Monday, April 16, 2018

American Family Physician Podcast passes 1,000,000 downloads: why podcasts matter

- Steven R. Brown, MD, FAAFP

We released the first episode of the American Family Physician (AFP) Podcast in December 2015. AFP Podcast is a collaboration between American Family Physician, the most-read journal in primary care, and faculty and residents of the University of Arizona College of Medicine – Phoenix Family Medicine Residency.

Today the podcast passed a significant milestone: 1,000,000 episode downloads! We began counting downloads in May 2016, so this milestone was achieved in less than two years. The AFP Podcast audience continues to grow, and our listeners are now downloading episodes an average of over 45,000 times per month. A podcast with over 20,000 downloads per month, averaged over a year, is considered “high impact” for scholarly work. AFP Podcast is regularly a Top 10 medical podcast on iTunes, and has over 170 five star ratings on the platform. Listeners to the podcast are engaged. The credits at the end of each episode have been read by medical students, residents, and practicing physicians in 39 states and 4 countries. The @AFPPodcast Twitter account has over 1300 followers and an average of over 30,000 impressions per month.

Additionally, AFP Podcast has received a 2017 Gold EXCEL Award from Association Media & Publishing: Educational Podcast category.

Why podcasts matter

The role of podcasts in medical education is growing. With the emergence of new technology, changes in learning preferences, and resident work-hour restrictions, asynchronous methods of education are increasingly relevant. 89% of emergency medicine residents listen to podcasts regularly and 72% report podcasts change their clinical practice. 86% of these emergency residents report podcasts as their favorite form of medical education because of portability, ease of use, and ability to listen while doing sometime else.

We have received multiple comments from practicing family physicians that the AFP Podcast is useful as an American Board of Family Medicine preparation resource. Clerkship directors tell us they recommend AFP Podcast to students in required family medicine clerkships.

Podcasts are also a useful platform for exploring not just practice-changing clinical evidence, but the humanistic aspects of medical practice. The 2016 post “25 podcasts that every family physician should listen to” remains one of the most read articles on the AFP Community Blog. Recommendations from that post include podcasts related to public health, improving learning, patient stories, and medical economics.

The podcast Greyscale, produced by family physician Ben Davis, explores the physician – patient relationship and its impact on practice. Sawbones, hosted by family physician Sydnee McElroy and her husband Justin McElroy, discusses medical history and is regularly ranked as a Top 100 podcast in the iTunes “Comedy” category.

Podcasting quality

While many residents, medical students, and physicians are listening to medical podcasts, there is scant literature related to podcast quality. How do we know which podcasts should be recommended? How can the AFP Podcast be sure we are producing a quality product, worthy of family physicians and learners everywhere?

Two recent studies (published here and here) have examined medical education podcast quality. Both acknowledge that study of this topic is in its infancy. Key criteria for excellence include credibility (transparency, trustworthiness, avoidance of bias), content (professionalism, academic rigor), and design (aesthetics, interaction, functionality, ease of use).

Our editorial team will continue to strive to meet these metrics. Engagement from listeners is essential to these efforts. As we say on the credits at end of each episode: “Please send us your thoughts by emailing AFPPodcast@aafp.org or tweeting @AFPpodcast.” Engagement from listeners will help us improve AFP Podcast for the next million downloads and beyond.

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Dr. Brown is an AFP Contributing Editor and Editor, AFP Podcast.

Monday, April 9, 2018

Increasing pneumococcal vaccination rates

- Jennifer Middleton, MD, MPH

A Medicine by the Numbers feature on Pneumococcal Vaccines in Chronic Obstructive Pulmonary Disease (COPD), in the current issue of AFP, gives pneumococcal vaccination in persons with COPD a "green" rating, indicating that the benefits outweigh potential harms. Despite these benefits, too few adults with COPD are receiving pneumococcal vaccination.

To clarify, adults with COPD aged less than 65 years should receive Pneumovax 23 (PPSV23); Prevnar 13 (PCV13) is only indicated for adults aged 18-64 with immunodeficiencies, certain hemoglobinopathies, and other specialized conditions (for a full list, check out this CDC Summary). All adults, regardless of co-morbid health conditions, should receive Prevnar 13 at age 65 followed by Pneumovax 23 at least one year later.

The article describes the evidence base demonstrating that, in persons with COPD, the number needed to treat (NNT) for pneumococcal vaccination is 21 to avoid an episode of community-acquired pneumonia and 8 to avoid an acute COPD exacerbation. (The authors reviewed studies that included adults both under and over age 65 to reach these conclusions.) While pneumococcal vaccination might not prevent mortality from COPD, patients are likely to be pleased with the benefit of avoiding pneumonia and/or exacerbations, especially given the lack of reported harms with this vaccine.

The CDC found that, in 2015, only 23% of adults eligible for pneumococcal vaccination had received one (the number eligible includes diagnoses other than COPD). Nonwhite adults and adults without health insurance reported lower vaccination rates. A study of vaccination attitudes and knowledge in Germany found that patient knowledge that pneumococcal vaccination was recommended correlated with increased rates of vaccination among eligible adults; interestingly, for influenza and tetanus vaccines, knowledge alone in this same study did not predict vaccination (though attitudes about each vaccine did).

Increasing awareness of the indications for pneumococcal vaccination is one step to increase vaccination rates; physician reminders, patient letters, and nurse-driven vaccination when used together were also effective at increasing rates in ambulatory specialty practices. In primary care practices, the 4 Pillars Toolkit has been effective; the 4 Pillars Toolkit includes online resources for increasing convenience, patient communication, systems of care, and practice motivation.

Pharmacist-driven interventions to increase influenza and pneumococcal vaccinations in patients with COPD have had mixed success. One study found pharmacist-initiated interventions did not increase pneumococcal vaccination rates for those with COPD or asthma in community settings. Inpatient pharmacist-led patient education, however, may increase pneumococcal vaccination. Employee health screenings that include a pharmacist review of vaccinations may also increase vaccination rates.

Ideal strategies are likely to differ by practice and locale; resources to guide your practice include the AFP By Topic on Immunizations (excluding Influenza) that includes this editorial on Navigating the Changes in Pneumococcal Vaccinations for Adults as well as this overview of the 2018 Advisory Committee on Immunization Practices (ACIP) Adult Immunization Recommendations. From Family Practice Management comes this article providing an overview of practice strategies to both increase vaccination rates and minimize lost costs from storing vaccines.

What strategies have worked to increase pneumococcal vaccination rates in your practice?

Tuesday, April 3, 2018

What's new in asthma treatment?

- Kenny Lin, MD, MPH

As part of the process of updating the 2007 National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines, the Agency for Healthcare Research and Quality (AHRQ) recently released two comparative effectiveness reviews. The first AHRQ review concluded that subcutaneous and sublingual immunotherapy for patients with environmental allergies both reduce the use of long-term controller medications for asthma, and that sublingual immunotherapy also improves asthma symptoms and quality of life. A previous article in American Family Physician discussed allergen immunotherapy for family physicians who wish to offer this treatment in their offices or to determine whether a patient would be a candidate for therapy for an allergist.

The second AHRQ review evaluated the effectiveness of inhaled corticosteroids, long-acting beta agonists (LABA), and long-acting muscarinic antagonists (LAMA) for asthma in different patient populations. In children younger than age five with recurrent wheezing, the authors found that intermittent inhaled corticosteroid use during upper respiratory tract infections decreases asthma exacerbations. Another section of the review, which was published as a research article in JAMA, found that in patients with uncontrolled, persistent asthma, adding LAMA to inhaled corticosteroids reduced exacerbations compared to adding placebo, but had similar benefits compared to adding LABA. Finally, a third section concluded that in patients age 12 years and older, the use of combined inhaled corticosteroids and LABA as controller and quick relief therapy was associated with a lower risk of asthma exacerbations than more traditional strategies involving a controller therapy plus a short-acting beta agonist as relief therapy.

It remains to be seen how this new evidence will be incorporated into the next version of the NAEPP guidelines, which have historically advocated a stepwise approach to management of persistent asthma until good control is achieved. A shortcoming of the AHRQ reviews is that they did not specifically examine harms of LABA, the subject of a Medicine By the Numbers in the March 1 issue of AFP. A Cochrane review examined 48 trials that compared step therapy with an inhaled LABA/steroid combination to a higher inhaled steroid dose in more than 33,000 patients with asthma. Although 1 in 73 patients in the LABA/steroid group avoided a mild asthma exacerbation, there was no benefit on hospitalizations, deaths, or severe exacerbations. Moreover, the authors concluded that 1 in 1,430 additional persons in the LABA/steroid group would experience an asthma-related death, leading them to conclude that combination LABA/steroid inhalers have no benefits. Given the close balance of benefits and harms and uncertainty surrounding these estimates, family physicians should practice shared decision-making with patients about the pros and cons of controller medication options.

Dr. Jennifer Middleton summarized some useful tools and apps for asthma management in a previous Community Blog post, and you can find more information on the diagnosis, prevention, and treatment of asthma in our AFP By Topic collection.

Monday, March 26, 2018

Which interventions benefit patients with dementia?

- Jennifer Middleton, MD, MPH

The prevalence of dementia continues to rise, and, according to "Evaluation of Suspected Dementia" in the latest issue of AFP, it's estimated that 14 million adults will be affected by 2050. This increasing prevalence brings increasing concern for many aging adults about developing dementia along with concern by families about how to support their loved ones. Several recent studies provide guidance; although information about diagnosing and caring for dementia patients is relatively robust, the evidence base is weaker regarding interventions that can slow cognitive decline.

Many patients and families worry about impending dementia when early signs of memory loss appear, but mild cognitive impairment (MCI) does not always lead to a dementia diagnosis. In a 2014 study, researchers followed 357 patients with MCI diagnoses over a 3 year period and found that only 22.4% of them progressed to a dementia diagnosis during this time. The majority of patients had stable symptoms that did not worsen.

For those patients who do receive dementia diagnoses, they and their caregivers may ask about interventions to decrease symptom progression. A recent series of systematic reviews explored several options. Despite earlier studies suggesting at least a small benefit from dementia medications, a 2018 systematic review examining the use of different medications (including dementia medications, antihypertensives, non-steroidal anti-inflammatory medications, aspirin, and statins) found that none delayed cognitive decline. Another systematic review examining the role of over-the-counter supplements found similarly; omega-3 fatty acids, various vitamins, soy, and gingko biloba all failed to demonstrate an effect. Turning to non-pharmacologic interventions, cognitive training increases cognitive abilities in normal adults, but studies have not, to date, supported a role in preventing or slowing dementia progression. Of all potential interventions, only physical activity has been found to slow cognitive decline, but the evidence behind this assertion is of low quality.

Although limited options are currently available to slow dementia's progress, several interventions do exist to help patients and families cope. Case managers can assist family physicians with meeting the most common needs of patients with dementia and their caregivers, early diagnosis and disease education, by providing education, connecting families to local resources, developing care plans, and coordinating social services. Caregivers who interacted with case managers reported increased confidence in caring for their family members. AAFP also has an online Cognitive Care Kit that includes cognitive evaluation tools, management resources, caregiver resources, and tools for discussing end of life planning. Shared group visits can offer patients and caregivers support and can increase practices' efficiency in caring for these often complex patients.

There's an AFP By Topic on Dementia if you'd like to read more; it includes these pro and con editorials regarding routine screening for cognitive impairment (about which the United States Preventive Services Task Force has issued an "I" statement). The AFP article on "Evaluation of Suspected Dementia" includes links to several assessment tools; I've added the Mini-Cog test and the Saint Louis University Mental Status Examination (SLUMS) to my AFP Favorites page for easy access at the point-of-care.

What resources and tools have you found useful in caring for patients with dementia?

Wednesday, March 21, 2018

For hypertension and diabetes, lower treatment targets not necessarily better

- Kenny Lin, MD, MPH

In a previous AFP Community Blog post, Dr. Jennifer Middleton analyzed the 2017 American College of Cardiology / American Heart Association clinical practice guideline on high blood pressure in adults, which proposed lowering the threshold for hypertension from 140/90 to 130/80 mm Hg. Later, the American Academy of Family Physicians and the American College of Physicians independently declined to endorse this guideline, citing concerns about its methodology (e.g., no quality assessment for included studies), management of intellectual conflicts of interest, and lack of information on harms of intensive drug therapy.

The March 15th issue of American Family Physician included a Practice Guideline summary and an editorial perspective on the ACC/AHA guideline by Dr. Michael LeFevre, a member of the panel that developed the JNC 8 guideline for hypertension in adults. In his editorial, Dr. LeFevre pointed out that the guideline's strengths include its emphasis on proper blood pressure measurement technique to avoid overtreating adults with normal out-of-office blood pressures. On the other hand, he argued that "it is an overreach" to classify everyone with a blood pressure above 130/80 as having uncontrolled hypertension. He predicted that since intensive behavioral counseling has only modest benefits in lowering blood pressure, many patients at low risk of cardiovascular disease will end up being treated with medication:

Much harm will come if this change [to the definition of hypertension] is widely accepted and implemented, particularly if quality measures that echo this definition are put into place. Harms from the consequences of poor measurement, overmedication, and arbitrary quality measures can easily offset the small reduction in CVD events found in trials of high-risk persons.

Blood pressure is not the only area of family medicine where there is ongoing debate about appropriate treatment thresholds. In a recent clinical guidance statement, the American College of Physicians recommended that clinicians "aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes," and "consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%." This statement elicited a critical response from the American Diabetes Association and endocrinology groups, who argued that lower blood glucose targets are sometimes appropriate to reduce the risk of microvascular and perhaps cardiovacular complications.

This debate between lower and higher A1c targets has been ongoing for years, as illustrated by a pair of Pro and Con editorials on this topic that appeared in AFP in 2012. On the whole, however, more relaxed glucose control can have substantial benefits, especially for older persons with type 2 diabetes, as Dr. Allen Shaughnessy and colleagues argued in 2015:

A large part of the acceptance that “lower is better” hinges on a false belief that a pathophysiologic approach to decision making is always correct. It seems logical that reducing blood glucose levels to nondiabetic normal, no matter the risk or cost, should result in improved patient outcomes. But it doesn't. Today, an older patient with type 2 diabetes is more likely to be hospitalized for severe hypoglycemia than for hyperglycemia.

Underlining this point, a vignette-based study in the March/April issue of Journal of the American Board of Family Medicine found that primary care clinicians (particularly internists and nurse practitioners) would often chose to intensify glycemic control in an older adult with a HbA1c level of 7.5% and multiple life-limiting comorbidities. As family physicians look for opportunities to improve care for patients with hypertension and diabetes, we should not miss opportunities to avoid harm. 

Monday, March 12, 2018

Breastfeeding + pacifiers = no problem

- Jennifer Middleton, MD, MPH

In the designated "Baby-Friendly" hospital where I round, the use of pacifiers is discouraged in breastfeeding infants in the newborn nursery. Advising breastfeeding mothers about the risks of pacifier use contributing to early weaning is common practice, despite conflicting studies regarding the validity of this risk. A Cochrane meta-analysis, reviewed in the March 1 issue of AFP, may put the controversy to rest, as the reviewers found that pacifier use did not interfere with the establishment or duration of breastfeeding.

The Cochrane reviewers identified two randomized controlled trials (RCTs) for their meta-analysis, both of which divided breastfeeding mothers of newborn infants into two groups: one where pacifiers were prohibited, and one where pacifiers were permitted. Researchers in both RCTs found no difference in breastfeeding rates at 3-4 months of life between these two groups. Arguments against pacifier use have cited previous observational studies finding that pacifier use correlates with diminished establishment of maternal milk supply; the permissive pacifier groups in both of these RCTs, however, included pacifier use even in the immediate newborn period.

As these RCTs only included outcomes on breastfeeding rates in the first months of life, the AFP reviewers rightly encourage future research focusing on pacifiers' possible effect on additional outcomes including maternal confidence and total duration of breastfeeding. These more robust outcomes may dispel any lingering concerns about pacifier use. Adding pacifiers back to the tools available for comforting newborns certainly may benefit both babies and parents; since nonnutritive sucking is a natural self-soothing reflex in newborns, I suspect many parents would concur with my own experience regarding a pacifier's utility in calming a fussy baby.

If you'd like to read more, there are recent AFP articles on "Strategies for Breastfeeding Success" and "Risks and Benefits of Pacifiers," an editorial on "The Maternal Health Benefits of Breastfeeding," and a patient information page on "Helpful Tips for Breastfeeding." (Although these earlier articles do not reflect the findings of this new meta-analysis regarding pacifier use, they still contain a wealth of useful information for supporting breastfeeding in your practice.) The AAFP has a position paper on breastfeeding which encourages breastfeeding education in medical schools and residencies, breastfeeding-friendly office practices, and community advocacy to support breastfeeding mothers. This Society of Teachers of Family Medicine blog post from 2013 puts a compelling personal spin on the challenges of returning to work while breastfeeding, including suggestions on supporting breastfeeding within our own profession of working mothers.