Wednesday, July 29, 2020

Guest Post: Providing house calls during the COVID-19 pandemic

- Marguerite Duane, MD, MHA

As a family physician with a house calls-based direct primary care practice, almost all of my in-person visits are conducted in patients’ homes. House calls and telemedicine visits form the foundation of our practice. Therefore, when the COVID-19 pandemic hit, we were prepared to transition most of our care to telemedicine. However, there have been instances when the patient’s illness or injury necessitated an in-person visit.

For instance, in March soon after the pandemic began spreading locally, a mother texted me that her young son had a fever of 101.9 degrees, associated with a mild sore throat and productive cough, She had kept him home from school for four days, but his symptoms were not improving. At that time, our practice had not yet acquired N-95 masks, but I knew I needed to “see” the patient and possibly perform a rapid strep or flu test. Therefore, the boy's mother and I agreed to meet on her front porch where I took the full history, including additional pertinent positives (specifically headache), and negatives, such as no shortness of breath, body aches, ear pain, nausea or vomiting.

Since streptococcal pharyngitis and influenza were at the top of my differential, I needed to evaluate the patient, but since COVID-19 was also possible, I wanted to limit my exposure so I did not go inside the home. Instead, I asked the mother to take a picture of her son’s throat (Figure 1) and then via a video call collected more information which indicated that a rapid strep test was necessary. I demonstrated for the mom how to swab the back of her son’s throat to collect the sample, which she did. Then I was able to run the test, which was positive. The diagnosis was a huge relief for the mother, as her son's fever was diagnosed without ever having to leave her home, minimizing their risk for possible exposure to the coronavirus.

Figure 1. Streptococcal pharyngitis.
I pride myself on caring for the whole person in the context of their community, considering not only their physical symptoms, but their social determinants of health. Rather than focus on one bodily system or disease, I consider patients’ preventive and chronic health care needs, as well as address acute issues or injuries.

Over the last couple of months, I did a series of family visits, conducting well child checks and administering vaccines, screening adults for disease, and in general providing the care patients needed in the comfort of their homes. One afternoon, I saw a father for an acute injury, addressed early pregnancy symptoms in the mother, and did well child checks for all of their children, including vision and hearing screens. A few days later, I received a call that one of the children had fallen and cut her head. The mother texted me a photo (Figure 2) from which I knew she needed to be seen. Rather than send her to an urgent care, I was able to treat the child's laceration appropriately at home.

Figure 2. Traumatic laceration treated at home.
House calls are a wonderful way to care for patients of all ages, and, in the midst of the COVID-19 crisis, allow patients to receive care more safely. By seeing patients and families in their homes, family physicians can minimize their exposure to infection and still address almost all of their health care needs. I hope that more of my colleagues will be inspired to integrate house calls into their practices.


Dr. Duane practices comprehensive family medicine with Modern Mobile Medicine, a direct primary care practice serving patients in the Washington, DC metro area. She co-authored the August 15 AFP article on house calls.

Monday, July 27, 2020

An epidemic within a pandemic: syphilis and COVID-19

- Kenny Lin, MD, MPH

In many communities, the same people who work on preventing the spread of sexually transmitted diseases such as syphilis have been called on to help prevent the spread of COVID-19. Departments are reporting mass interruptions in STD care and prevention services. 
- Kaiser Health News, June 4, 2020

Contact tracing is a public health tool that was developed long before the current pandemic. It is an essential element of sexually transmitted disease (STD) prevention and treatment programs that rely on notifying partners of infected persons so that they can be treated with antibiotics in time to stop the chain of transmission. As discussed in the review article "Syphilis: Far From Ancient History" and my accompanying editorial in the July 15 issue of AFP, the national increase in the number of primary and secondary syphilis infections since 2000 has fueled increases in the incidence of congenital syphilis, with 1306 cases diagnosed in 2018.

Although the essentially flat (40% decreased in inflation-adjusted dollars) Centers for Disease Control and Prevention (CDC) budget for STD prevention programs since 2003 has likely worsened this problem, a CDC analysis of year 2018 cases identified four types of missed prenatal prevention opportunities that can be addressed by family physicians, obstetricians, and other maternity care providers: 1) lack of timely prenatal care (and consequently no syphilis screening); 2) lack of timely syphilis screening despite timely prenatal care; 3) inadequate maternal syphilis treatment; 4) diagnosing syphilis less than 30 days before delivery. In my editorial, I added that "family physicians can prevent congenital syphilis by following national screening guidelines; taking accurate, detailed sexual histories; providing evidence-based interventions to people who use injection drugs; and advocating to reduce structural barriers to care."

COVID-19 has complicated congenital syphilis prevention by diverting health department personnel who would typically staff STD programs and discouraging expectant mothers from attending in-person prenatal visits due to infection concerns. In a Health Affairs blog post, Dr. Marcus Plescia and Elizabeth Ruebush from the Association of State and Territorial Health Officials affirmed that "there’s nothing non-essential about prenatal care and appropriate testing and treatment for syphilis," and discussed strategies for continuing to provide these critical health care services:

In our current environment, we’re seeing healthcare providers develop creative strategies to limit the number of in-person clinical visits by concentrating care around critical visits (e.g., for tests and ultrasounds) and leveraging the use of telemedicine when appropriate. Telemedicine visits should incorporate a comprehensive sexual history, and timely syphilis testing should be a key consideration when planning for prenatal care visits. ... It's also important to take a closer look at the maternal syphilis treatment regimen, which—depending on how long the mother has had syphilis—can involve three shots of penicillin, each seven days apart. ... Text and email reminders can be used to prompt individuals to return for their complete series of penicillin shots, and partnerships with clinical sites in the community can provide alternative models for delivering injectable therapy.

Monday, July 20, 2020

PPI use and COVID-19 infection: a meaningful correlation?

- Jennifer Middleton, MD, MPH

In its current issue, the American Journal of Gastroenterology preliminarily published the results of a health survey correlating proton pump inhibitor (PPI) use with COVID-19 infection. The journal placed a disclaimer at the top of the document noting that "[t]his version will undergo additional copyediting, typesetting and review before it is published in its final form." Its findings, widely reported in the lay press, may result in patient questions regarding PPI safety during the pandemic, but discontinuing PPIs on the basis of this study is likely premature.

The authors enlisted an online research firm to conduct a health survey throughout the United States. The survey asked participants about their use of PPIs or H2-receptor antagonists (H2RA) and also asked if they had been diagnosed with COVID-19. The manuscript does not specify how the 250,000+ adults were chosen to receive a survey invitation, but they report that over 86,000 took the survey. Of those persons who responded between May 3 and June 24, 2020, just over 53,000 reported gastroesophageal reflux disease (GERD) symptoms. This cohort of 53,160 individuals comprised the study population. 6.4% of this group reported a positive COVID-19 test. The researchers then compared PPI and H2RA use among participants who did and did not report a positive COVID-19 test. The odds ratio (OR) for a positive COVID-19 test among participants reporting use of a PPI once a day, compared to those not taking any antacid therapy, was 2.15 (95% confidence interval [CI] 1.90-2.44); the odds ratio among those reporting use of a PPI twice daily for a positive COVID-19 test was 3.67 (95% CI 2.93-4.60). The results for H2RA use were not deemed statistically significant (though the CI for once daily H2RA, compared to no therapy, fell just below 1.0 [OR 0.85, 95% CI 0.74-0.99]).

Methodological concerns with this study include an inadequately-described participant recruitment strategy and the decision to narrow the study cohort to only those participants who self-reported GERD symptoms. The demographic information in Table 1 also brings up some odd discrepancies; while it's not unexpected that a larger percentage of participants with COVID-19 used tobacco, identified as Latinx, and had not completed high school, it's harder to explain why a significantly higher percentage of participants with COVID-19 were married compared to those without a COVID-19 diagnosis (74.5% vs 27.1%) or reported an annual income of greater than $200,000 (63.5% vs 7.4%).

PPI use has previously been associated with an increased risk of enteric infections, pneumonia, and fractures, though a 2019 meta-analysis of PPI safety largely refuted those claims. Hopefully, future research will further elucidate any possible PPI-COVID connection; in the meantime, it's certainly advisable to continue to discourage twice-daily PPI use for most patients, since once-daily PPI use results in similar symptom improvement

Monday, July 13, 2020

Addressing adverse childhood experiences and their sequelae in primary care

- Kenny Lin, MD, MPH

In a recent editorial on the relationship between stress and chronic disease, Dr. Jennifer Middleton mentioned that adverse childhood experiences (ACEs), "such as physical or sexual abuse, witnessed domestic violence, loss or incarceration of a parent, and poverty," are associated with later development of diabetes, cardiovascular disease, asthma, and cancer. A 2019 report from the Centers for Disease Control and Prevention (CDC) found that 60% of U.S. adults surveyed from 2015 to 2017 had experienced at least one ACE, while 1 in 6 adults had experienced four or more. In addition, the CDC identified a dose-response relationship between number of ACEs and prevalence of health risk behaviors, socioeconomic challenges, and chronic health conditions.

In a Curbside Consultation in the July 1 issue of AFP, Drs. Jennifer Hinesley and Alex Krist discussed the primary care approach to a woman who presented with irritability, depression and anxiety and a history of childhood physical and sexual abuse. The U.S. Preventive Services Task Force (USPSTF) does not have a recommendation for screening for ACEs; however, a sample screening tool is available in a recent FPM article. In patients who disclose a history of ACEs, Drs. Hinesley and Krist suggested assessment for mental health conditions such as post-traumatic stress disorder and substance use disorders. For other health care needs, including preventive care, applying principles of trauma-informed care may reduce the risk of re-traumatization and increase patients' comfort.

Can screening for ACEs at well-child visits improve resilience and prevent future ACEs and associated toxic stress? Similarly, what types of interventions might help adults with a history of ACEs but no symptoms of related chronic issues? Dr. Krist previously wrote an AFP editorial about the necessary prerequisites for the USPSTF to recommend routine screening for social needs:

an accurate screening test to identify patients with the social need, an effective treatment to address the social need once identified, and evidence demonstrating a meaningful health outcome improvement for patients. We know that having a social need leads to poorer health. In some cases, we even know that screening identifies those with a need, but often we do not know what to do after we have identified the need.

Substituting "ACE" for "social need" highlights some potential problems with systematic identification of ACEs in primary care. As Dr. Thomas Campbell noted in a JAMA Viewpoint, the evidence is lacking that ACE-related clinical interventions in children or adults improve any health outcomes. It is possible that screening for ACEs might inadvertently cause harm by reducing trust between clinicians and patients or parents/guardians, or by erroneously labeling patients as "high risk" for future problems based on a high number of ACEs alone.

Monday, July 6, 2020

Should we screen all adolescent and adult women for anxiety?

- Jennifer Middleton, MD, MPH

At first glance, the question mark in that title might seem misplaced. Anxiety is prevalent among both women and men, and the current stress of the global COVID-19 pandemic is exacerbating those symptoms for many. A new recommendation statement making the lay press rounds urges us to screen all adolescent and adult women for anxiety, but the evidence behind that recommendation merits further examination.

The Women's Preventive Services Initiative (WPSI) is a "national coalition of women's health professional organizations and patient representatives" led by the American College of Obstetricians and Gynecologists (ACOG) which includes the AAFP and the American College of Physicians (ACP). The WPSI's "Screening for Anxiety in Adolescent and Adult Women" recommendation statement, published last month, describes the prevalence and scope of anxiety disorders in women and also reviews available treatment methods in detail. Its recommendation to adopt universal screening is based on a systematic review, published alongside the recommendation statement, which sought to "evaluate evidence on the effectiveness of screening for anxiety disorders in primary care in improving symptoms, function, and quality of life; harms of screening; accuracy of screening instruments; and effectiveness and harms of treatments." The systematic review's abstract transparently states that "[n]o studies evaluated the overall effectiveness or harms of screening;" it did identify valid screening instruments and confirm the treatment benefits of both cognitive behavioral therapy and anti-anxiety medications.

The WPSI is citing this systematic review, which found that "[e]vidence on the overall effectiveness and harms of screening for anxiety is insufficient," to justify its universal screening recommendation. While most physicians and patients would agree that patients with generalized anxiety disorder deserve recognition and treatment, screening initiatives that fail to justify the costs of doing so relative to their benefits, as well as fail to adequately consider potential harms, may not result in the health gains they promise. The WPSI's website states that "participation in the WPSI does not constitute organizational endorsement of the recommendations,"and it remains to be seen whether the AAFP and/or ACP will endorse this guideline.

In the meantime, you can find resources for diagnosing and treating anxiety disorders in the AFP By Topic on Anxiety Disorders.