Guest Post: Family doctors can easily treat hepatitis B "in-house"

- Richard Andrews, MD, MPH

In 2008, I replaced another family physician as the sole physician at HOPE Clinic, a federally qualified health center in southwest Houston. The clinic was founded by members of the local Asian community to ensure that Asians would have a place to receive linguistically and culturally-appropriate medical care. From the outset, we treated anyone who came in the door, including many non-Asian patients. Due to our core mission, we cared for a large proportion of foreign-born patients from all over the world, speaking more than eighty different languages.

Many of our patients' countries of origin, including China, Vietnam, Myanmar, Iraq, and Nigeria, have a high (>= 8%) or intermediate (2-7%) prevalence of chronic hepatitis B (CHB), leading to a high prevalence in our patients. Initially, they were reflexively referred to hepatologists, but due to access and cost barriers, the community asked us to start treating hepatitis B right at HOPE.

I was an experienced, board-certified family physician, but I had never done any hepatitis B management. I sought training with local hepatologists, mostly through lectures and question-and-answer sessions, and gradually became comfortable with the vocabulary, epidemiology, concepts, and pharmacology of care for patients with hepatitis B.

Because of the HOPE Clinic's origins, most of our hepatitis B patients are of Asian ancestry. In the United States as a whole, roughly half of patients with CHB are of Asian descent, but in your community you might find a different ethnic/language mix. We are seeing an increasing number of non-Asian patients with CHB, including younger native-born Anglo patients with a history of unsafe drug use. Significantly, many American adults have not received hepatitis B vaccinations, leaving them susceptible to infection from sex, injection drug use, or snorting cocaine.

Different social approaches to drug use and addiction in some European countries (such as Portugal) have coincided with marked reductions in the number of new cases of viral hepatitis and HIV. Conversely, infection rates in Americans appear to be increasing. Now that a two-dose hepatitis B vaccine is available, family doctors have a valuable role to play in screening and immunizing susceptible patients, and in managing their patients with CHB.

Factors that make uncomplicated CHB care easy to learn for family physicians

Factor	Remarks
Many patients don’t need antiviral medications	These visits are particularly simple
Very few medications are used, usually just one at a time	1.       Entecavir 2.       Two forms of tenofovir:  TAF or TDF 3.       Interferon use is rare at primary care level 4.       Older medications not used in USA due to resistance
Medications are well tolerated	One pill per day, side effects are uncommon
Medications are effective	Most patients achieve viral levels below the limits of detection, viral resistance is uncommon.
Straightforward liver cancer surveillance	RUQ abdomen ultrasound and serum AFP every six months in cirrhotics. Other patients:  RUQ u/s + AFP q 6-12 mos. based on guidelines. Consider CT/MRI as appropriate
Infrequent visits needed	Once patient is established, 2-3 visits per year is a typical pattern
Telehealth/telemedicine	The availability of free online-video specialist consultation is increasing. Example:  check for availability in your region, at https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/ Though there are only two listed ECHO hepatitis B-specific programs in the USA, there are 64 infectious disease programs, many of which include viral hepatitis
Knowing when to refer	Decompensated cirrhosis:  ascites, esophageal variceal bleed, hepatic encephalopathy, bacterial peritonitis, hepatorenal syndrome, liver cancer.

Minimizing "spring forward" sleep disruptions

- Jennifer Middleton, MD, MPH

For most of the United States, next weekend marks the transition to Daylight Savings Time (DST), when we’ll “spring forward” an hour over the night of March 10 to allow for our dawns to start later and our daylight to last longer into the evening. While the pros and cons of DST continue to be debated, the health risks from disrupted sleep schedules certainly fall into the cons. Preparing in advance may help mitigate these negative effects.

Moving our clocks forward one hour may not seem like a big transition, but disrupted sleep schedules and sleep latency may last for at least a week afterward. An increased prevalence of heart attacks is noted in the United States the Monday after DST begins, as are an increased number of work-related injuries. A review of Australian suicide rates found an increase after DST arrives in the spring. Parents of young children, along with caregivers for developmentally disabled and cognitively impaired individuals, can struggle to transition their loved ones to a new time schedule. 

Sleep experts recommend beginning the transition at least a week prior to the official start of DST, gradually shifting bedtimes and wake-up times by 10-15 minutes every couple of days. Catching up any pre-existing sleep deficit before the DST transition can help, as can getting plenty of sunlight in the morning and dimming lights in the evening. 

Emphasizing good sleep hygiene is also important, as reviewed in this AFP article on the “Management of Common Sleep Disorders.” Minimizing late day caffeine and alcohol use, along with evening screen time, can help improve sleep quality year-round. For children struggling with sleep issues, this AFP article on “Common Sleep Disorders in Children” provides guidance regarding age-appropriate norms and strategies. Both of these articles are in the AFP By Topic on Sleep Disorders in Adults and the AFP By Topic on Sleep Disorders in Children, respectively, each of which also include useful patient education materials.

Does diet soda consumption increase stroke risk?

- Jennifer Middleton, MD, MPH

Perhaps your patients have been asking you, as several of mine have, about a new study getting lay press attention regarding stroke risk and artificially sweetened beverages. Published last week, this study from the Women’s Health Initiative (WHI) found an increased risk of stroke, coronary heart disease (CHD), and mortality among post-menopausal women who consumed 2 or more artificially sweetened beverages a day. Although observational studies like this one can only demonstrate correlation, and not causation, it still may provide an opportunity for discussing dietary changes that can meaningfully affect health.

This WHI observational study examined the diet soda habits of over 80,000 postmenopausal women. Participants self-reported their artificially sweetened beverage consumption, and researchers followed them for an average of 11.9 years. Only 5.1% of participants consumed 2 or more artificially sweetened beverages a day, but these participants were more likely to have a stroke (hazard ratio 1.23 [95% confidence interval 1.02, 1.47]) or coronary heart disease (HR 1.29 [1.11, 1.51]), and the risk of stroke was even higher in women with a body mass index of 30 or greater (HR 2.03 [1.38-2.98]). It’s difficult to know, in an observational study such as this one, whether these women had other risk factors that increased their stroke and CHD risk; the researchers state that recalculating their results excluding women with known diabetes, hypertension, and/or CHD from their analysis “did not materially change the association with risk.” As this study only included postmenopausal women, any conclusions generalizing its results to men or premenopausal women could be premature.

Certainly, however, this study may prompt some people to decrease their diet soda consumption. Plain water, water infused with fruit, and unsweetened sparkling/seltzer beverages are all reasonable alternatives. Working with parents and our youngest patients to avoid developing a preference for sweetened beverages is also important, as outlined in this Centers for Disease Control and Prevention (CDC) Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages. From a public health perspective, education campaigns such as this one urging people to “Stop. Rethink Your Drink. Go on Green,” which categorizes beverages as “Red: Drink Rarely” (sugar sweetened beverages), “Yellow: Drink Occasionally” (100% fruit juice, artificially sweetened beverages), and “Green: Drink Plenty” (water, seltzer water, milk) may help encourage new beverage consumption norms.

Conversations about beverage choice can easily lead to overall diet discussions as well; emphasizing a diet rich in whole foods and recommending apps to help with healthy food choices can empower our patients to make better choices. There's an AFP By Topic on Nutrition if you'd like more resources for yourself and/or your patients.

Therapies for type 2 diabetes: improving outcomes that matter

- Kenny Lin, MD, MPH

When comparing therapies for type 2 diabetes, physicians, patients, and quality measures often get caught up in the disease-oriented outcome of glycemic control. However, a 2014 editorial in AFP pointed out that of the medications then available to lower blood sugar levels, only metformin reduced mortality and clinically relevant complications. Since that time, studies of newer diabetes medications have demonstrated mortality benefits in patients with cardiovascular disease. However, the best second-line medication after metformin remains unclear. Although the World Health Organization guideline recommended inexpensive sulfonylureas as second-line therapy in low-resource settings, the American College of Physicians and the American Academy of Family Physicians suggested "the choice of drug [after metformin] should be based on a conversation with the patient about benefits, possible harms, and cost."

In the February 15 issue of AFP, Drs. Joshua Steinberg and Lyndsay Carlson applied the STEPS criteria (safety, tolerability, effectiveness, prince, and simplicity) to each of the 10 categories of diabetes medications (including insulin). Their analysis confirmed that metformin should be first-line pharmacotherapy for most persons with type 2 diabetes. Other key points from this article include:

Safety - Sulfonylureas, insulins, meglitinides, and pramlintide increase risk of hypoglycemia. Metformin and acarbose require monitoring, dose adjustments, or discontinuation in patients with chronic kidney disease.

Tolerability - Side effects across different drug classes range from gastrointestinal effects (metformin, acarbose, meglintinides, pramlintide, GLP-1 receptor agonists, SGLT-2 inhibitors) to weight gain (sulfonylureas), edema (TZDs), severe arthralgias (DPP-4 inhibitors), and genital and urinary tract infections (SGLT-2 inhibitors).

Effectiveness - Recent trials showed improved patient-oriented outcomes from some GLP-1 receptor agonists and SGLT-2 inhibitors in patients at high cardiovascular risk or with known cardiovascular disease. Acarbose also reduces cardiovascular events.

Price - Metformin, acarbose, sulfonylureas, and generic pioglitazone are the most affordable options.

Simplicity - Acarbose and meglitinides are taken three times daily before meals, while insulins, GLP-1 receptor agonists, and pramlintide require subcutaneous injections.

The family physician's role in vaccine-preventable disease outbreaks

- Jennifer Middleton, MD, MPH

The Centers for Disease Control and Prevention (CDC) is monitoring 3 current measles outbreaks in the United States, and most of the affected individuals are children under the age of 10 who did not receive the measles, mumps, and rubella (MMR) vaccine. Infected travelers to the US appear to be the sources for these outbreaks, but the disease's spread after its arrival has primarily been due to under-vaccination. Reporting suspected cases, discussing vaccine hesitancy with caregivers, and optimizing our office vaccination processes are all tangible ways for family physicians to respond.

Coughing and sneezing spread the highly contagious measles virus, and individuals are infectious from 4 days prior to 4 days after the appearance of its pathognomonic rash. Measles infection complications include pneumonia, ear infections, permanent hearing loss, encephalitis, permanent brain injury, and death. Physicians who suspect a patient may have measles should promptly contact their local health department. Unfortunately, CDC data demonstrate that these current measles outbreaks in the US are nothing new. Pockets of under-vaccinated communities across the US have provided easy targets for measles' spread once it's introduced.

Increasing vaccination rates is a critical but challenging component of the solution. With vaccine hesitancy now among the World Health Organization's (WHO) top 10 threats to global health, it's critical that we redouble our efforts to combat the spread of misinformation about vaccines. Discussions with vaccine-hesitant parents in the office can feel futile, but family physicians should remember that their recommendation is the most common reason cited when parents do decide to vaccinate. Phrasing vaccine recommendations as statements instead of questions correlates with higher vaccination rates. Eliciting and responding to caregivers' specific concerns can also be useful.

Our office staff can work with us to reinforce these messages, too. This 2016 AFP Editorial on Strategies for Addressing and Overcoming Vaccine Hesitancy includes links to several additional resources. An FPM article on improving influenza vaccination rates includes office strategies relevant to all types of vaccinations. The WHO's Addressing Vaccine Hesitancy website provides "a guide for exploring health worker/caregiver interactions on immunization" along with an online training module on "conversations with hesitant caregivers."

In the face of these outbreaks, combating vaccine hesitancy remains as critical as ever. What strategies have you found useful?

Does subspecialist medical care add sufficient value to be worth the added cost?

- Kenny Lin, MD, MPH

The latest Graham Center One-Pager in the February 1 issue of AFP contained good news and bad news for Family Medicine. Examining the entry of medical students into residency programs between 2008 and 2018, Dr. Robert Baillieu and colleagues reported that the total number of graduates who entered Family Medicine through the National Residency Matching Program increased by 64% over the past decade. However, the annual proportion of U.S. allopathic (MD) graduates remained static at around 50%, reflecting the continued migration of most students into higher-paying medical subspecialties.

Two previous AFP Community Blog posts reviewed research demonstrating that students entering family medicine are more likely to make patient-centered, cost-conscious clinical decisions and that primary care physicians who trained in low-cost hospital service areas are more likely to provide high-value care in practice. The late health services researcher Barbara Starfield, MD, MPH once argued that a lack of investment in primary care is a major reason that the U.S. health system spends so much but produces poor outcomes:

The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality. [This] is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. ... We have done a reasonably good job at making subspecialty care available, but a lot of subspecialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily.

In a recent nationally representative study in JAMA Internal Medicine, Dr. David Levine and colleagues examined associations between receipt of outpatient primary care and care value and patient experience. Using Dr. Starfield's definition of primary care as "first-contact care that is comprehensive, continuous, and coordinated," the authors compared the quality and experience of care in more than 70,000 U.S. adults with and without primary care who participated in the Medical Expenditure Panel Survey from 2012 to 2014. 70% of the primary care clinicians identified by patients were family physicians (19% were general internists). After adjustment for potential sources of confounding, respondents with primary care were more likely to receive high-value preventive care and counseling and to report better patient experiences than those without primary care. However, respondents with primary care were also slightly more likely to receive low-value prostate cancer screening and antibiotics for respiratory infections.

In an accompanying editorial that noted the disparity in primary care investment between the U.S. (7% of total health care spending) and the health systems of other industrialized nations (20%), Dr. Allan Goroll asked: "Does primary care add sufficient value to deserve better funding?" Although this formulation recognizes that the American status quo is a subspecialist-oriented health system, it seems to me that the question ought to be, "Does subspecialist medical care add sufficient value to primary care be worth the added cost?" From this study and previously published evidence, the answer appears to be no.