The AFP Community Blog

How often should you screen for osteoporosis?

2012-01-25T20:20:00.001-05:00

Last year, AFP published the U.S. Preventive Services Task Force's updated recommendations on screening for osteoporosis, which advised dual-energy x-ray absorptiometry (DEXA) in "women 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors." However, the USPSTF statement left one important question unanswered: when should a woman be re-screened if her first test shows normal or slightly decreased bone mineral density (BMD)? Put another way, what are the chances that a woman without osteoporosis today will develop it in the future?

A research team led by former AFP medical editor Margaret Gourlay, MD, MPH recently shed light on this question by following nearly 5000 U.S. women age 67 years or older with normal BMD or osteopenia for up to 15 years. They defined the BMD re-testing interval as the estimated time it took for 10% of women to develop osteoporosis before having a hip or clinical vertebral fracture. According to their report in the January 19th issue of the New England Journal of Medicine, more than 90% of women with initially normal BMD or mild osteopenia did not develop osteoporosis after 15 years. As might be expected, women with moderate and advanced osteopenia progressed faster, with 10% of each group developing osteoporosis after 5 years and 1 year, respectively.

This study's results have substantial implications for family physicians and their patients. In the absence of new risk factors for osteoporosis (e.g., significant weight loss, corticosteroid use), a woman with normal BMD at age 65 may not need to be re-tested until age 80, an interval that is substantially longer than current clinical practice. That's good news, since as Dr. Gourlay pointed out in a previous AFP editorial, many U.S. women who are at risk for osteoporosis have yet to receive any screening at all. Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.

AFP Journal Club casts doubt on NEJM study

2012-01-18T16:38:00.000-05:00

Do children younger than 2 years of age with acute otitis media (AOM) require antibiotics, or is a watchful waiting approach just as effective? A study designed to answer this question was published last year in the New England Journal of Medicine and concluded that a 10-day course of amoxicillin-clavulanate "tended to reduce the time to resolution of symptoms and reduced the overall symptom burden and the rate of persistent signs of acute infection on otoscopic examination." However, an analysis of this study by Drs. Andrea Darby-Stewart, Mark Graber, and Robert Dachs in the November 15, 2011 AFP Journal Club concluded that the results actually supported a watchful waiting strategy because the primary outcome (likelihood of treatment failure) was disease-oriented rather than patient-oriented:

The only clinically significant outcome was likelihood of treatment failure; yet, this was defined as the presence of any symptom of AOM and persistent otoscopic signs of AOM on day 10 to 12. Treatment did not fail in any children based on symptoms alone—all treatment failures were defined by persistent inflammation on examination. The treatment failed even if the patient was symptomatically better. Most of these asymptomatic children likely would never have presented for follow-up in routine practice. And, only four to six children had to be treated to cause diarrhea, rash, or diaper dermatitis.

The January 15th AFP Journal Club continues this story by reporting an apparent discrepancy between the predesignated primary outcomes in study's original protocol (published on ClinicalTrials.gov and posted to the NEJM's website) and those that were ultimately reported in the study abstract's conclusions:

There were only three primary outcomes planned and the fourth outcome, otoscopic resolution, was one of many planned secondary outcomes. ... What is even more concerning is that the otoscopic findings are only one of 22 secondary outcomes evaluated in this study. It amazes me that a significant number of these findings, the ones that just happen to support placebo, were never reported. The secondary outcomes that demonstrated no difference between placebo and amoxicillin/clavulanate were analgesia requirements in these children; number of needed follow-up visits to a primary care physician; number of visits to the emergency department; missed hours of work by the parents; and parental satisfaction.

The bottom line: family physicians should not conclude that this NEJM study showed that antibiotics are superior to watchful waiting for acute otitis media in young children. In fact, by showing that only 6 children needed to be treated with antibiotics to cause one additional episode of diarrhea, it suggests that the opposite conclusion may be true.

Curbing overuse of CT scans

2012-01-11T13:25:00.001-05:00

The urban public hospital where I completed most of my training as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present the patient's case to the on-call Radiology fellow and explain how the result of the scan would potentially change management. Since my attending surgeons were usually too busy to trudge down to the Radiology suite, they deputized their residents to do so, and most of the time my residents passed this thankless task down to the students. Thus, my classmates and I learned early on the difference between appropriate and inappropriate reasons for ordering CT scans.

Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, an editorial published last year in AFP reviewed the accumulating evidence that CT scans are highly overused in current medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.

Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published recently in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.

In their AFP editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommend that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:

1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.

Since 2007, AFP has published a series of articles in collaboration with the American College of Radiology on appropriate criteria for diagnostic imaging (including CT) in specific clinical situations. The ACR Appropriateness Criteria are periodically updated, and current versions are available on the ACR website.

First, do no harm: preventing elective inductions before 39 weeks

2011-12-28T16:14:00.001-05:00

A recent article published in the Journal of the American Board of Family Medicine reported that fewer than 1 in 5 board-certified family physicians provide routine prenatal care, and just over 13 percent perform deliveries. Therefore, more family physicians are referring patients for maternity care and have less influence over troubling national trends, such as declining rates of vaginal births after previous Cesarean delivery (VBAC) and increasing rates of "late" premature delivery (between 34 and 38 6/7ths weeks gestation) due for the most part to elective inductions.

In an editorial in the December 15th issue of AFP, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:

The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.

If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.

Screening mammography decisions are close calls

2011-12-20T13:29:00.000-05:00

A physician reader of AFP submitted the following post.

**

I read with interest the December 1st Cochrane for Clinicians article by Dr. Joanne Wilkinson, "Effect of Mammography on Breast Cancer Mortality." On the first page of the article in big print is the "Evidence-Based Answer," which gives a SORT "A" recommendation in favor of mammography because of an approximate 15% reduction in mortality from breast cancer attributed to mammography screening. In small print inside are the conclusions from the Cochrane abstract, which note a 30% rate of overdiagnosis and overtreatment. The Cochrane authors write:

This means that for every 2,000 women invited for screening over 10 years, one will have her life prolonged, and 10 healthy women who would not have been diagnosed if there had not been screening will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false-positive findings. It is not clear whether screening does more good than harm.

Having read this - I wonder how many women would continue to opt for regular mammography screening if told that only 1 out of every 2,000 will benefit, whereas 10 out of 2,000 will be overtreated (some presumably with mastectomy), and 200 out of 2,000 (10%) will be temporarily overdiagnosed (and subject to important psychological distress for many months) because of a false-positive mammography reading. Given these statistics, observers outside of the medical community might wonder why "primary care physicians should continue to recommend mammography every two years in women 50 to 74 years of age," as the last paragraph of Dr. Wilkinson's commentary states.

As in much that the primary care clinician does, there are pros and cons to any intervention. For patients to give truly informed consent, it is essential for us to convey to them the numerical chance for life-prolonging benefit (1 in 2,000 for women who undergo yearly mammography for a decade) versus the 1 in 10 risk of a falsely positive mammogram report, and the 1 in 200 risk of overtreatment during that 10-year period. For some women who subscribe to the "n of 1" theory, screening mammography may be worth the risk, effort and cost because of the chance that it may save their lives. Others may decide that the odds of experiencing benefit are not in their favor. Shouldn't the choice to undergo mammography be up to the patient?

Ken Grauer, MD
Gainesville, Florida
http://ecg-interpretation.blogspot.com/

AFP By Topic is your 24-7 virtual Scientific Assembly

2011-12-06T14:10:00.000-05:00

Since we first introduced AFP By Topic in June 2010, this online and mobile-friendly collection of the journal's best current content selected by AFP's medical editors has grown to include 52 topics that family physicians and other primary care clinicians commonly diagnose and treat in their patients. Recently, we compared the list of AFP By Topic collections to the most popular sessions at the 2011 American Academy of Family Physicians' Scientific Assembly in Orlando, Fla. Of the clinical subjects of 13 non-plenary sessions with an attendance of at least 500 physicians, 10 regularly rank among our most widely viewed topic collections, encompassing a diverse spectrum of acute (e.g., abdominal pain, pulmonary embolism) and chronic (e.g., diabetes, kidney disease, hyperlipidemia) health conditions.

Also at the Scientific Assembly, David T. Walsworth, MD, gave a presentation titled “Medical Applications: Finding the Right App for That." In his presentation, Dr. Walsworth discussed the utility of mobile devices and tablets, including the many uses for related apps in a family physician’s day-to-day practice. Some of the criteria he uses in appraising a medical app include asking the following questions: Does the app do something that I will use frequently? Do I trust the source? and Does the value justify the cost? Ranking highly on all of these criteria, the free AFP By Topic Mobile App not only made his personal Top Ten list, but came in at number 2!

Whether you access AFP By Topic collections on the Web or your mobile device, content links are updated continually to ensure that they remain as current and as useful as possible. The collections include pertinent AFP articles and departments, summaries of practice guidelines from major medical organizations, articles from Family Practice Management, and the AAFP's METRIC practice improvement modules. In short, we aim for AFP By Topic to be your 24-7 virtual Scientific Assembly. Please let us know how we're doing.

Managing symptoms in end-of-life care

2011-12-01T09:15:00.001-05:00

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of AFP, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care. A collection of previous Cochrane for Clinicians articles is also available online.

Universal cholesterol screening in children: what is the evidence?

2011-11-11T12:30:00.005-05:00

New guidelines released today by the American Academy of Pediatrics and the National Heart, Lung, and Blood Institute recommend replacing risk-based approaches to cholesterol testing with universal screening for all children at ages 9 and 17. To inform the debate that is sure to follow, we note that AFP has previously published commentaries that review the potential benefits and harms of different screening strategies. Below is our blog post on this topic from September 1, 2010.

The September 1 issue of American Family Physician inaugurates a new editorial feature that presents two opposing views on a controversial clinical topic and asks readers to post comments online. In this issue, Dr. Robert Gauer argues that because atherosclerosis begins in childhood, using cholesterol-lowering drugs in children with hyperlipidemia is essential to prevent coronary events and cardiovascular mortality in later life. On the other hand, Dr. Michael LeFevre contends that since only 40 to 55 percent of children with elevated cholesterol levels will have persistent hyperlipidemia as adults, and the potential benefits and harms of decades of drug therapy are unknown, physicians should demand a high "evidence bar" for instituting screening and treatment.

Since hyperlipidemia causes no symptoms, these views reflect in large part the dueling guidelines of the American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) on lipid screening in children. While the AAP recommends that screening for hyperlipidemia begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors, the USPSTF found insufficient evidence to recommend for or against screening in any group of children. [Editorial note: the AAP now recommends universal, rather than targeted, screening.]

This leaves family physicians and other clinicians who care for children with an important clinical dilemma. Should they act now based on disease-oriented evidence and extrapolation from studies of primary prevention of cardiovascular disease in adults, or should they instead wait for patient-oriented evidence from long-term followup studies of children with elevated lipid levels? Which approach do you take in your practice, and why? You are welcome to post comments here or on AFP's Facebook page; AAFP members can also post comments on the AFP web page. We look forward to the discussion!

Graham Center: Integrate mental health into primary care

2011-11-01T13:38:00.003-04:00

Based in part on a positive recommendation from the U.S. Preventive Services Task Force, the Centers for Medicare and Medicaid Services recently announced that it will cover annual depression screenings for Medicare patients in primary care settings "that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up." However, as the below Figure illustrates, translating the USPSTF guideline into practice has been challenging for many primary care physicians.

A Policy One-Pager from researchers at the Robert Graham Center, published in the November 1st issue of AFP, details the obstacles that clinicians face in identifying and treating depression and other mental health problems. As Dr. Robert Phillips and colleagues observe, "Current health care policy makes it difficult for most primary care practices to integrate mental health staff because of insufficient reimbursement, mental health insurance carve-outs, and difficulty of supporting colocated mental health professionals, to name a few."

On a related note, an editorial in the November 1st issue discusses strategies for improving adult immunization rates, which have historically lagged far behind rates of immunizations in children. According to Dr. Alicia Appel, immunization registries and electronic clinical decision-support systems can complement low-tech interventions such as patient reminders and standing orders. What has been your experience with incorporating depression screening and immunizations into routine care for adult patients?

ACIP recommends routine use of HPV vaccine in boys

2011-10-25T11:47:00.001-04:00

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices voted earlier this morning to recommend that boys be routinely vaccinated against human papillomavirus (HPV). With this new recommendation, the cervical cancer-preventing vaccine that the AAFP's ACIP liaison Johnathan Temte, MD, PhD has called a "cornerstone of female health" is now poised to be incorporated into the ACIP's childhood vaccination schedule for boys as well. Previously, the advisory group had taken a "permissive" stance toward HPV vaccine in boys, noting that it could be administered to prevent genital warts but not recommending it routinely.

Important AFP online content on HPV infection includes a recent clinical overview of its manifestations, testing, and prevention; and short drug reviews of the quadrivalent and bivalent vaccines. The latter review notes that the bivalent vaccine "does not protect against the two strains of HPV responsible for genital warts and is of no value in males."

What do you think of the new ACIP recommendation, especially in light of recent political controversies over HPV vaccine mandates? Have you been following the ACIP's previous recommendation to routinely administer HPV vaccine to girls, and if so, do you now plan to do so with boys? We would love to hear your thoughts.

Should ADHD in preschool-aged children be treated with medication?

2011-10-17T15:52:00.000-04:00

A new clinical practice guideline on ADHD from the American Academy of Pediatrics is making some waves among pediatricians and family physicians for its recommendation to evaluate and treat children as young as age 4 years. Past AAP guideline statements focused on identifying and treating children between the ages of 6 and 12 years. Although the AAP recommends behavior therapy as first-line treatment for younger children with inattentiveness or hyperactivity, it includes the option of starting medications in children who do not respond to behavior therapy. "In areas where evidence-based behavioral treatments are not available," the guideline adds, "the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment." It may only be a matter of time, then, before stimulants are being prescribed to large numbers of preschool-aged children.

Although unrecognized ADHD can cause significant social problems and learning difficulties in affected children, data on the incremental benefits and harms of detecting ADHD in younger (as opposed to school-aged) children and the long-term effects of stimulant medications is limited. As you consider how to incorporate information from this new guideline to the care of children your practice, we hope that you will find the AFP By Topic Collection on ADHD to be an indispensable resource.

Family physicians and the Goldilocks principle

2011-10-10T20:15:00.002-04:00

A recent national survey of internal medicine and family physicians published in the Archives of Internal Medicine found that 42 percent of physicians felt that their patients were getting "too much" health care, while only 6 percent thought that patients were receiving "too little." These opinions contrast with multiple previous studies showing that primary care clinicians fall short when it comes to providing guideline-recommended care; a 2007 study, for example, found that children received less than half of indicated care.

So which is it: too much care, too little, or some of both? And how can AFP help family physicians avoid these extremes and strive for the happy medium, which in other fields is known as the "Goldilocks Principle"? In addition to bringing readers the latest Practice Guideline updates, such as the Centers for Disease Control and Prevention's 2011-12 recommendations for influenza vaccination, we provide information that allows you to evaluate these guidelines against the best design criteria previously proposed by AFP Deputy Editor Mark Ebell, MD, MS:

The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information—“best” implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and “available” implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.

There are, of course, many reasons - financial, medical-legal, and practical, to name a few - that care may diverge from that supported by the best evidence-based guidelines. Still, we hope that every section of the journal makes it easier for family physicians to provide care that is "just right."

Prostate screening resources for you and your patients

2011-10-07T09:13:00.002-04:00

According to an article in today's New York Times, U.S. Preventive Services Task Force officials have confirmed that they plan to release an updated recommendation statement on screening for prostate cancer early next week that changes their current "I" (insufficient evidence) statement to a "D" grade ("recommends against"). Our AFP By Topic collection on Cancer includes several resources that may help you explain this upcoming change in practice to your colleagues and patients:

Cochrane for Clinicians: PSA Testing Is Not Effective

Practice Guidelines: ACS Recommendations on Prostate Cancer Screening

Review Articles: Prostate Cancer Screening: The Continuing Controversy and Treatment Options for Localized Prostate Cancer

Patient Education handout from FamilyDoctor.org: Prostate Cancer

Over-the-counter drug abuse: a growing concern

2011-10-03T20:50:00.001-04:00

Physicians who regularly treat patients with upper respiratory infections are familiar with the 2005 federal law that moved the decongestant pseudoephedrine "behind the counter" to make it more difficult to illegally manufacture the stimulant methamphetamine. Unfortunately, "meth" abuse is only the tip of the iceberg of over-the-counter medication abuse. In an editorial in the October 1st issue of AFP, Drs. Chih-Wen Shi and Margaret Bayard provide helpful tips on recognizing and treating this common problem in the primary care of adolescents and young adults:

When treating a patient for a drug overdose, it is important to screen for multiple drugs, because many OTC cough and cold medications contain more than one active ingredient. Furthermore, overdoses can occur with a combination of OTC, prescription, and illicit drugs, as well as alcohol and other substances. In such instances, toxicity may be additive. Reporting overdoses to poison control centers is crucial so that data can be collected to support policy changes, such as placing an OTC drug behind the pharmacy counter or taking it off the market.

You can find additional current AFP content on the prevention, diagnosis, and treatment of substance abuse in our AFP By Topic collection.

For cardiovascular prevention, is this Figure worth a thousand words?

2011-09-20T14:41:00.009-04:00

A previous AFP Community Blog post discussed challenges involved in recommending aspirin prophylaxis. Although aspirin reduces the risk of cardiovascular events in persons with no history of coronary artery disease, the absolute risk reduction is relatively small, and needs to be balanced against the inconvenience of taking a daily medication and side effects such as gastrointestinal bleeding. Family physicians who engage in shared decision-making with patients about aspirin may find it difficult to put these statistical risks and benefits in perspective.

In their clinical review "Global Risk of Coronary Heart Disease: Assessment and Application," which appeared last year in AFP, Drs. Anthony Viera and Stacy Sheridan included an easily understandable Figure that illustrated the benefits of 10 years of aspirin chemoprevention among 1,000 persons with a 10 percent 10-year global risk of coronary heart disease. However, as pointed out in a Letter to the Editor published in the September 15th issue, that Figure did not include an illustration of the potential harms of aspirin chemoprevention. In response, Drs. Viera and Sheridan have proposed modifying the figure as follows:

The pictograph shows a population of 1,000 men 45 to 59 years of age who have a 10 percent global risk of a coronary heart disease (CHD) event and who have been receiving aspirin for 10 years to reduce their risk. Green faces represent the number of men who would not benefit because they are not among the 10 percent predicted to have a CHD-related event. The red faces represent the approximate number of men who would have an event despite receiving aspirin. The yellow faces represent the men who would not have an event because it was prevented by aspirin. The reddened rectangle highlights the approximate number of people who would have a gastrointestinal bleed. The red X indicates the one person on average who would sustain a hemorrhagic stroke as a result of receiving the aspirin.

Reprinted with permission from Dr. Chris Cates' EBM Web site. http://nntonline.net/visualrx. Accessed May 23, 2011.

Does this figure exemplify the adage that "A picture is worth a thousand words," or does it oversimplify a complex medical decision? What do you think?

Clinical problem-solving is a strength of family medicine

2011-09-12T08:33:00.001-04:00

Working with family physicians since 1978, I have noticed two things in particular.

First, they take great pride in their interest in relationship-based care. They talk about the value of continuity. They tell stories that describe how much they treasure relationships with patients. They tell these stories in their teaching. They write books about it. It's a powerful force that energizes their work and their career satisfaction.

They rarely, if ever, mention the power of their clinical problem-solving abilities. Why is that? The absence of mention and the seeming lack of pride (my assumption) in this area makes me wonder if FPs really believe they are effective in the area of clinical problem-solving.

From my earliest days in family medicine, I came to believe that FPs' impact as physicians was a result of their patient/relationship-centered approach that included effective communication skills, their fund of knowledge, and their clinical problem-solving skills. All three are essential; any two working alone, except in special circumstances, will not lead to the best results.

Family physicians embraced the work of Barbara Starfield, MD, MPH, who told the world that FPs, in particular, and primary care clinicians, in general, had a positive effect on population health while reducing the cost of care. When I hear FPs take pride in their relationship centered approach to care but never mention their approach to clinical problem-solving, it leads me to believe they think that continuity alone produces the impact documented by Dr. Starfield.

I put this issue to a number of colleagues and heard the following.

"Because of the variety of patients and undefined illnesses that family physicians see, they become better at development of realistic differential diagnosis than any other medical specialty." - Doug Smith, MD, Orono Family Medicine, Orono, Minnesota

Shantie Harkisoon, MD, director of the Phelps Family Medicine Residency Program in Sleepy Hollow, New York, told me that she thinks the strength of FPs is strong skill with differential diagnosis of the patient as person while sub-specialists are generally more effective at differential diagnosis of a disease.

I have been talking to a documentary film maker who wants to tell a story about family medicine and primary care innovation. In his interviews with FPs, all he hears about is the value of relationship centered care. He can't understand how the care provided by FPs costs less money. When I told him that FPs are effective clinical problem-solvers and their approach to decision making is a key piece of this story, he almost did not believe me. When he interviewed FPs, he was not hearing about this. Why do we not hear more about family physicians' clinical problem-solving prowess?

Laurence Bauer, MSW, MEd

Chief Executive Officer

Family Medicine Education Consortium

Laurence.Bauer@gmail.com

Compromising the medical literature

2011-09-05T20:34:00.004-04:00

To ensure that our clinical review articles reflect current medical literature, American Family Physician requires prospective authors to consult several evidence-based resources that synthesize the best available evidence from clinical trials and other high-quality studies. The goal of this process is to produce unbiased recommendations for primary care physicians. But what if the authors of clinical reviews are actually professional scientific writers paid by pharmaceutical companies, rather than the physicians whose names are listed as authors?

In fact, drug-company funded "ghostwriters" have been publishing articles in the medical literature for years. A study by the editors of JAMA found that from 2 to 11 percent of articles published in 2008 in six major journals (including the New England Journal of Medicine) were actually written by people who were not named as authors. While the study could not establish that these ghostwriters had been directly financed by industry, the practice of writing up a scientific study and then recruiting a lead author (usually an academic physician under pressure to "publish or perish") has been well-documented in the case of previous "blockbuster" drugs that were taken by millions of patients for common conditions but later turned out to have dangerous or fatal side effects, including Wyeth's Prempro and Merck's Vioxx.

Ghostwriting is not the only way that the pharmaceutical industry is able to influence the interpretation of evidence in its favor. A Letter to the Editor in the Sept. 1 issue points out that a 2005 Cochrane Review on medications for diabetic neuropathic pain (cited in a 2010 AFP article on this topic) unintentionally exaggerated the effectiveness of gabapentin in treating this condition due to the manufacturer's selective publication of favorable trials and suppression of unfavorable ones. In an accompanying editorial, Drs. Adriane Fugh-Berman and Jay Siwek review these and other "stealth marketing" tactics that can potentially compromise the medical literature, along with ways that readers can help correct these biases:

Distorted information, once ensconced in the medical literature, is propagated by industry and by well-intentioned authors who unwittingly cite these studies. The medical literature is a permanent record that scientists and physicians rely on for decisions that ultimately affect patient care. Although the scientific process is never linear, the self-correcting process by which evidence is continually refined can be corrupted by the infiltration of medical journals with research studies and review articles distorted by a hidden marketing agenda.

Although there is no foolproof way for readers to detect undue industry influence, readers should be alert for marketing messages that disparage older, generically available drugs or that position newer branded (or upcoming) drugs as more effective, more convenient, safer, or filling an unmet need. The last sentence of the abstract is typically where the marketing spin is inserted. Readers should alert medical journals to suspicious articles by writing letters to the editor.

Convincing new mothers that "breast is best"

2011-08-31T09:13:00.001-04:00

A recent report from the Centers for Disease Control and Prevention found that despite evidence that birthing environments strongly influence new mothers' feeding practices, only 3.5 percent of surveyed U.S. hospitals met most quality indicators of the Baby-Friendly Hospital Initiative, an international program that seeks to reduce obstacles to successful breastfeeding. Hospitals received low marks on items such as restricting pacifier use and supplemental infant formula, and only a minority permitted 24-hour "rooming in," which makes it easier for infants to breastfeed on demand.

Although the American Academy of Family Physicians and the American Academy of Pediatrics recommend that mothers exclusively breastfeed infants for the first 6 months of life, and supports continuing breastfeeding to at least one year of age, data from the 2004-2008 National Immunization Survey document that only 73% of U.S. women attempt to breastfeed after birth, and only 42% and 21% are still breasfeeding at 6 and 12 months of life. The percentages are even lower for Black women: only 54% attempt breastfeeding, and just 27% and 11% are still doing so at 6 and 12 months.

Family physicians can help convince expectant and new mothers that "breast is best" by applying a number of evidence-based interventions recommended by the U.S. Preventive Services Task Force. Patients should be informed that the Department of Health and Human Services mandates first dollar coverage of comprehensive lactation support and breastfeeding equipment (e.g., breast pumps) for insurance plans starting in August 2012. Recognizing that primary care clinicians have many opportunities to support breastfeeding throughout pregnancy and the newborn period, we have included related content in each of the AFP By Topic collections on Prenatal Care, Labor and Delivery, and Newborn Care.

Does aspirin prophylaxis improve health in older adults?

2011-08-22T08:46:00.001-04:00

Every day, family physicians are confronted with the clinical question of whether or not to start a patient on aspirin for the primary prevention of cardiovascular disease. The editorials in the June 15th issue of AFP by Dr. W. Fred Miser ("Appropriate Aspirin Use") and Drs. Bailey, Smyth, and Campbell ("The Case Against Routine Aspirin Use") highlight the current difficulties in putting the 2009 U.S. Preventive Services Task Force recommendations on aspirin prophylaxis into practice. There is limited information available to inform benefit versus risk decisions regarding aspirin prophylaxis in healthy older adults. Given the significant projected growth of the elderly population, especially of older minorities, family physicians will need to address aspirin prophylaxis decisions more frequently in the future.

To address areas of uncertainty beyond the 2009 USPSTF guidelines, the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial aims to answer a simple question with significant public health relevance: Does daily low-dose aspirin use maintain longevity without cognitive and functional disability in healthy men and women age 70 years or older? Currently, recruitment of 19,000 older adults who do not require aspirin for a cardiovascular condition is ongoing at over 20 sites in the U.S. in addition to general practices in Australia. In the U.S., results from ASPREE should hopefully provide insight on how aspirin works in all older persons, including members of minority groups. In order to succeed, ASPREE will require the engagement of family physicians and other primary care clinicians. Family physicians can make a significant contribution by identifying healthy, older persons from minority communities and providing them with information about how to participate in the study. More information about the study and locations of study sites in the United States can be found at www.ASPREE.org.

Raj C. Shah, MD
Rush University Medical Center
Chicago, Illinois
Raj_C_Shah@rush.edu

Disclosure: The author is a co-investigator on the ASPREE study.

Autism: to screen or not screen?

2011-08-16T10:08:00.003-04:00

The August 15th issue of AFP features a pair of editorials that stake out opposite positions in the intensifying debate about the benefits of routinely screening young children for autism spectrum disorders (ASDs). Dr. Paul Lipkin and Susan Hyman argue that the rising incidence of ASDs and studies suggesting a benefit from early diagnosis and behavioral interventions make it imperative for pediatricians and family physicians to incorporate developmental screening tools into their practices. They assert that developmental screening does not impose significant time burdens on physicians, and that false-positive screening results can be minimized by scheduling follow-up interview visits.

On the other hand, Dr. Doug Campos-Outcalt counters that screening for ASDs has not yet met several critical criteria for establishing the effectiveness of a screening test. In particular, the following important questions remain unanswered:

1) What are the sensitivity and false-positive rate of the best screening test for ASDs available in an average clinical setting?

2) How much earlier can screening tests detect ASDs compared with an astute clinician who asks a few key questions about, and acts on, parental concerns regarding a child's communication and interactions?

3) What are the potential harms of testing?

4) Does earlier detection by screening result in meaningful and long-lasting improvements compared with detection through routine care?

Although a recent systematic review published in Pediatrics found limited evidence that early intensive behavioral interventions improve "cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs," it remains uncertain if routine screening leads to improved outcomes. Therefore, Dr. Campos-Outcalt recommends, "Family physicians who provide care for young children should ask parents about any concerns, be alert for the signs and symptoms of ASDs, and use available diagnostic testing tools to assist in making clinical decisions when an ASD is suspected."

AFP Community Blog: Top 10 most-read posts

2011-08-10T08:36:00.005-04:00

This month, the AFP Community Blog celebrates its first anniversary. For those of you who started following us recently, or don't read regularly, here is a list of the blog's top 10 most-read posts:

1) AFP By Topic now available for IPhone and Android (4/20/11)

2) Dabigatran for stroke prevention in atrial fibrillation: is it worth it? (1/18/11)

3) Prostate-specific antigen screening is not effective (3/30/11)

4) Screening and treatment of hyperlipidemia in children (9/1/10)

5) Autism spectrum disorders: increasing prevalence or diagnosis shift? (5/22/11)

6) Antibiotics for acute bronchitis: just don't do it (12/9/10)

7) Screening colonoscopies performed more often than necessary (5/9/11)

8) Geriatric assessment tools (1/3/11)

9) Should pharma have unrestricted access to your prescribing profile? (4/25/11)

10) Advice for physicians on using social media (7/6/11)

Thank you all for continuing to make American Family Physician the best-read journal in primary care!

Climate change and family physicians

2011-08-02T15:02:00.000-04:00

At first glance, the topic of the cover article of AFP's August 1st issue, "Slowing Global Warming: Benefits for Patients and the Planet," might seem out of place in a journal that aims to provide practical clinical guidance for family physicians. Past summer-themed articles have included clinical reviews of heat-related illness, medical advice for commercial air travelers, and even health issues for surfers. By addressing climate change, AFP joins other widely read medical journals such as The Lancet and BMJ in recognizing the essential role that physicians can play in mitigating the negative impacts of environmental stress on patients' health.

After summarizing the serious potential health effects of climate change, Dr. Cindy Parker recommends that primary care clinicians counsel patients regarding two lifestyle changes that are likely to improve personal health as well as slow global warming: reducing meat consumption and increasing "active transportation" (substituting bicycling or walking for short car trips). In addition, physician practices and larger medical organizations can positively affect climate change by "going green":

Medical offices and hospitals can help by recycling; using recycled items and Energy Star certified appliances and computers; minimizing waste and waste transport by replacing single-use items with sterilizable or washable items; purchasing wind-generated electricity; and reducing energy use by turning off appliances, computers, and lights when not in use. In 2008, the U.S. health care sector spent $8.8 billion on energy to meet patient needs, not including the transportation of employees or patients to and from health care facilities, resulting in 8 percent of all U.S. greenhouse gas emissions.

In an accompanying editorial, Dr. Robert Gould reviews several national and international initiatives that encourage hospitals and health systems to reduce greenhouse gas emissions, including the Healthier Hospitals Initiative and Health Care Without Harm.

Tobacco quitlines suffer from budget cuts

2011-07-31T21:45:00.000-04:00

An editorial in the July 15th issue of AFP by Drs. Stephen Rothemich and Scott Strayer extols the value of telephone quitlines in helping family physicians convince patients to stop smoking. Noting that many practices "lack the time and resources to provide effective counseling," the authors recommend that busy clinicians refer patients to the national toll-free quitline number (800-QUIT-NOW) to fill in these gaps. In addition, they review high-quality evidence that quitlines improve smoking cessation rates over counseling or medications alone:

The effectiveness of quitline counseling is well established. A Cochrane review reported successful cessation in patients who received counseling from quitlines (number needed to treat = 32). Quitline counseling combined with smoking cessation medications is particularly effective, with a cessation rate of 28.1 percent (more than three times the rates with minimal or no counseling or with self-help).

Unfortunately, funding for quitlines has recently fallen victim to budget cuts in at least two states. In Ohio and Washington State, quitlines that were once free to all smokers now only serve patients with certain types of insurance. State officials attributed their inability to continue to fully fund the quitlines to ending of federal grants and the need to divert funds from the 1998 Master Settlement Agreement with tobacco companies to other non-tobacco-related programs.

These cuts could not have come at a worse time, as the U.S. Food and Drug Administration's new requirement that cigarette packs display graphic health warning labels by September 2012 seems to have increased smokers' interest in using quitlines. For information about any eligibility limitations on your state's quitline, you can consult the website of the North American Quitline Consortium at http://www.naquitline.org/.

Diagnosing patients who itch

2011-07-25T15:51:00.004-04:00

In a fascinating 2008 New Yorker article, "The Itch," Harvard surgeon Atul Gawande told the story of a patient who experienced a nearly fatal complication from treatment-resistant pruritis of her scalp following an episode of herpes zoster:

One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, “this fluid came down my face, this greenish liquid.” She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain.

Although this sort of complication is highly unusual, pruritis - far from being only a "nuisance" symptom - is often associated with underlying systemic conditions, Dr. Brian Reamy and colleagues observe in "A Diagnostic Approach to Pruritis" in the July 15th issue of AFP. Clinicians should consider evaluating patients who present with generalized, unexplained pruritis for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes. Many dermatoses of pregnancy can cause intense pruritis. Also, some psychiatric disorders are associated with pruritic sensations, leading to "neurotic excorations." Certain historical findings, including recent travel, exposure to animals, and constitutional symptoms such as weight loss and fatigue, can help to narrow the extensive differential diagnosis of this common and troublesome symptom.

Making informed choices about family planning and contraception

2011-07-18T13:15:00.001-04:00

For reproductive-age women who have medical comorbidities such as epilepsy, diabetes, and hypertension, choosing a family planning method can be challenging. The September 1, 2010 issue of AFP reviewed the risks and benefits of hormonal contraceptives for these patients, based on guidelines from the American College of Obstetricians and Gynecologists. However, the scope of that article did not include nonpharmacologic options such as barrier or fertility awareness-based methods, also known as natural family planning (NFP). Two letters in the July 1st issue of AFP remind readers that NFP is an effective family planning option for appropriately educated couples and provide helpful training resources for clinicians. As Drs. Robert Conkling and Leslie Chorun observe:

Counseling in natural methods of fertility regulation is currently being provided by a growing number of trained physicians, nurse practitioners, and allied health professionals. ... These family planning methods should not be confused with calendar rhythm method and are not dependent on the regularity of a woman's cycle. Population-based surveys have shown a significant interest in NFP—approximately 25 percent of women and 40 percent of men are interested in using NFP to avoid pregnancy, and 33 percent of women are interested in using NFP to conceive. This interest is not associated with religion, education, age, or income level.

For further reading on patient outcomes associated with various fertility awareness-based methods, family physicians can consult a clinical review published in the Journal of the American Board of Family Medicine. Also, a recent AFP By Topic collection compiles the journal's current online content on all aspects of family planning and contraception, including preconception care, the infertility evaluation, and advantages and disadvantages of hormonal and non-hormonal methods.