Monday, February 12, 2018

Treating and preventing disease with dietary fiber

- Jennifer Middleton, MD, MPH

The current issue of AFP includes a review article on Hemorrhoids: Diagnosis and Treatment Options that discusses the roles fiber intake has both in contributing to hemorrhoids (when too low) and treating them (when appropriately increased). The authors recommend that patients with hemorrhoids increase their fiber intake to 25-35 grams per day and provide a link to a handout listing high fiber foods. As a high fiber diet can also help prevent and treat hyperlipidemia, constipation, and diverticulosis, family physicians should be proficient in discussing this important digestive component with patients.

Adequate daily fiber intake may protect against the development of hyperlipidemia. Children with chronic constipation consume less fiber than their peers with normal bowel patterns. Inadequate fiber intake is associated with the development of diverticulosis, which can put patients at risk for diverticulitis.

Increasing dietary fiber can modestly reduce LDL levels, improve constipation, and, along with exercise and weight loss if indicated, reduce the risk of recurrent diverticulitis. (Of note, a Cochrane meta-analysis found no role for using fiber supplementation to improve symptoms of irritable bowel syndrome.) Increasing fiber by increasing consumption of high-fiber whole foods, and not with fiber product supplementation, provides the most benefit.

Most Americans consume less than half of those recommended 25-35 grams of fiber daily, though many are trying to increase their consumption by choosing more fruits, vegetables, and whole grain products. Unfortunately, many products marketed as "whole grain" in the United States contain very little fiber. We should counsel patients to look beyond claims about whole grain content and examine food labels to choose products with a minimum of 3 grams of fiber per serving. Advising patients, also, to gradually increase their fiber intake may help them minimize the unpleasantness of bloating and excess flatulence that can accompany a rapid change in fiber consumption. Patients may find nutrition tracking apps such as My Diet Coach, reviewed in the current issue of Family Practice Management, to be useful in monitoring their daily fiber intake. Other apps such as (Fooducate and Shopwellcan help patients make more informed choices at the grocery store.

Providing specific advice in the context of motivational interviewing increases our patients' likelihood of success at making any behavioral modification stick; there's an AFP By Topic on Health Maintenance and Counseling as well as an AFP By Topic on Nutrition if you'd like to read more. What resources have you found useful to help patients increase their daily fiber intake?

Friday, February 2, 2018

The changing of the guard: from Dr. Siwek to Dr. Sexton

- Kenny Lin, MD, MPH

The February 1 issue of AFP marked the first time since 1988 that a family physician other than Dr. Jay Siwek was serving as the journal's editor-in-chief. Dr. Siwek, who bade farewell to readers in a poignant, memory-filled editorial in the January 15 issue, will stay on as editor emeritus. This month, Dr. Siwek introduced his successor, longtime associate editor Dr. Sumi Makkar Sexton. You can read about Dr. Sexton's extensive qualifications and experience in Dr. Siwek's latest piece, and learn about her plans for the future of AFP, which include making journal content more usable at the point of care, in her introductory editorial.

It has been my good fortune to know Jay and Sumi for the past 14 years, since I arrived at Georgetown University School of Medicine as AFP's medical editing fellow in the summer of 2004. Both played critical roles in my development as a family physician and medical editor, during and after my one-year fellowship. It was Jay, in his previous capacity as Chair of Georgetown's Department of Family Medicine, who hired me as a junior faculty member and supported each of my subsequent promotions to assistant, associate, and full professor. After I left the department for several years to work as a medical officer at the Agency for Healthcare Research and Quality and earn a master's degree in public health, it was Jay who convinced me to return and deploy my new skills to direct the department's health policy fellowship and eventually take on other leadership and teaching positions in population health.

On the other hand, it was Sumi, as the editor of Tips from Other Journals (an AFP department that ended in 2013) who continued to hone my writing and evidence-based medicine skills for years after my fellowship ended. Under her supervision, from 2005 to 2010 I wrote more than 60 summaries of primary care-relevant research studies for AFP. And after my first post-fellowship clinical position unexpectedly fell through, it was Sumi who hired me to see patients at her thriving practice, Premier Primary Care Physicians, which was an early adopter of innovations such as electronic medical records and advanced-access scheduling.

As AFP's new deputy editor, I have worked closely with Sumi and Jay for the past several months to support their changing of the guard at editor-in-chief, and I look forward to many more years of collaborating with them both. Moving on from Dr. Siwek to Dr. Sexton is an important transition, but the best-read journal in primary care won't miss a beat.

Monday, January 29, 2018

What's new in opioid prescribing, treatment, and education?

- Jennifer Middleton, MD, MPH

Coverage regarding the opioid epidemic shows no sign of slowing, and a flurry of articles this month -- 5 articles across 4 different Family Medicine journals -- bring several important insights and tools for family physicians to consider incorporating into their practices.

The first is an editorial published online in AFP this past week on "Treating Opioid Use Disorder as a Family Physician: Taking the Next Step." The editorial reviews 12 different models for providing buprenorphine-based medication assisted therapy (MAT) for opioid addiction in a primary care office, including outpatient models, inpatient models, and models that both do and don't incorporate behavioral counseling. Project ECHO is one model that may appeal to rural physicians, as it connects physicians interested in providing this treatment with experts via the internet. The editorial also includes a table with several valuable resources for physicians providing MAT, including the American Society of Addiction Medicine's website which has a wealth of resources for both physicians and patients.

A cross-sectional study regarding "Prescription Opioid Use and Satisfaction with Care Among Adults with Musculoskeletal Conditions" in the Annals of Family Medicine found greater satisfaction associated with prescription opioid use. The authors examined 6 years of data from the Medical Expenditure Panel Survey for adults with documented musculoskeletal diagnoses; patients receiving prescription opioid medications had higher patient satisfaction scores than those not receiving opioids (odds ratio = 1.32; 95% confidence interval, 1.18–1.49). The authors found that patients taking opioids reported more pain and greater disability, however, than those not taking opioids and cautioned that:
"The lack of an association between opioid prescribing and improvements in pain on a population health level has been highlighted by the Centers for Disease Control and Prevention, who report that since 1999, the quantity of prescription opioids sold in the United States has almost quadrupled, yet there has not been an overall change in the amount of pain that Americans actually report."
Two articles examining office-based strategies for managing patients on chronic opioids in the Journal of the American Board of Family Medicine each share interesting insights. "Structured Management of Chronic Nonmalignant Pain with Opioids in a Rural Primary Care Office" describes a rigorous office process required of all patients receiving chronic opioid prescriptions, including administration of several validated scales at each visit (Brief Pain Inventory Short Form, Zung depression scale, SOAPP-R diversion risk assessment tool, and the Roland disability rating scale for back pain), a standard patient handout describing opioid risks, and a standardized documentation template. This approach increased compliance with state and federal opioid prescribing regulations and also decreased the total number of opioid prescriptions written by their office. "Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety" found that adding a pharmacist previsit to appointments for chronic pain decreased overall opioid prescribing with no change in reported patient pain scores.

Finally, from the Society of Teachers of Family Medicine's Family Medicine journal comes "Teaching Chronic Pain in the Family Medicine Residency," a cross-sectional survey of Family Medicine residency program directors about their program's curricula regarding chronic pain. With a 53% response rate of program directors from across the United States, they found that an average of 33 hours (with a wide range of 2-180 hours across programs) of curricular time is devoted to teaching about chronic pain in Family Medicine residencies. The authors hypothesized that residency programs with directors who had negative attitudes about chronic pain and/or MAT would provide less education on these subjects, but this hypothesis was not borne out in their findings; the only predictor of higher curricular time, interestingly, was a strong belief in the benefit of nonopioid treatments for chronic pain. The wide range of curricular hours across the US suggests that residency programs have some work to do to validate and standardize effective teaching on this important subject.

Which of these ideas and/or tools will you consider incorporating into your own practice? Or, perhaps, you have a different model of success to share with AFP readers; we welcome your comments below.

Tuesday, January 23, 2018

Should your next prescription be a mobile app?

- Kenny Lin, MD, MPH

Earlier this month, a blog post from Dr. Jennifer Middleton highlighted recent content in AFP that can help family physicians support patients' resolutions to make healthy lifestyle changes. Increasingly, I also recommend that patients consider using smartphone apps to give them extra motivation and allow them to chart their progress toward personal goals. The latest in a series of articles on medical apps in FPM reviewed four mobile apps designed to encourage healthy habits, including healthy eating, physical fitness, substituting water for sugary drinks, and taking prescribed medications. Although the evidence that apps provide greater benefits than usual care remains limited (a randomized trial of a fitness app reviewed previously by FPM found no statistical differences in weight loss, blood pressure, or satisfaction), "digital therapy" is now being used to promote wellness and improve self-management of chronic conditions as diverse as substance use disorder and atrial fibrillation.

A draft technical brief issued by the Agency for Healthcare Research and Quality reviewed the evidence on health outcomes for 11 commercially available mobile apps for self-management of type 1 or type 2 diabetes. For five apps, studies demonstrated clinically significant improvements in hemoglobin A1c levels at 3 to 12 months. However, no studies showed improvements in quality of life, blood pressure, weight, or body mass index.

Regarding apps for clinicians, the U.S. Food and Drug Administration (FDA) clarified in a recent guidance document how it intends to treat digital decision support software going forward. Software that functions as a diagnostic device will be regulated, while digital tools that merely assist clinicians in making diagnoses will be excluded from regulation and "cleared" for use. On its website, the FDA provides a list of examples of mobile medical apps that it has cleared or approved to date.

Whether mobile apps will complement traditional prevention, diagnosis and treatment in primary care, or replace them, remains to be seen. Do you routinely prescribe apps to your patients, and do you expect to do so more often in the future?

Monday, January 15, 2018

Supporting family physicians who provide maternity care

- Jennifer Middleton, MD, MPH

An editorial on Immediate Postpartum LARC: An Underused Contraceptive Option in the current issue of AFP has generated a lot of interest. Several comments have been left online, and (as of this writing), all of them are quite positive. At a time when family physicians' interest in obstetrics (OB) continues to wane, these commenters exemplify the vibrant community of family physicians who do choose to provide OB care; as a specialty, we should support these physicians and the often underserved communities they care for.

Family physicians who attend deliveries are a critical component of improving the health of rural communities. Obstetrician/gynecologists (OB/GYNs) tend to cluster in metropolitan areas, with many rural counties in the United States reporting that family physicians are their only source for OB care. Supporting training opportunities in residency is critical to encouraging future family physicians to consider including OB in their practices; exposure to models of care like prenatal group visits and physician group coverage models may reduce concerns about the feasibility of doing so.

Even those of us who do not attend deliveries, however, have an obligation to advocate for those who do. Several of the comments left on the current AFP LARC editorial point to the need for state and national advocacy efforts to eliminate reimbursement barriers to providing this valuable service. This advocacy does not have to be time-consuming or burdensome; it's easy to send messages to your state AFP chapter and/or state legislators.

We also have an obligation to support preconception and prenatal care. All family physicians should discuss contraception and family planning with not only our expecting patients but all of our patients of child-bearing age. We should encourage folic acid supplementation for all women capable of pregnancy. We should discuss healthy birth spacing intervals at well child visits. There's an AFP By Topic on Family Planning and Contraception if you'd like to read more.

The comments regarding the LARC editorial enriched future readers' experience with their ideas and references. The ability to comment on articles online is one way you can directly engage with AFP; find us on Facebook and Twitter to join those conversations. Don't forget, too, about the opportunity to comment below here on the Community Blog every week.

Monday, January 8, 2018

The top ten AFP Community Blog posts of 2017

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

For the first time since we started putting together lists of the year's most-read posts, three guest posts made the 2017 list, including the top two. We welcome submissions of guest posts from readers on topics of interest to family physicians; please send inquiries and submissions to Kenneth.Lin@georgetown.edu.

1. Guest Post: I have a new patient (January 3) - 1952 page views

I realize, again, that sometimes we family physicians are called to comfort and not cure. I see how filling her remaining days by helping others continues to bring her a sense of purpose. I have learned a great deal from her in a short time and am grateful that I accepted a new patient.

2. Guest Post: On the front lines of the opioid epidemic (February 21) - 1843 page views

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus.

3. What's in a name? Obesity, ABCD, and prediabetes (January 10) - 1558 page views

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.


4. The 2017 ACC/AHA Clinical Practice Guideline for High Blood Pressure (November 27) - 1281 page views

It's difficult to argue with this CPG's emphasis on nonpharmacologic treatment, ambulatory BP monitoring, team-based care, integration of QI efforts, and population health advocacy. Its new BP diagnosis definitions and treatment goals, however, may be more open to discussion, especially as no primary care societies were involved in their development.

5. Strategies to limit antibiotic resistance and overuse (June 26) - 1170 page views

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more.

6. Safety net doesn't shield patients from low-value care (April 17) - 1147 page views

The study authors found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.


7. After emergency contraception: what next? (January 21) - 1011 page views

Discussions about EC should include options for initiating a regular form of contraception along with information about ulipristal's effectiveness and possible interactions. Providing this information to women will allow them to choose both an EC method and a regular contraceptive method that best fit their priorities and wishes.

8. Simplifying treatment of acute asthma (March 27) - 978 page views

For the time being, we'll need to use patient-centered decision making to arrive at the best treatment plan for each patient with acute asthma, though it certainly seems reasonable to consider shorter durations of oral corticosteroids in uncomplicated pediatric and adult patients.


9. Guest post: innovating connections in family medicine (February 6) - 970 page views

While I delight in new technology that enhances our care for patients, some aspects of family medicine won’t change. Technology won’t change the reassuring words we can offer to a worried parent or acutely ill patient. It won’t alter the power of our receptive ears being present for a scared patient. And it definitely won’t replace the wisdom, laughs, perspectives, and connections we encounter with our patients each day.


10. Vaccines in the news: controversies & updated recommendations (February 15) - 970 page views

Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.