Monday, March 30, 2020

Telehealth: improving connections or widening disparities?

- Jennifer Middleton, MD, MPH

Telehealth is taking off as family physicians strive to remain connected with patients during the COVID-19 pandemic. An AAFP News Brief this past week highlighted the experience of two family physicians as they transitioned the bulk of their outpatient care to telehealth. While telehealth shows promise as an efficient method of delivering effective care, it may also leave our patients with less comfort and/or access to its associated technologies behind.

One recent rapid review found that, overall, the quality of the care delivered via telehealth was equivalent to that of in-person care. Telemedicine peripherals, such as electronic stethoscopes, can be integrated into visits to provide clinical examination data. Telehealth can expand healthcare access to persons living in rural areas. This AFP AHRQ Effective Health Care Review regarding "The Effectiveness of Outpatient Telehealth Consultations" found that telehealth improved patient-oriented outcomes in mental health and wound care, while more limited quality evidence suggests possible patient satisfaction benefits and reduced health care costs.

Although many patients embrace virtual office visits, some are resistant. A 2014 systematic review found that nearly 1/3 of patients with chronic heart failure and/or COPD offered telehealth visits declined them; reasons cited included "[t]echnical problems, believing telehealth to be unnecessary, preference for in-person care, technology anxiety, difficulty remembering to interact with system, need for technical support, and finding telehealth to be a repetitive process." A 2018 study adds to this list "concerns over equipment or technology, concerns over service change, ease-of-use, knowledge of the benefits of telehealth, access to care, cost, and privacy." If these barriers are not overcome, a substantial minority of patients may miss out on the convenience and health benefits of virtual office visits.

This potential care gap has been minimized to date by telehealth's limited uptake, with only 15% of family physicians participating in telehealth in 2016. As more patients and physicians gain comfort with these platforms, though, it seems increasingly likely to persist once the pandemic is over. Eliminating health disparities is a core value of family medicine, and we will need innovative solutions to ensure that all of our patients who could benefit from telehealth can access it.

If you'd like to read more, this AAFP website provides in-depth information and resources regarding telehealth visits, and this recent FPM blog post reviews temporary rule changes regarding telehealth reimbursement.

Sunday, March 22, 2020

Breast cancer screening is harmful after age 75

- Kenny Lin, MD, MPH

To increase acute care capacity during the COVID-19 pandemic, hospitals have suspended elective surgical procedures, and family medicine practices have postponed visits for preventive care and monitoring of stable chronic diseases - particularly in patients older than 70 years, whose risk of developing serious illness from SARS-CoV-2 contracted in a health care setting likely outweighs potential benefits. For example, women in this age group should cancel or postpone screening mammograms.

Even in the best of times, though, it's not known if screening mammography beyond 75 years of age is helpful or harmful. The U.S Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of breast cancer screening after age 75, and decision tools have been developed to help women decide whether or not to continue to be screened, relying on limited evidence and the patient's predicted life expectancy. As the authors of a recent AFP editorial observed, though, discussing the clinical implications of life expectancy with older patients can be challenging and fraught with pitfalls.

Since it is unlikely that a randomized controlled trial of screening mammography in older women will be performed, researchers recently used observational data from the U.S. Medicare program to emulate such a trial in more than 1 million beneficiaries aged 70 to 84 years with a life expectancy of at least 10 years and no previous breast cancer diagnosis. The primary outcome was eight-year risk of breast cancer mortality.

While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years. Although guidelines already discourage screening for cancer in adults with a life expectancy of less than 10 years, this study suggested that stopping breast cancer screening after age 75 may be the right decision for all women, regardless of health status.

Monday, March 16, 2020

Optimizing mental health during the COVID-19 pandemic

- Jennifer Middleton, MD, MPH

Novel coronavirus cases continue to increase in the United States, consistent with the predictions shared by Dr. Lin in last week's Community Blog post. An increase in anxiety, both in the lay public and in healthcare workers, is an unsurprising consequence of the novel coronavirus' continued spread. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) issued statements in the last week regarding mental health as it relates to this global pandemic. Besides validating the experience of heightened anxiety during this time of stress, both organizations provide helpful tips and resources. These practical strategies apply not only to patients, but also for those of us in primary care on the front lines of caring for those who are ill.

The WHO's tip sheet includes several categories including general population, health care workers, and those in quarantine/isolation. Commonalities across categories include limiting news exposure to once or twice per day from reputable sites, sharing positive stories of healing, and prioritizing self-care. The CDC outlines common symptoms of increased stress and/or anxiety: fear, worry, changes in eating and/or sleep patterns, worsening of chronic health problems, and increased use of alcohol, tobacco and drugs. They also recommend limiting news exposure with the perspective that "strong feelings will fade" while focusing on healthy meals, adequate rest, and exercise.

Both sites devote separate sections to caring for children during this time. They advise maintaining routines as much as possible, answering children's questions in a straightforward, age-appropriate manner, and reassuring them that they are safe and will be cared for. The WHO adds that "[c]hildren will observe adults’ behaviors and emotions for cues on how to manage their own emotions during difficult times," while the CDC advises that parents limit children's media exposure while being a "role model" by maintaining their own self-care.

"Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed," authored by a group of psychiatrists and behavioralists from China, was published last month with the following recommendations:

First, multidisciplinary mental health teams...should deliver mental health support to patients and health workers....Second, clear communication with regular and accurate updates about the 2019-nCoV outbreak should be provided to both health workers and patients in order to address their sense of uncertainty and fear....Third, secure services should be set up to provide psychological counselling (sic) using electronic devices and applications (such as smartphones and WeChat) for affected patients, as well as their families and members of the public...Fourth, suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals working in hospitals caring for infected patients should receive regular clinical screening for depression, anxiety, and suicidality by mental health workers. 

Including mental health care in our offices', hospitals', and healthcare systems' COVID-19 planning efforts will likely benefit patients and healthcare workers alike, both in the short- and long-term. Here are additional resources you, your colleagues, your staff, and your patients may find beneficial:

AFP By Topic on Anxiety Disorders
CDC: Coping After a Disaster (activity book for children) 
CDC: Emergency Responders: Tips for taking care of yourself
CDC: Helping Children Cope with Emergencies 
Mind (UK mental health charity): Coronavirus and your wellbeing
SAMHSA: Disaster Preparedness, Response, and Recovery
WHO: Coping with stress during the 2019-nCoV outbreak
WHO: Psychological first aid: Guide for field workers

Tuesday, March 10, 2020

Coronavirus disease 2019: updates and resources

- Kenny Lin, MD, MPH

There's a bedtime folktale that I've read countless times to each of my four children called One Grain of Rice. If you aren't familiar with it, it is the story of a raja who lived "long ago in India" and hoarded his people's excess rice production for years, supposedly as insurance against a famine, but when the famine arrives, he refuses to open the royal storehouses. A clever "village girl" named Rani happens to catch a small amount of rice that trickles from a basket on the way from a royal storehouse to the palace. She goes to the palace to give it back, and is told by the grateful raja that he will give her any reward she desires for returning what belongs to him. She asks him for a single grain of rice. The raja protests that he can do much better than that.

"Very well," said Rani. "If it pleases Your Highness, you may reward me in this way. Today, you will give me a single grain of rice. Then, each day for thirty days you will give me double the rice you gave me the day before. Thus, tomorrow you will give me two grains of rice, the next day four grains of rice, and so on for thirty days."

"This seems to be a modest reward," said the raja. "But you shall have it."

It's clear that the raja had never seriously studied math or exponential growth. The illustrated version that we have includes colorful images of ever-larger baskets and, eventually, giant bags of rice as the days go by and the doubling continues. By the 30th day, it takes 256 elephants to make the final delivery of 536,870,912 grains of rice, for a grand total of more than one billion. The analogy here, of course, is that while the American "raja" pats himself on the back that there have only been (as of March 10) 647 cases and 25 deaths from COVID-19 in the U.S., we're almost exactly where Italy found itself two weeks ago, and where China was on Jan. 22. Today all of Italy is under an effective quarantine, and more than 3,000 have perished from COVID-19 in China.

Exponential spread of an infectious disease epidemic doesn't go on forever, of course. At some point, the virus runs out of hosts, or people are too far apart for it to easily find the uninfected. But if the peak of the epidemic curve exceeds the surplus capacity of our health care system (and as others have pointed out, it's not like hospitals maintain thousands of empty intensive care unit beds just waiting for an epidemic to strike), then more people will die, as health care professionals fall ill or succumb to exhaustion and there aren't enough resources for the critically ill to go around. That's why it's so important to start social distancing now, and to cancel or postpone mass gatherings such as conferences, concerts, political rallies, and athletic events - including March Madness.


To keep clinicians up-to-date on the evolving epidemic, the U.S. Centers for Disease Control and Prevention (CDC) has posted a comprehensive collection of resources for health care professionals who encounter patients with suspected SARS-CoV-2, including an assessment flowchart and interim management guidance for patients with confirmed infection. The American Academy of Family Physicians has an updated web page containing resources for coding, clinical management, communication, and patient education. Forward-thinking family physicians can also consult a Family Practice Management (now FPM) article for tips on on preparing your office for an infectious disease epidemic. Key points highlighted in this article include:

- Begin planning now.
- Master the detection, prevention and management of seasonal influenza and community-acquired pneumonia.
- Practice scrupulous infection control - "wash in and wash out."
- Communicate at all levels, and coordinate with public health agencies.
- Focus on staff management and business continuity.

The good news: we know a lot more now about the epidemiologic characteristics and clinical course of COVID-19, thanks to a recent analysis of more than 70,000 cases from the Chinese CDC. The mean incubation period appears to be around 5 days, and nearly all persons who develop symptoms doing so within 2 weeks of infection. Public health experts are calling for states and communities to update earlier preparedness plans and to ready hospitals and clinics to respond to the expected surge in respiratory illnesses. And after what can be fairly described as a national fiasco, it appears that reliable diagnostic testing for the novel coronavirus should soon be widely available in the U.S. To paraphrase NASA flight controller Gene Kranz during the ill-fated Apollo 13 mission, this crisis still has the potential to be public health's finest hour.

Monday, March 9, 2020

In Memoriam: Joyce A. Merriman, Executive Editor, 2005-2020

- Carrie Morantz

Joyce A. Merriman, executive editor of American Family Physician, passed away recently after an 11-month battle with cancer.

Joyce came to the American Academy of Family Physicians (AAFP) in January 2005 after spending most of her career with the Association of periOperative Registered Nurses, ultimately as editorial director of their clinical journal. Although we were thrilled she was joining us at AFP, the transition wasn’t an easy one for her. She moved 600 miles to Kansas City while her husband, Bruce, and their three sons stayed behind in Denver to finish the school year. Joyce’s arrival at AFP overlapped with the retirements and departures of four senior-level editors, leaving her to take over a journal that had just lost nearly 70 years of combined editorial experience. I and the rest of the AFP staff half-expected Joyce—missing her family, in a new city, at a new job where she immediately faced such an overwhelming challenge—to throw in the towel and book the next flight back to Denver. Instead, she set about teaching herself start to finish how AFP is produced, forever questioning why we did things the way we did and brainstorming with us about how to improve, not infrequently over margarita-fueled “teambuilding sessions.”

In a column introducing Joyce to our readers soon after she was hired, Bob Edsall, AFP’s editorial director at the time, predicted “enormous tasks ahead” for Joyce, but “great things from AFP” under her leadership. As daunting as that sounded then, in hindsight it was a bit of an understatement. In 2005, the publishing industry was on the brink of a massive change in the way readers use and interact with online media. When Joyce joined AFP, our website was little more than an online archive of articles—and a rather unattractive and difficult-to-navigate one at that. Under Joyce’s direction, it evolved into what it is today: the most trusted online resource for primary care physicians.

Stephanie Hanaway, the AAFP’s Director of Journal Media, described Joyce as “the planner, the super-organizer, the rock that we counted on to hold every little piece together.” Joyce spent her last months ensuring that AFP would transition seamlessly after what she referred to as her “retirement,” delegating tasks from her never-ending to-do list, attending meetings by phone when she was too sick to come into the office, and reviewing manuscripts at home, scrawling notes in the margins with her typically excessive use of exclamation marks.

Dr. Sumi Sexton, AFP’s editor-in-chief, praised Joyce’s thoughtfulness, work ethic, and willingness to go above and beyond to answer questions, calling Joyce her “go-to person for anything and everything at the journal and AAFP.” Dr. Jay Siwek, AFP’s former editor-in-chief and current editor emeritus, called Joyce the best professional editor he’d ever worked with. He added: “Joyce had great dedication to the journal and her staff, and great attention to detail. AFP is definitely better because of her!”

Joyce’s goal throughout her illness was to continue working until her 15th anniversary with AFP, which we celebrated in mid-January. Not much later, we got the news that she was gone.

The job of an editor can be hard to explain to people who aren’t in the publishing industry. What it boils down to is problem solving: We fix things behind the scenes, and if we do our job well, readers shouldn’t notice that we’ve done anything at all. Because of Joyce’s extraordinary problem-solving skills, we’re confident our readers didn’t notice a difference last week when they picked up the March 1 issue of AFP—the first issue that went to press after her passing.

But for those of us who worked closely with Joyce, her absence is acute. We miss seeing the conservative 62-year-old from Minnesota sporting bright purple hair in the days after her first chemo treatment. We miss her indignation at Bruce for letting her water an artificial orchid for weeks before clueing her in. Some of us miss her (extremely outspoken) preferences for Alan Jackson songs, sensible shoes, and dogs vs. cats. But most of all, we miss her toughness, determination, and loyalty.

AFP’s next executive editor will have big—but sensible—shoes to fill.


Carrie Morantz is Senior Associate Editor of AFP.

Monday, March 2, 2020

Will patients accept x-rays without gonad shielding?

- Jennifer Middleton, MD, MPH

For decades, patients have come to expect shielding of their pelvises when receiving x-rays. This norm has been challenged by the radiology community over the last year as not only unnecessary but potentially harmful, and perhaps some of your patients have had a similar experience to mine where I was not offered a shield during an x-ray two weeks ago.

The American Journal of Roentgenology published "Patient Shielding in Diagnostic Imaging: Discontinuing a Legacy Practice" last year. In this review article, the authors discuss the original intent behind shielding - to lower the risk of germ-line mutations within gonads - along with decades of data showing no such risk has ever been substantiated. Additionally, shields can make it more difficult for radiologists to interpret x-rays, and the authors raise concern regarding most modern x-ray equipment's automatic exposure control settings, which may inadvertently increase the radiation dose in response to the presence of shielding. Since this article's publication, the American Association of Physicists in Medicine released a position statement asserting its agreement with discontinuing routine pelvic shielding during x-rays. Consequently, the US Food and Drug Administration is considering amending the regulations around x-ray shielding as are, according to this NY Times article, regulatory bodies in both Australia and Canada.

Patient acceptance of these changes may be more variable. Much of the lay public remains concerned about radiation safety; concerns about the safety of mammography contribute to its underuse for breast cancer screening, and a study by the US National Cancer Institute estimated that 65% of the general public worries about the safety of medical imaging. In an era where mistrust of medical care is already common, removing a perceived safety measure may be a sizable barrier for regulatory bodies and health systems to overcome. Preemptively anticipating our patients' concerns when ordering x-rays may be one first step for us as physicians; working collaboratively within our health systems to ensure that the decisions and messaging around this issue are scientifically based may be another.

And, of course, many patients still receive x-rays that are unlikely to be of benefit; a quick search of the AFP Choosing Wisely database reminds us that most pre-operative chest x-rays, imaging for acute low back pain, and x-rays for plantar fasciitis are not helpful. The AFP By Topic on Point-of-Care-Guides includes several evidence-based algorithms to guide your diagnostic imaging decisions as well.