Monthly Archives: December 2013

Access to Primary Care Associated With Lower Likelihood of Colorectal Cancer

From the AAFP

October 22, 2013 02:03 pm Sheri Porter

Family physicians, along with their colleagues in other primary care specialties, play a key role in helping their Medicare patient populations survive — or avoid altogether — the potential devastation of a colorectal cancer (CRC) diagnosis.

That’s according to a population-based, case-control study titled “Primary Care Utilization and Colorectal Cancer Incidence and Mortality Among Medicare Beneficiaries(annals.org)” in the Oct. 1 issue of Annals of Internal Medicine.

CRC takes a heavy toll on the health of Americans. For example, study authors estimated 142,820 new cases of CRC were diagnosed in the United States in 2013, and more than 50,000 individuals died from the disease. The cost to Medicare runs into the billions. And yet, according to researchers, fewer than 60 percent of U.S. adults ages 50 and older have ever received CRC screening, and just 39 percent of cases are diagnosed while the disease is still localized.

Lead researcher Jeanne Ferrante, M.D., M.P.H., talked to AAFP News Now about the study and summed up the most important message to family physicians in one sentence: “Increasing visits to primary care physicians (PCPs) decreases CRC incidence and mortality.”

STORY HIGHLIGHTS
  • A recently published study found that Medicare patients who had multiple primary care visits were less likely to develop or die from colorectal cancer (CRC).
  • Researchers noted that primary care physicians often provide patients with CRC screening and polypectomy procedures and diagnose CRC when it is still at an early stage.
  • Primary care physicians also encourage healthy behaviors, ask patients to not use tobacco products, urge patients to engage in preventive services, and coordinate patient care to reduce medication and laboratory errors.

“In this (study) population, only 49 percent of patients had ever received screening in a 10-year period,” said Ferrante. Furthermore, she noted, researchers were surprised to learn that close to 30 percent of the population studied saw a primary care physician only once — if at all — in a two-year period.

For purposes of the study, primary care physicians were defined as those in general practice, family medicine, internal medicine, geriatric medicine and obstetrics-gynecology.

Ferrante urged family physicians to talk with their Medicare patients about establishing regular primary care visits and suggested two to five such visits should occur each year. “Since we found that primary care visits decrease CRC incidence through screening, it’s important for primary care physicians to recommend or perform CRC screening (such as fecal occult blood testing),” said Ferrante.

Specific Study Findings

Individuals included in the study were 67 to 85 years old, had fee-for-service Medicare, and received a CRC diagnosis between 1994 and 2005. (Editor’s Note: The AAFP recommends against routine colorectal cancer screening in individuals ages 76-85. See below under “More From AAFP.”)

Researchers measured the number of primary care visits by patients in the four- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality and all causes of mortality. They used Medicare claims histories up to 10 years before a patient’s CRC diagnosis and assessed receipt of CRC screening and polypectomy procedures.

Researchers found that the likelihood of CRC diagnosis decreased with increasing primary care visits. Specifically,

  • patients who had five to 10 primary care visits had 6 percent lower odds of a CRC diagnosis when compared with patients who had no or only one primary care visit;
  • in patients who were diagnosed with CRC, they were more likely to receive a diagnosis of early-stage cancer or proximal cancer with increased primary care visits, and
  • patients with five to 10 visits to a primary care physician had 22 percent lower odds of CRC mortality than patients with no or one primary care visit.

Furthermore, patients who saw a primary care physician at least two times in a year had close to 20 percent lower odds of all-cause mortality when compared with patients in the control group.

Researchers also found that patients who saw nonprimary care physicians also had lower rates of CRC incidence and mortality. “The effect of non-PCP visits may reflect the effect of PCP visits because these physicians facilitate referrals and access to specialists,” wrote the authors.

CRC screening at primary care visits, polypectomy and early-stage CRC diagnosis all contributed to the positive association of primary care physician visits with lower CRC mortality, noted the authors. But they suggested that additional factors may be at play.

For instance, primary care physicians often encourage healthy behaviors such as diet and exercise and encourage patients to not use tobacco products. Primary care physicians also encourage patients to take advantage of available preventive services and coordinate patient care to reduce medication and laboratory errors.

“Another possibility is the healthy-user effect, in which healthier patients are more likely to seek primary care and adhere to medications or use preventive services,” noted the authors.

Ensuring Access to Primary Care

Study authors lamented the fact that despite the availability of universal Medicare insurance, more than 20 percent of beneficiaries did not visit a primary care physician for two years and 10 percent of patients did not have contact with any physician.

They pointed out that these beneficiaries had more CRC incidence, CRC mortality and all-cause mortality.

“Medicare’s recent expanded coverage for preventive care and annual wellness visits may help emphasize the importance of PCP visits and preventive screenings,” wrote the authors. “However, the current difficulties in accessing primary care will be exacerbated by the looming primary care shortage along with the influx of newly insured adults using primary care because of recently enacted health reform law. Policies and programs are needed to increase access to and supply of PCPs.”

Ferrante suggested that waiving copays or deductibles could help promote the importance and value of patients seeing their primary care physicians on a regular basis.

“We also need to make sure there is adequate access to primary care physicians through policy changes to increase the supply,” said Ferrante. She added that a good place to start would be to increase training venues, stabilize pay inequities between primary care physicians and subspecialists, and build the prestige of primary care medicine as a specialty of great importance to all patients.

Choosing Wisely for Neurology Top 5: 5 things neurologists say you shouldn’t do:

Clinical QuestionWhat common neurologic practices have strong evidence of no clinical benefit or of harm?

Bottom Line

Although this Top Five list is intended for neurologists, many conditions are also managed by primary care physicians who are often guilty of referring patients for useless tests or interventions. We all need to stop useless and harmful practices.

  1. Don’t order electroencephalograms for patients with headaches;
  2. Don’t order carotid studies for patients with simple faints;
  3. Reserve opiates and barbiturates as a last resort for treating migraines;
  4. Don’t prescribe interferon-? or glatiramer for patients with stable multiple sclerosis; and
  5. Don’t recommend endarterectomy for asymptomatic carotid artery stenosis unless the rate of complications is less than 3%. (LOE = 5)

Reference

Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s Top Five Choosing Wisely recommendations. Neurology 2013;81(11):1004-1011.

Synopsis

The United States spends more on medical care than any other country on the planet, yet the health outcomes rank near the bottom of most measures. Among the explanations include an underemphasis on primary care and wasteful spending for services that are unlikely to benefit patients. In response to a challenge from Howard Brody, Director of the Institute for Medical Humanities, the medical societies and Consumer Reports have convened panels to identify common practices that meet the following criteria: the procedure offers no benefit to most patients or is harmful; in aggregate, the service is expensive; and eliminating the practice or shifting to a more appropriate alternative is within the control of physicians. The American Academy of Neurology (AAN) convened a group with expertise in evidence-based medicine and guideline development to serve on the Choosing Wisely Working Group. The members, unfortunately, had many ties to industry. The Working Group e-mailed all members of the AAN to obtain submissions for candidate wasteful practices. This yielded an amazing 178 possible candidates! The Working Group then used electronic means to implement a modified Delphi process to cull this list down to 11 “finalists.” These finalists addressed various forms of imaging or other testing for syncope, headaches, fainting, and various treatments for back pain, headaches, carotid stenosis, and stable multiple sclerosis. The Working Group then weighed the evidence behind these and generated the Top Five list. It remains to be seen how these recommendations are implemented and if actual cost savings are realized.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Planned Vaginal Delivery Of Cephalic 1st Twin Does Not Increase Neonatal Risks Compared to Planned C-section

Twin pregnancies are associated with greater perinatal risks than singleton pregnancies, and due in part to caution over these risks, rates of elective cesarean births for twins have increased worldwide in recent years. Some observational data have suggested that vaginal delivery may increase adverse outcomes compared to elective cesarean, but there has been no strong evidence to recommend a policy of planned cesarean delivery in pregnancies without specific indications. A recent large randomized trial compared the delivery strategies of planned vaginal delivery and planned cesarean section in 2,804 twin pregnancies in which the first twin was presenting cephalically.
Women with twin pregnancy (gestational age 32 weeks to 38 weeks and 6 days) were randomized to planned vaginal delivery (with cesarean section only if indicated) vs. planned cesarean section. Inclusion criteria included first twin in cephalic presentation and expected birth weight of both twins 1,500-4,000 g (3.3-8.8 lbs) confirmed by ultrasound < 7 days before randomization. In cases of non-cephalic presentation of the second twin in the planned vaginal delivery group, the delivery method was at the discretion of the obstetrician, and could include total breach extraction, external cephalic version with cephalic vaginal delivery, or cesarean section. Exclusion criteria included monoamniotic twins, fetal reduction at  13 weeks gestational age, and contraindication to labor or vaginal delivery. Mothers and neonates were followed to 28 days after delivery. The primary outcome was a composite of fetal or neonatal death and serious neonatal morbidity.
Cesarean deliveries were performed in 90.7% of the planned cesarean group. In the planned vaginal delivery group, 39% had cesarean delivery for both twins and 4.2% had cesarean for the second twin only. The rates of the composite primary outcome were 1.9% with planned vaginal delivery vs. 2.2% with planned cesarean (not significant). Fetal or neonatal death occurred in 0.6% with planned vaginal delivery and 0.9% with cesarean, and serious neonatal morbidity occurred in 1.3% of each group. There were no significant differences in rates of maternal death or serious morbidity between groups. This trial suggests one way in which the current high rates of cesarean section may safely be reduced.
For more information, see the Multiple gestation topic in DynaMed.

IUD’s and implantable birth control have superior continuation rates

POSTED BY  ⋅ NOVEMBER 8, 2013

The Contraceptive CHOICE study, which provides women with free and accessible contraception of choice, has now provided us with great longer term data on contraception continuation. A new study using this data (O’Neil-Callahan Obstet Gynecol November 2013) tells us what women are likely to be using for birth control two years later. This information is key because switching methods is a time where user error is more likely or gaps in coverage resulting in unplanned pregnancy. It is best to try and hit a satisfaction bullseye with the first choice.

The clear winner is the intrauterine device (both the Mirena and Copper) with the etonorgestrel implant (Implanon) a close second (these 2 methods are considered long acting reversible contraception or LARC). Pills, the ring, depo-provera, and the patch are all considered short acting reversible methods.

At 12 months 87% of LARC users were still using there initial method of contraception compared with 57% of non-LARC users. At 2 years 77% of women who chose a LARC were still using that method compared with a relatively dismal 41% for non-LARC. There was essential no difference between types of IUD, with 79% still using the Mirena and 77% the Copper although slightly fewer women (69%) were still using the Implanon. There was minimal difference between the short-acting hormonal methods (see the table below detailing the breakdown by method).

Adults were more likely to stick with their method if contraception compared with adolescents (no surprise), but at 2 years 66% of adolescents were still using their long acting method versus 37% who were still using their short-acting contraception.

While the study doesn’t tell us why some women chose a particular method, they do tell us that when women are free to choose they are most likely to stay with an IUD or Implanon than any other method. This study also doesn’t tell us what happened to women who switched, did they intentionally get pregnant, have an unplanned pregnancy, or successfully switch methods?

What is the take home message? If you choose an IUD you are most likely to still be using this method at 2 years than if you choose any other method. Don’t like the idea of an IUD, then you are still more likely to be happy with an Implanon than a short-acting option.

Preventing dissatisfaction with contraception is key. Given failure rates with IUDs are clearly the lowest, they represent the best option for reproductive control and clearly when providers talk about reversible contraception they should be presenting IUDs and the implant as first-line options.

And for the lawmakers? Want to prevent abortion, the answer isn’t laws it’s free, accessible long-acting contraception.

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New High Blood Pressure Guidelines: JNC 8 Report Released

AAFP NewsNow: Summary of new JNC 8 hypertension guidelines

Per family physician Paul James, the work group focused on 3 questions:

  1. At what BP do you start medication?
  2. At what BP do you maintain medication?
  3. What are the medications (or antihypertensive drugs) that doctors should use to get to goal?

“We considered these the 3 most important questions that any doctor in American needs to know the answer to.”

Overview of Guideline’s Recommendations

The evidence review focused on studies that examined adults 18 or older with hypertension, including studies that involved numerous specified subgroups, such as patients with diabetes, coronary artery disease, previous stroke and chronic kidney disease (CKD). Studies that focused on older adults also were included, as were those that examined both men and women, various racial and ethnic groups, and smokers. The guideline panel chose to review only randomized controlled trials (RCTs) involving at least 100 subjects.

A 2/3 majority was considered acceptable, with the exception of recommendations for which no RCT evidence was eligible for review. For these areas, recommendations were based on expert opinion and required approval by 75 percent of panel participants.

Key Points:

Treatment goals:

  • In the general population ages 60 and older, pharmacologic treatment to lower BP should be initiated at a systolic blood pressure (SBP) of 150 mmHg or higher or a diastolic blood pressure (DBP) of 90 mmHg or higher.
    • Patients should be treated to a goal SBP lower than 150 mmHg and a goal DBP lower than 90 mmHg. If treatment results in lower achieved SBP and is not associated with adverse effects, treatment does not need to be adjusted.
    • In the general population younger than age 60, start pharmacologic treatment at a DBP of 90 mmHg or higher or an SBP of 140 mmHg or higher and treat to goals below these respective thresholds.
    • In the population ages 18 years or older with diabetes or CKD, start pharmacologic treatment at an SBP of 140 mmHg or higher or a DBP of 90 mmHg or higher and treat to goals below these respective thresholds.

Drug choices

    • In the general non-black population, including those with diabetes, initial treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).
    • In the general black population, including those with diabetes, initial treatment should include a thiazide-type diuretic or a CCB.
    • In the population ages 18 or older with CKD and hypertension, initial (or add-on) treatment should include an ACE inhibitor or an ARB to improve kidney outcomes. This applies to all patients in this population regardless of race or diabetes status.
    • ACE inhibitors and ARBs should not be used together.

Finally, the main objective of hypertension treatment is to attain and maintain goal BP.

  1. If goal BP is not reached within a month, increase the dose of the initial drug or add a second drug from one of these four classes.
  2. Continue to assess BP and adjust the treatment regimen until goal BP is reached.
  3. If goal BP cannot be reached with two drugs, add and titrate a third drug
  4. If goal BP cannot be reached using the above-named drugs because of a contraindication or the need to use more than three such drugs to reach goal BP, antihypertensive drugs from other classes may be used.

Referral may be indicated for patients in whom goal BP cannot be reached using the above strategy or to manage complicated patients for whom additional clinical consultation is needed.

Takeaways for Family Physicians

Per Dr. James, the new guideline stands to simplify the management of high blood pressure in their patients.

  1. ” it’s going to simplify the goals (of treatment because) there are only two goals to remember.”
  2. “I do think a lot of physicians who take care of the elderly have been concerned over the years about the potential for causing harm by overtreating blood pressure.”

“It’s certainly not uncommon for elderly patients to become dizzy on standing because of the antihypertensive medication or medications they take.” Such patients, James noted, are at an increased risk for falls and their sequelae.  From that perspective alone, he noted, “I think many people who take care of the very elderly will think these guidelines make more sense.”

“One thing that family doctors may not realize is that beta blockers, which are a tried-and-true and beloved medication for treating high blood pressure, actually got pushed down to the second tier. That may come as a surprise to many of them.”

(http://www.aafp.org/news-now/health-of-the-public/20131218hypertensiongdln.html?cmpid=10036-em-1)

Can urinary tract infections be simply diagnosed in women using history alone?

POEMs Research Summaries

Bottom Line

History alone can correctly classify slightly more than half the women with suspected urinary tract infections (UTIs). (LOE = 2b)

Reference

Knottnerus BJ, Geerlings SE, Moll van Charante EP, Ter Riet G. Toward a simple diagnostic index for acute uncomplicated urinary tract infections. Ann Fam Med 2013;11(5):442-451.

Study Design: Cross-sectional          Funding: Unknown/not stated

Setting: Outpatient (primary care)   Allocation: Unknown

Synopsis

The 196 women in this study complained of dysuria for less than 1 week, were 12 years or older, and were recruited from primary care practices in the Netherlands. The researchers excluded: pregnant or lactating women; those with symptoms of pyelonephritis; recent antibiotic use; recent urologic procedures; known structural or functional anomalies; and an immunocompromised state. Each patient underwent a structured clinical assessment and submitted a urine sample for dipstick testing, a urinalysis, and culture. The gold standard for UTI diagnosis was more than 10^3 colony-forming units of a single uropathogen per milliliter. Additionally, the authors polled practicing clinicians and learned that clinicians believe that probabilities of less than 30% and more than 70% are clinically meaningful for guiding UTI treatment decisions. The authors then did a bunch of statistical stuff to identify a range of factors that might discriminate women with UTIs from those without UTIs. This generated several models using only the history or various combinations of the history and various urine tests. As in many other studies, the prevalence of UTI in these women was 61%. Using only the history correctly classified more than half of the women.

Three factors arose as important:

      1. a positive response to “Do you think you have a UTI?”;
      2. a positive response to having significantly severe dysuria; and
      3. a negative response to having vaginal irritation.

These items correctly classified 56% of women with a less than 30% or more than 70% likelihood of having a UTI. Adding a urine dipstick test increased the likelihood to 73%. However, performing a dipstick test only for women whose responses are mixed (placing their likelihood of UTI between 30% and 70%) increased the diagnostic accuracy to 83%. Finally, these authors found that neither examining the urine sediment nor the dipslide test were very useful.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Dual-antiplatelet regimens for prevention of recurrent stroke promote antithrombotic effects but may increase the risk for hemorrhage

PURPOSE: To qualitatively and quantitatively examine the risk for recurrent stroke and intracranial hemorrhage (ICH) linked to long-term dual and single antiplatelet therapy among patients with ischemic stroke and transient ischemic attack.

DATA SOURCES: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials through March 2013 without language restrictions.

STUDY SELECTION: The search identified 7 randomized, controlled trials that involved a total of 39 574 participants and reported recurrent stroke and ICH as outcome measures.

DATA EXTRACTION: All data from eligible studies were independently abstracted by 2 investigators according to a standard protocol.

DATA SYNTHESIS: Recurrent stroke risk did not differ between patients receiving dualantiplatelet therapy and those receiving aspirin monotherapy (relative risk [RR], 0.89 [95% CI, 0.78 to 1.01]) or clopidogrel monotherapy (RR, 1.01 [CI, 0.93 to 1.08]). Risk for ICH did not differ between patients receiving dual-antiplatelet therapy and those receiving aspirin monotherapy (RR, 0.99 [CI, 0.70 to 1.42]) but was greater among patients receiving dual-antiplatelet therapy than among those receiving clopidogrel monotherapy (RR, 1.46 [CI, 1.17 to 1.82]). LIMITATIONS: Agents used in dual- and single-antiplatelet therapies varied across trials, and the relatively modest number of trials limited subgroup analysis.

CONCLUSION: Compared with monotherapy, dual-antiplatelet therapy lasting more than 1 year after an index ischemic stroke or transient ischemic attack is not associated with a greater reduction in overall recurrent stroke risk. However, long-term dual-antiplatelet therapy is linked to higher risk for ICH than clopidogrel monotherapy in this patient population.

PRIMARY FUNDING SOURCE: Chang Gung Memorial Hospital.

Lee M, Saver JL, Hong KS, et al. “Risk-Benefit Profile of Long-Term Dual Versus Single-Antiplatelet Therapy Among Patients With Ischemic Stroke: A Systematic Review and Meta-analysis”. Ann Intern Med. 2013 Oct 1;159(7):463-470