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.