Monday, April 30, 2018

Top research studies of 2017 for primary care practice

- Kenny Lin, MD, MPH

In the most recent installment in an ongoing series in American Family Physician, Drs. Mark Ebell and Roland Grad summarized research studies of 2017 that were ranked highly for clinical relevance by members of the Canadian Medical Association who received daily summaries of studies that met POEMs (patient-oriented evidence that matters) criteria. This year's top 20 studies included potentially practice-changing research on cardiovascular disease and hypertension; infections; diabetes and thyroid disease; musculoskeletal conditions; screening; and practice guidelines from the American College of Physicians and the U.S. Preventive Services Task Force.

The April issue of Canadian Family Physician, the official journal of the College of Family Physicians of Canada, also featured an article on "Top studies relevant to primary care practice" authored by an independent group that selected and summarized 15 high-quality research studies published in 2017. Not surprisingly, some POEMs ended up on both lists:

1) Home glucose monitoring offers no benefit to patients not using insulin

2) Treatment of subclinical hypothyroidism ineffective in older adults

3) Pregabalin does not decrease the pain of sciatica

4) Steroid injections ineffective for knee osteoarthritis

The common theme running through these four studies is "less is more": commonly provided primary care interventions were found to have no net benefits when subjected to close scrutiny.

On the other hand, in a randomized trial that appeared on CFP's but not AFP 's list, adults and children with small, drained abscesses who received clindamycin or trimethoprim-sulfamethoxazole were more likely to achieve clinical cure at 10 days than those who received placebo, although the antibiotics also caused more adverse events, particularly diarrhea (number needed to harm = 9 to 11). As Dr. Jennifer Middleton explained on this blog last year, these findings challenge a previous Choosing Wisely recommendation from the American College of Emergency Physicians that states, "Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up." More can sometimes be, well, more.

Speaking of the Choosing Wisely campaign, Drs. Grad and Ebell will highlight more primary care-relevant research studies from 2017 consistent with the principles of the campaign in AFP later this year.

Monday, April 23, 2018

Caring for agitated patients...and ourselves

- Jennifer Middleton, MD, MPH

A patient of mine, who works in healthcare, was allegedly assaulted by a patient last week with injuries serious enough to warrant an Emergency Department visit. I suspect many healthcare workers can tell stories of times when they, or a colleague, felt unsafe with a patient. Nearly 70% of workplace assaults in the U.S. occur in healthcare or social services settings. A 2010 study of family physicians in Canada found that 39% reported at least one serious assault at some point during their career. Although thoughtful preparation can't provide a complete guarantee of safety, it can help to reduce the risk of serious injury at the hands of an agitated patient.

A recent AFP review of the American Psychiatric Association's (APA) Practice Guidelines on Psychiatric Evaluation in Adults includes taking a thorough mental health and social history, assessing for substance abuse, and assessing for risk of harm to self or others:
If the patient reports having aggressive ideas, the APA recommends that clinicians assess the patient's impulsivity, including anger management issues; determine the patient's access to firearms; identify specific persons toward whom homicidal or aggressive ideas or behaviors have been directed; and ask about the history of violent behaviors in the patient's biological relatives.
Patients can be agitated for reasons besides a mental health issue, according to a recent article in the Journal of Family Practice. Before determining whether a patient's agitation is due to a mental/behavioral health issue, metabolic/physiological cause, substance use, and/or perceptions of unfair treatment, though, we should employ the same de-escalation techniques: stay calm, be non-confrontational, assess the availability of help, and explore solutions. The article provides suggestions for maximizing safety with agitated patients in a variety of practice settings and also suggests the use of scales like the Agitated Behavior Scale to assess risk. It also includes a discussion on interventions to mitigate the development of post-traumatic stress disorder (PTSD) in healthcare workers including Critical Incident Stress Debriefing (CISD) and workplace support measures like Cleveland Clinic's "Code Lavender."

"What to Do When Emotions Run High" from the current issue of Family Practice Management centers on the importance of recognizing, and then addressing, patients' upset feelings before they escalate. The author encourages physicians to pay attention to nonverbal cues (such as "a blank stare or an angry tone") and respond to them by sharing your observation and making gentle inquiries ("'[I]t seems like something is really bothering you today,'" or "'I sense I may have done something to upset you, and if so I'd like for us to discuss it'"). Providing empathic statements can help to defuse tensions, and the author's advice to not "take it personally" reminds us that patients' upset feelings "are usually not about us."

Have you discussed workplace safety where you practice? What resources have you found helpful?

Monday, April 16, 2018

American Family Physician Podcast passes 1,000,000 downloads: why podcasts matter

- Steven R. Brown, MD, FAAFP

We released the first episode of the American Family Physician (AFP) Podcast in December 2015. AFP Podcast is a collaboration between American Family Physician, the most-read journal in primary care, and faculty and residents of the University of Arizona College of Medicine – Phoenix Family Medicine Residency.

Today the podcast passed a significant milestone: 1,000,000 episode downloads! We began counting downloads in May 2016, so this milestone was achieved in less than two years. The AFP Podcast audience continues to grow, and our listeners are now downloading episodes an average of over 45,000 times per month. A podcast with over 20,000 downloads per month, averaged over a year, is considered “high impact” for scholarly work. AFP Podcast is regularly a Top 10 medical podcast on iTunes, and has over 170 five star ratings on the platform. Listeners to the podcast are engaged. The credits at the end of each episode have been read by medical students, residents, and practicing physicians in 39 states and 4 countries. The @AFPPodcast Twitter account has over 1300 followers and an average of over 30,000 impressions per month.

Additionally, AFP Podcast has received a 2017 Gold EXCEL Award from Association Media & Publishing: Educational Podcast category.

Why podcasts matter

The role of podcasts in medical education is growing. With the emergence of new technology, changes in learning preferences, and resident work-hour restrictions, asynchronous methods of education are increasingly relevant. 89% of emergency medicine residents listen to podcasts regularly and 72% report podcasts change their clinical practice. 86% of these emergency residents report podcasts as their favorite form of medical education because of portability, ease of use, and ability to listen while doing sometime else.

We have received multiple comments from practicing family physicians that the AFP Podcast is useful as an American Board of Family Medicine preparation resource. Clerkship directors tell us they recommend AFP Podcast to students in required family medicine clerkships.

Podcasts are also a useful platform for exploring not just practice-changing clinical evidence, but the humanistic aspects of medical practice. The 2016 post “25 podcasts that every family physician should listen to” remains one of the most read articles on the AFP Community Blog. Recommendations from that post include podcasts related to public health, improving learning, patient stories, and medical economics.

The podcast Greyscale, produced by family physician Ben Davis, explores the physician – patient relationship and its impact on practice. Sawbones, hosted by family physician Sydnee McElroy and her husband Justin McElroy, discusses medical history and is regularly ranked as a Top 100 podcast in the iTunes “Comedy” category.

Podcasting quality

While many residents, medical students, and physicians are listening to medical podcasts, there is scant literature related to podcast quality. How do we know which podcasts should be recommended? How can the AFP Podcast be sure we are producing a quality product, worthy of family physicians and learners everywhere?

Two recent studies (published here and here) have examined medical education podcast quality. Both acknowledge that study of this topic is in its infancy. Key criteria for excellence include credibility (transparency, trustworthiness, avoidance of bias), content (professionalism, academic rigor), and design (aesthetics, interaction, functionality, ease of use).

Our editorial team will continue to strive to meet these metrics. Engagement from listeners is essential to these efforts. As we say on the credits at end of each episode: “Please send us your thoughts by emailing or tweeting @AFPpodcast.” Engagement from listeners will help us improve AFP Podcast for the next million downloads and beyond.


Dr. Brown is an AFP Contributing Editor and Editor, AFP Podcast.

Monday, April 9, 2018

Increasing pneumococcal vaccination rates

- Jennifer Middleton, MD, MPH

A Medicine by the Numbers feature on Pneumococcal Vaccines in Chronic Obstructive Pulmonary Disease (COPD), in the current issue of AFP, gives pneumococcal vaccination in persons with COPD a "green" rating, indicating that the benefits outweigh potential harms. Despite these benefits, too few adults with COPD are receiving pneumococcal vaccination.

To clarify, adults with COPD aged less than 65 years should receive Pneumovax 23 (PPSV23); Prevnar 13 (PCV13) is only indicated for adults aged 18-64 with immunodeficiencies, certain hemoglobinopathies, and other specialized conditions (for a full list, check out this CDC Summary). All adults, regardless of co-morbid health conditions, should receive Prevnar 13 at age 65 followed by Pneumovax 23 at least one year later.

The article describes the evidence base demonstrating that, in persons with COPD, the number needed to treat (NNT) for pneumococcal vaccination is 21 to avoid an episode of community-acquired pneumonia and 8 to avoid an acute COPD exacerbation. (The authors reviewed studies that included adults both under and over age 65 to reach these conclusions.) While pneumococcal vaccination might not prevent mortality from COPD, patients are likely to be pleased with the benefit of avoiding pneumonia and/or exacerbations, especially given the lack of reported harms with this vaccine.

The CDC found that, in 2015, only 23% of adults eligible for pneumococcal vaccination had received one (the number eligible includes diagnoses other than COPD). Nonwhite adults and adults without health insurance reported lower vaccination rates. A study of vaccination attitudes and knowledge in Germany found that patient knowledge that pneumococcal vaccination was recommended correlated with increased rates of vaccination among eligible adults; interestingly, for influenza and tetanus vaccines, knowledge alone in this same study did not predict vaccination (though attitudes about each vaccine did).

Increasing awareness of the indications for pneumococcal vaccination is one step to increase vaccination rates; physician reminders, patient letters, and nurse-driven vaccination when used together were also effective at increasing rates in ambulatory specialty practices. In primary care practices, the 4 Pillars Toolkit has been effective; the 4 Pillars Toolkit includes online resources for increasing convenience, patient communication, systems of care, and practice motivation.

Pharmacist-driven interventions to increase influenza and pneumococcal vaccinations in patients with COPD have had mixed success. One study found pharmacist-initiated interventions did not increase pneumococcal vaccination rates for those with COPD or asthma in community settings. Inpatient pharmacist-led patient education, however, may increase pneumococcal vaccination. Employee health screenings that include a pharmacist review of vaccinations may also increase vaccination rates.

Ideal strategies are likely to differ by practice and locale; resources to guide your practice include the AFP By Topic on Immunizations (excluding Influenza) that includes this editorial on Navigating the Changes in Pneumococcal Vaccinations for Adults as well as this overview of the 2018 Advisory Committee on Immunization Practices (ACIP) Adult Immunization Recommendations. From Family Practice Management comes this article providing an overview of practice strategies to both increase vaccination rates and minimize lost costs from storing vaccines.

What strategies have worked to increase pneumococcal vaccination rates in your practice?

Tuesday, April 3, 2018

What's new in asthma treatment?

- Kenny Lin, MD, MPH

As part of the process of updating the 2007 National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines, the Agency for Healthcare Research and Quality (AHRQ) recently released two comparative effectiveness reviews. The first AHRQ review concluded that subcutaneous and sublingual immunotherapy for patients with environmental allergies both reduce the use of long-term controller medications for asthma, and that sublingual immunotherapy also improves asthma symptoms and quality of life. A previous article in American Family Physician discussed allergen immunotherapy for family physicians who wish to offer this treatment in their offices or to determine whether a patient would be a candidate for therapy for an allergist.

The second AHRQ review evaluated the effectiveness of inhaled corticosteroids, long-acting beta agonists (LABA), and long-acting muscarinic antagonists (LAMA) for asthma in different patient populations. In children younger than age five with recurrent wheezing, the authors found that intermittent inhaled corticosteroid use during upper respiratory tract infections decreases asthma exacerbations. Another section of the review, which was published as a research article in JAMA, found that in patients with uncontrolled, persistent asthma, adding LAMA to inhaled corticosteroids reduced exacerbations compared to adding placebo, but had similar benefits compared to adding LABA. Finally, a third section concluded that in patients age 12 years and older, the use of combined inhaled corticosteroids and LABA as controller and quick relief therapy was associated with a lower risk of asthma exacerbations than more traditional strategies involving a controller therapy plus a short-acting beta agonist as relief therapy.

It remains to be seen how this new evidence will be incorporated into the next version of the NAEPP guidelines, which have historically advocated a stepwise approach to management of persistent asthma until good control is achieved. A shortcoming of the AHRQ reviews is that they did not specifically examine harms of LABA, the subject of a Medicine By the Numbers in the March 1 issue of AFP. A Cochrane review examined 48 trials that compared step therapy with an inhaled LABA/steroid combination to a higher inhaled steroid dose in more than 33,000 patients with asthma. Although 1 in 73 patients in the LABA/steroid group avoided a mild asthma exacerbation, there was no benefit on hospitalizations, deaths, or severe exacerbations. Moreover, the authors concluded that 1 in 1,430 additional persons in the LABA/steroid group would experience an asthma-related death, leading them to conclude that combination LABA/steroid inhalers have no benefits. Given the close balance of benefits and harms and uncertainty surrounding these estimates, family physicians should practice shared decision-making with patients about the pros and cons of controller medication options.

Dr. Jennifer Middleton summarized some useful tools and apps for asthma management in a previous Community Blog post, and you can find more information on the diagnosis, prevention, and treatment of asthma in our AFP By Topic collection.