Overcoming HPV vaccine hesitancy

Human papillomavirus (HPV) vaccines, which prevent infection with HPV genotypes that cause cervical, anal, vaginal, and penile cancers, are hardly new. The quadrivalent and bivalent HPV vaccines were reviewed in American Family Physician in 2007 and 2010, respectively, and a 9-valent vaccine was approved by the U.S. Food and Drug Administration in 2014. Although long-term studies have yet to demonstrate that HPV vaccines reduce cancer rates, a recent systematic review found that introduction of the quadrivalent vaccine in 9 countries (including the U.S.) was associated with a 90% reduction in infections from the targeted genotypes and similar reductions in genital warts and high-grade cervical abnormalities. Women who receive HPV vaccine are at considerably lower risk for undergoing colposcopy and associated invasive diagnostic or therapeutic procedures.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that all boys and girls receive the 3-dose HPV vaccine series at age 11 to 12. However, CDC data from 2014 show that only 40% of girls and 21% of boys had completed the series by age 17. (These percentages increased slightly in 2015.) In contrast, 80% of 13 to 17 year-olds had received meningococcal vaccine, and 88% had received TdaP (tetanus, diphtheria, and acellular pertussis) vaccine, which provide protection against serious, but comparably rare, infections. Earlier this year, all 69 National Cancer Institute-designated Cancer Centers released a consensus statement expressing concern about persistently low HPV vaccination rates in the U.S. compared to other countries, which they labeled a "serious public health threat."

A 2015 AFP editorial by Drs. Herbert Muncie, Jr. and Alan Lebato examined parental and physician impediments to HPV vaccination. Parents often express concerns about vaccine safety and worry that their children may be more likely to start having sex after receiving the vaccine. Family physicians can reassure parents on both of these questions:

Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010, although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache). Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier, nor is their risk of acquiring an STI increased.

In other cases, physicians have been the primary obstacles to vaccination: they are sometimes reluctant to bring up the topic of sex, they believe the vaccine is unnecessary because Pap smears will detect early cervical cancer, or they present the vaccine as "optional" or don't offer it at all. Drs. Muncie and Lebato suggested several effective strategies for improving HPV vaccination rates:

Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent. Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.

An editorial in AFP's July 15th issue by Drs. Jamie Loehr and Margot Savoy provided additional tips for physicians on addressing and overcoming vaccine hesitancy in general. More immunization resources, including the latest childhood and adult immunization schedules from the ACIP, are available in AFP's Immunizations Topic Collection.

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This post first appeared on the AFP Community Blog.

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Can point-of-care tests reduce inappropriate antibiotic use?

Why do physicians prescribe antibiotics for viral infections when they ought to know better? An editorial from the Centers for Disease Control and Prevention in the August 1st issue of American Family Physician suggests several talking points that may persuade the patient who wants "Vitamin Z" (azithromycin) for his (or his child's) common cold and reviews evidence that delayed antibiotic prescriptions, effective communication strategies, and public commitments to use antibiotics appropriately reduce unnecessary antibiotic use. But what if these interventions aren't enough?

The rapid strep test helps to distinguish a viral sore throat from streptococcal pharyngitis. In patients with an intermediate pre-test probability, a negative rapid strep test lowers the post-test probability of strep enough for doctors (and most patients) to feel comfortable withholding antibiotics. Wouldn't it be nice if other point-of-care tests could effectively rule out bacterial infections and curb antibiotic prescribing in patients with acute respiratory symptoms?

Procalcitonin seems ready to go. A FPIN Clinical Inquiry in the July 1st issue of AFP evaluated the effects of a procalcitonin-guided antibiotic therapy algorithm on antibiotic use and clinical outcomes. A Cochrane review and meta-analysis of 14 randomized, controlled trials (RCTs) comparing procalcitonin-guided to standard care in European adults with acute respiratory infections found that patients in the procalcitonin group received 3.47 fewer days of antibiotic therapy with no differences in 30-day mortality or treatment failure. In a single RCT of 337 children presenting to pediatric emergency departments in Switzerland, patients in the procalcitonin group were as likely as the standard care group to receive antibiotic prescriptions, but received nearly 2 fewer days of therapy.

C-reactive protein (CRP): the jury is still out. A Cochrane for Clinicians examined the performance of point-of-care measurement of CRP on similar outcomes. Although treatment thresholds varied, most studies considered a CRP level of less than 20 mg per L to suggest a viral infection and no need for antibiotics. A Cochrane review of 6 RCTs conducted in primary care settings (mostly in adults) in Europe and Russia found that groups assigned to CRP-assisted evaluation were 22 percent less likely to receive antibiotic prescriptions for acute respiratory infections, with no differences in clinical improvement at day 7, complications, or mortality. However, Dr. Irbert Vega observed in the Practice Pointers that "the meta-analysis did not identify an optimal algorithm and therefore should be considered proof of concept until further research can be performed, including research in the U.S. population."

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This post first appeared in a different form on the AFP Community Blog.

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Reflections on my summer publications

When I haven't been blogging, editing, teaching, or seeing patients this summer, I have experienced the satisfaction of having reports of a couple of my longer-term projects appear in medical journals. In contrast to a blog post, which can be conceived, written, and published in a few hours (although the thought process often takes much longer), the timeline from submission to publication in a journal is usually several months at a minimum.

For example, in the spring of 2014, after having helped to develop a search tool for primary care-relevant Choosing Wisely recommendations, I wondered what proportion of these recommendations were based on evidence of patient-oriented outcomes, as opposed to expert consensus. I convinced a collaborator, a family physician at Fort Belvoir Community Hospital, to help me apply the Strength of Recommendation Taxonomy (SORT) to 224 different recommendations that had been generated by various medical specialty societies. It took many hours of working on our own and several conference calls to complete this project, which we presented at the Preventing Overdiagnosis conference at the National Institutes of Health last September. We then wrote the paper and submitted it to what we thought was an appropriate journal, but the editors of the journal (which will remain nameless) disagreed, rejecting it without even sending it for peer review. So we resubmitted it to the Journal of the American Board of Family Medicine, which accepted it after peer review and revision and finally published it in their July/August issue. Here is the bottom line:

We found that a majority of primary care–relevant Choosing Wisely recommendations are based on expert consensus or disease-oriented evidence. In light of other factors that drive unnecessary medical interventions, such as patient satisfaction and fee-for-service reimbursement, this may make it more difficult to convince clinicians to change established practices. Further research is warranted to strengthen the evidence base supporting these recommendations in order to improve their acceptance and implementation into primary care.

Not long afterward, the journal Family Medicine published a book review that I wrote about Dr. Robert Taylor's enjoyable and useful What Every Medical Writer Needs to Know. I love reading good books about the process of writing, medical or otherwise, and recommended it highly:

Although students and novice writers may want to purchase a more traditional and/or less expensive book on the craft, I recommend What Every Medical Writer Needs to Know as a valuable resource not only for “serious” medical authors who write for a living but for family physicians and clinicians who write occasionally for publication and would enjoy learning more about the inspiring history of the profession.

After it was published, a residency mentor, whom I credit for giving me my start in medical writing, e-mailed me to say that he had decided to purchase a copy of the book based on my review!

Although blogging has advantages over traditional medical publications (perhaps my favorite being that I get to be the writer and the editor), I am glad that I invested the time to be published in these family medicine journals.

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Should we look for pulmonary emboli in patients with syncope?

The standard evaluation of patients with syncope has changed little over the years, with considerable continuity between American Family Physician reviews published in 2005, 2011, and this March. But the field received an unexpected jolt last October, when Dr. Paolo Prandoni and colleagues published a cross-sectional study in the New England Journal of Medicine that calculated a surprisingly high prevalence of pulmonary embolism (PE) of 17.3% in patients hospitalized for a first episode of syncope. In this study, 230 of 560 patients at 11 Italian hospitals who did not have a low pretest probability of PE by the Wells rule and negative D-dimer assay underwent computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion lung scans. 97 of these patients had evidence of PE. Overall, the investigators identified PE in 25% of patients with no alternative explanation for syncope and 13% of patients with an alternative explanation.

Algorithms for syncope evaluation focus on identifying cardiac and neurally mediated causes and do not include routine testing for PE. The question raised by the Italian study is if all inpatients with syncope need evaluation, since nearly 1 in 6 patients may have PE. There are good reasons not to jump to this conclusion. First, we don't know if the prevalence of PE in this study was representative of the general population of adults hospitalized for syncope, as it only included patients admitted from emergency departments (and not patients initially evaluated in primary care settings). Second, the study did not determine if PE was the etiology of syncope, as opposed to an incidental finding. This is important because evidence suggests that the enhanced sensitivity of CTPA for detecting small, subsegmental PE is increasing overdiagnosis and overtreatment of clinically insignificant clots. Finally, the absence of a comparison group means that it is not known if the systematic workup for PE improved the patients' prognoses or just added additional cost and risk to the evaluation.

A retrospective cross-sectional study in JAMA Internal Medicine recently used clinical and administrative data from 4 hospitals in Toronto to estimate the prevalence of PE in 1305 patients with a first episode of syncope who were not receiving anticoagulation at the time of admission. 120 of these patients received CTPA, ventilation-perfusion scan, and/or compression ultrasonography, leading to the diagnosis of PE in 18 patients. As opposed to the Italian study, where all persons received at least a D-dimer test, the decision to evaluate for PE was driven by clinical judgment. Nonetheless, of 146 patients in the Toronto study who received any test for PE (presumably those who were most likely to have one), only 12% were positive, and the overall prevalence of PE was a mere 1.4%. The authors concluded that "there is little, if any, justification for routine testing for [venous thromboembolism] in all patients hospitalized for a first episode of syncope."

Based on both studies, I agree that evidence does not support routinely looking for PEs in patients with syncope. In patients with possible signs or symptoms, another clinical decision rule may be used to confidently rule out the diagnosis without resorting to the less sensitive Wells rule or less specific D-dimer test, where a positive result often leads to unnecessary CTPA.

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A slightly different version of this post first appeared on the AFP Community Blog.

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Reforming medical school rankings and admissions criteria to meet urgent national needs

If you read my curriculum vitae, you might assume that I must have a high opinion of the U.S. News & World Report higher education rankings. I earned my bachelor's degree from Harvard University, #2 behind Princeton in the "Best National Universities" category. My Master of Public Health degree is from Johns Hopkins, the #1 public health school. And my medical degree is from NYU, tied with Cornell and the Mayo Clinic as the 9th ranked research medical school, and likely to move up due to its decision to go tuition-free last fall (though whether NYU will improve its middling primary care ranking is uncertain at best). To top it all off, I even wrote a blog for U.S. News for a year called "Healthcare Headaches."

I admit that when I applied to college and medical school, I placed a great deal of stock - far too much - in these rankings. (I ended up at Johns Hopkins for public health because it was local, offered a part-time/online option, and I already had connections there.) But as my formal education recedes into the rearview mirror of my career, I find, instead, that I agree with Northwestern University professor William C. McGaghie's renewed critique of the U.S. News rankings published recently in Academic Medicine.

Dr. McGaghie observed that "the methods used by U.S. News & World Report to rank medical schools are based on factors that can be measured easily but do not reflect the quality of a medical school from either a student or patient perspective." For example, 20% of the research and primary care ranking reflects "student selectivity," a combination of incoming students' mean undergraduate grade point averages (GPAs), Medical College Admission Test (MCAT) scores, and acceptance rates. These criteria may modestly predict academic performance in preclinical courses, but have virtually no impact the quality of doctors schools produce. They also have real downsides. As Dr. Arthur Kellermann, dean of the Herbert School of Medicine at Uniformed Services University, wrote in explaining his school's 2016 decision to stop participating in the U.S. News medical school rankings:

Schools have a perverse incentive to boost their rank at the expense of applicants and the public. Based on the methodology used by U.S. News, a medical school that wants to boost its rank should heavily favor applicants with super-high MCAT scores and grade point averages and ignore important attributes such as character, grit, and life experiences that predict that a student will become a wonderful doctor. A school might also encourage applications from large numbers of people with little or no chance of acceptance simply to boost its “selectivity” score.

This isn't to say that prospective medical students can't have stellar test scores and GPAs and great character and life experiences - I interview several every year. But I wonder how many outstanding future physicians we also prematurely weed out by our slavish devotion to the former metrics. I write from personal experience: my overall undergraduate GPA was 3.4, and my GPA in science prerequisite courses closer to 3.2, which caused my applications to be automatically rejected at several medical schools I applied to - including the one where I'm now a full Professor.

From the perspective of a patient or a community, the outcome that matters most for a medical school is how well it fulfills its social mission: to produce physicians who improve the health of the communities it serves, including an optimal mix of generalists and subspecialists; urban, suburban, and rural physicians; practicing physicians, teachers, and researchers. In 2010, Dr. Fitzhugh Mullan and colleagues published the first ranking of medical schools based on social mission, which eventually evolved into the Robert Wood Johnson Foundation-supported Social Mission Metrics Initiative, a national survey that enables dental, medical, and nursing school deans to receive confidential feedback on their performance in 18 social mission areas.

As Dr. Eric Topol wrote in Deep Medicine, the forthcoming integration of artificial intelligence (AI) into medical care over the next few decades is another good reason to change the way we evaluate medical school applicants:

Are we selecting future doctors on a basis that can be simulated or exceeded by an AI bot? ... Knowledge, about medicine and individual patients, can and will be outsourced to machine algorithms. What will define and differentiate doctors from their machine apprentices is being human, developing the relationship, witnessing and alleviating suffering. Yes, there will be a need for oversight of the algorithmic output, and that will require science and math reasoning skills. But emotional intelligence needs to take precedence in the selection of future doctors over qualities that are going to be of progressively diminished utility.

In another Academic Medicine commentary, Dr. Melanie Raffoul (a former Georgetown Health Policy Fellow) and colleagues offered a starting point for medical and other health professions schools to "meet the needs of tomorrow's health care system." Among other things, they proposed 1) incorporating emotional intelligence testing into admissions criteria; 2) specifically recruiting from rural and underserved settings; 3) "consciously reaching out to disadvantaged and underrepresented students at the primary and secondary education levels"; 4) establishing community partnerships to develop pools of eligible trainees; 5) bridging gaps between health care and public health; and 6) supporting health professions education research. Ironically, the most effective way to motivate schools to make these wide-ranging changes might be for U.S. News to weigh these factors heavily in next year's rankings. If that happened, my current dim view of the rankings would change dramatically.

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Reducing medication cost burden in primary care: challenges and opportunities

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) finalized a new rule requiring that pharmaceutical companies disclose drug list prices in direct-to-consumer television advertisements for drugs that cost more than $35 for a month's supply or usual course. A fact sheet further explaining the rule noted that "the 10 most commonly advertised drugs have list prices ranging from $488 to $16,938 per month or usual course of therapy." Although pricing transparency could push patients to select more affordable or non-pharmacologic alternatives, and help clinicians improve high-value prescribing, it unfortunately does not make these drugs any less expensive.

In an editorial in the April 1 issue of American Family Physician, Dr. Randi Sokol discussed four strategies for helping patients with type 2 diabetes mellitus afford insulin while providing evidence-based care: 1) Relax A1c goals to 8% or less; 2) Switch to human insulins instead of insulin analogues; 3) use Health Resources and Services Administration-certified 340B pharmacies and patient assistance programs; and 4) join advocacy efforts to reduce the high cost of insulin and other drugs, such as the Lown Institute's Right Care Alliance and the American Medical Association's Truth in Rx.

Family physicians can take a systematic approach to reducing prescription costs for all of their patients. In an article published in FPM, Dr. Kevin Fiscella and colleagues described the approach taken by 7 primary care practices in New York, Georgia, and California. Office staff screen patients for prescription cost concerns by privately asking them, "Is the cost of any of your medications a burden for you?" For patients who answer yes, clinicians briefly explore the circumstances (e.g., unmet deductible, use of brand name drugs) and employ several cost-reducing strategies, including deprescribing unnecessary medications, using extended (90-day) prescriptions, and substituting lower-cost medications or referring patients to large chain pharmacy discount programs (e.g. "$4 lists").

In a preliminary study published in a supplement to the Annals of Internal Medicine, Dr. Fiscella's team found that a single 60-minute training for clinicians and staff on cost-of-medication importance, team-based screening, and cost-saving strategies increased the frequency of cost-of-medication conversations from 17% to 32%. Other helpful articles in the same supplement supported by the Robert Wood Johnson Foundation included "The 7 Habits of Highly Effective Cost-of-Care Conversations" and "Tools to Help Overcome Barriers to Cost-of-Care Conversations." The American College of Physicians offers several additional cost-of-care conversation resources on its website.

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This post first appeared on the AFP Community Blog.

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Is Common Sense Family Doctor a professional liability?

In the many talks I've given about blogging and social media over the years, one question that almost always came up was some variation of, "can being opinionated on social media hurt my career?" My usual response is no, provided that you don't do unprofessional things like post photos of identifiable patients or insult current or former supervisors. And even if some readers have been turned off by my less-is-more medical philosophy (which my friend and cardiologist John Mandrola recently termed "being a medical conservative"), for me any negative consequences of blogging are greatly outweighed by the positives. These include many speaking and writing invitations, positive recognition in family and conservative medicine communities, and appointments to practice guideline and advisory panels such as the Advisory Committee on Breast Cancer in Young Women. At the Society of Teachers of Family Medicine conference in Toronto, I was humbled by how many people introduced themselves to me the way I imagine one would approach a celebrity or high-ranking dignitary, simply because they counted themselves among my ten thousand or so Twitter followers.

That was my view, anyway, until this year. Now I wonder if my nearly 10-year commitment to blogging for Common Sense Family Doctor and other outlets (e.g., Medscape) is more of a professional liability than I believed.

Before getting into that, I want to make clear that I recognize how fortunate I've been in my career path to this point. I divide my time between teaching, editing, writing, and patient care so that these activities often complement each other, and I greatly appreciate the flexibility and support that the family medicine department at Georgetown/Medstar has provided for the past several years since I returned to academic practice. Being deputy editor of the most-read medical journal in primary care is a great privilege. I have a terrific relationship with the editor-in-chief, who goes out of her way to acknowledge the value of my contributions and has been extremely understanding when I have pursued other opportunities that could significantly reduce the time I have to devote to American Family Physician.

That said, last month I experienced a crushing professional disappointment. I had the opportunity to interview for a senior science position at an organization I greatly respect, and for which I have volunteered hundreds of hours of time over the past 5 years. The position would have involved moving my family across the country, and frankly, I could not imagine a more qualified candidate being willing to do so. In short, I thought that I had the inside track on the job. So I was shocked to receive a form e-mail from their Human Resources department just two days after my on-site interview, informing me that they had decided to move forward with another candidate. A more personal follow-up e-mail the next day explained that they wanted to fill the position more quickly than I was willing to leave my current institution and clinical practice.

Fair enough. Except this: the position is now being widely advertised again on social media and multiple listserves to which I subscribe. It clearly has not been filled by a competing candidate, and if negotiations with that candidate unexpectedly fell though, they haven't reached out to me to extend a backup offer. Did I really bomb the interview that badly? Were my shirt buttons misaligned, or was there something hanging out of my nose? It got me thinking about something that vaguely bothered me about the interview and the telephone interview that preceded it: their repeatedly asking me if I would be willing to publicly support organizational positions that I personally disagreed with. I repeatedly answered yes, explaining that I understood the nature of the position required it, and as long as I had input in coming up with any scientific stance (as they assured me I would), that would be fine by me. Maybe they didn't buy my assurances. Maybe they didn't believe that an opinionated social media star could suppress his ego in order to toe the party line. (They would have been wrong. Had I accepted this position, I fully intended to stop writing this blog and substantially tone down my Twitter feed.)

So is Common Sense Family Doctor sometimes a professional liability? It probably is; I can't say for certain either way. But as a dear friend consoled me after learning that I was not offered this position that I coveted, "they are truly missing out and we get to retain a fabulous family doc and educator at Georgetown." I hope she's right. I am grateful to my colleagues, students, and patients for making this latest disappointment sting a little bit less than it could have.

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Making the case for primary care-led, federally funded clinical practice guidelines

Talk about throwing down the gauntlet. In a provocative editorial published last year in Circulation: Cardiovascular Quality and Outcomes, Dr. John Ioannidis, who in 2005 shocked the scientific research community with his article "Why Most Published Research Findings Are False," took aim at medical professional societies authoring clinical practice guidelines and disease definition statements. He observed that despite notable progress in improving the trustworthiness of guidelines since the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, guideline panels continue to be plagued by financial conflicts of interest, lack of methodologist involvement, and domination by specialists "who have overt preferences (even without overt conflicts)."

Recent studies support Dr. Ioannidis's points. One study found that more than half of authors of gastroenterology guidelines received industry payments between 2014 and 2016. Another study of the top 10 highest-revenue medications of 2016 determined that more than half of authors of related guidelines had financial conflicts of interest, many of which were not disclosed in the journal publications. Finally, a study evaluating levels of evidence supporting U.S. and European cardiology guidelines from 2008-2018 found that only 8 to 14% of recommendations were supported by evidence from multiple randomized, controlled trials (RCTs) or a single, large RCT, while 42% and 55% of U.S. and European recommendations, respectively, were based on expert opinion only. In sum, even when guideline authors weren't on the take, eminence-based medicine trumped evidence-based medicine.

Poorly conducted professional society guidelines don't benefit front-line clinicians, but Ioannidis noted that they do have other benefits:

Guidelines writing activities are particularly helpful in promoting the careers of specialists, in building recognizable and sustainable hierarchies of clan power, in boosting the impact factors of specialty journals and in elevating the visibility of the sponsoring organizations and their conferences that massively promote society products to attendees. However, do they improve medicine or do they homogenize biased, collective, and organized ignorance?

A way to move beyond the production of clinical practice guidelines that are essentially "industry-friendly opinion pieces" is to centralize development efforts within government health agencies, or publicly-supported independent panels such as the U.S. Preventive Services Task Force (USPSTF). A recent review of 421 clinical practice guidelines for noncommunicable diseases in primary care concluded that guidelines developed or financed by governments were substantially more likely to be rated high-quality according to the AGREE-II tool than those developed by others. Dr. Michael LeFevre, a family physician colleague and former USPSTF chairman, suggested in a 2017 editorial that public investment is "essential" to producing trustworthy guidelines:

A substantial and consistent funding stream should be available for the development of clinical practice guidelines and should be awarded competitively through a process similar to research grant funding. The logical place for this funding to occur is through the Agency for Healthcare Research and Quality (AHRQ). ... The topic, guideline development panel, and methodology would be part of a competitive grant proposal. ... Proposals receiving funding would be assigned an evidence-based practice center (EPC) to work with the guideline development panel to provide an independent systematic review of the literature. The [EPC] program would need additional funding, but the focus of the efforts would shift to be channeled to producing reviews that would be assured of being used in the development of a clinical practice guideline we can trust.

Unfortunately, funding for AHRQ has always been politically precarious, and the closure of the National Guideline Clearinghouse last year does not bode well for starting a major new program to support guideline development and assessment, even as AHRQ-supported researchers continue to break new ground with the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) instrument.

And what about the problem of intellectual bias - being unable to see beyond the scope of one's own limited clinical experience to evaluate evidence impartially? Dr. Ioannidis first proposed having methodologists and patients write guidelines, with content experts serving as non-voting reviewers. Alternatively,

another possibility is to recruit also to the writing team medical specialists who are unrelated to the subject matter. Involvement of such outsiders (eg, family physicians involved in cardiology guidelines) could be refreshing. These people may still have strong clinical expertise, but no reason to be biased in favor of the specialized practices under discussion. They may scrutinize comparatively what is proposed, with what supporting evidence, and at what cost. Devoid of personal stake, they can compare notes to determine if this makes sense versus what are typical trade-offs for evidence and decisions in their own, remote specialty.

As a family physician who has served on guideline panels for cardiology (Pharmacologic management of newly detected atrial fibrillation) and otolaryngology (Cerumen impaction) topics, I find a great deal of merit in the latter approach, and a similar effort led by Dr. Ray Moynihan and primary care colleagues to reform disease definitions so that potential harms of expanding diagnostic criteria are considered along with the benefits for chronic conditions such as hypertension. It's no accident that the USPSTF has long been considered an exemplar of guideline development: the panel's members are all primary care clinicians or methodologists, and have one of the strictest conflict-of-interest policies in the field. Their recommendations don't make everyone happy or anyone wealthy, and that's most likely a good thing for patients.

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This post first appeared on The Daily Physician.

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High blood pressure: is lifestyle change counseling underutilized?

Since July 2018, the U.S. Food and Drug Administration (FDA) has issued more than 20 recalls of the angiotensin-receptor blockers (ARBs) valsartan, irbesartan, and losartan because they contained potentially carcinogenic contaminants. As a result, there are now widespread shortages of these blood pressure lowering drugs that have affected many of my patients. Although the FDA's internal analyses and published studies suggest that the excess cancer risk is small even with long-term use, and the FDA has posted a list of currently available ARBs that have been tested and found safe, identifying substitutes has been difficult. Many patients prescribed ARBs already take other first-line anti-hypertensive drugs at maximum doses and/or are unable to tolerate angiotensin-converting enzyme (ACE) inhibitors due to cough.

One underutilized alternative is motivating patients with high blood pressure to make therapeutic lifestyle changes. In a Lown Right Care article in the March 15 issue of AFP, Drs. Ann Lindsay, Ajay Sharma, and Alan Glaseroff observed that "physicians ... often go straight to telling patients what to do without listening to what the patient thinks or is willing to do." Evidence suggests that patients are more likely adhere to treatment plans if physicians first get to know the patient's story and health goals, and that five key clinician behaviors are associated with better health outcomes: "(1) emphasizing patient ownership—work on patient goals; (2) partnering with patients on what they are willing and able to do; (3) identifying small steps to ensure success; (4) scheduling frequent follow-up visits to cheer successes or problem solve; and (5) showing care and concern for the patient."

A recent commentary in the Annals of Internal Medicine noted that the 2017 ACC/AHA hypertension guideline barely mentioned the value of lifestyle interventions for persons with hypertension or the barriers to providing them in primary care settings:

Practices that are not structured and staffed to systematically assess patient lifestyle factors, support behavior modification counseling, and provide follow-up will face obstacles to implementation. Clinicians in these practices also must be supported by relevant competencies; professional guidelines; routine feedback; and on-site training in practice change, such as academic detailing and practice facilitation. ... Ensuring that clinicians knowledgeable in behavior change theory and evidence-based lifestyle interventions are part of the primary care team is even more important.

Clinicians and patients may question if exercise programs have the same blood pressure-lowering benefits as medications. The answer appears to be yes. Although no randomized, controlled trials have directly compared exercise against medication, a systematic review and network meta-analysis of 391 trials found that in persons with hypertension, endurance or dynamic resistance exercise was equally effective for lowering systolic blood pressure as ACE inhibitors, ARBs, beta-blockers, and diuretics.

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This post first appeared on the AFP Community Blog.

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