literacy, which has not been shown to improve outcomes, Dr. Hersh and colleagues recommend taking "universal health literacy precautions," a group of strategies for enhancing verbal and written communication, and visual aids (including online videos). For example, clinicians can use "teach back" to ask patients to restate the medical concept or plan in their own words to confirm understanding. Online tools are available to quickly assess the reading level of written patient materials. Patients also benefit from being encouraged to participate actively in formulating their care plans and being connected to community literacy resources, if needed.

For more information on how to bridge the health literacy gap with your patients, see this recent Family Practice Management article and the Agency for Healthcare Research and Quality's Health Literacy Universal Precautions Toolkit.