For acute low back pain, naproxen alone works best

In urgent and primary care settings, when a patient requests medication for acute low back pain without radicular symptoms, I typically prescribe naproxen and cyclobenzaprine, adding oxycodone/acetaminophen if the pain seems especially severe. But two recent articles in American Family Physician will likely lead me to change my practice.

The first article is a Medicine by the Numbers that reviewed the number needed to treat (NNT) and number needed to harm (NNH) from a pooled analysis of trials evaluating cyclobenzaprine for low back pain. Compared to placebo, cyclobenzaprine was more likely to lead to global symptom improvement by day 10 of treatment, with an impressive NNT of 3. Unfortunately, it was also much more likely to cause dizziness, nausea, drowsiness, and dry mouth, with a NNH of 4 for any adverse effect. In other words, participants were almost as likely to feel worse on the drug as they were to feel better. Further, most trials did not use intention-to-treat analysis or had other important flaws in quality, making even this marginal benefit uncertain.

The second article is a POEM that summarized a randomized trial comparing functional outcomes in adults with acute, nontraumatic, nonradicular low back pain who received naproxen plus placebo, naproxen plus cyclobenzaprine, or naproxen plus oxycodone/acetaminophen for 10 days. Research associates blinded to treatment arm assignment assessed participants for pain and functional outcomes in telephone interviews conducted at 7 days and 3 months of follow-up. There were no statistical differences between groups in either outcome at either time point. However, the NNH for adverse effects was 7.8 for cyclobenzaprine and 5.3 for oxycodone/acetaminophen.

Based on this information, I plan to prescribe naproxen alone for most patients with acute low back pain and no contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs); reserve cyclobenzaprine for patients who can't use NSAIDs; and prescribe oxycodone/acetaminophen only in patients who can't tolerate NSAIDs or cyclobenzaprine.

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This post first appeared on the AFP Community Blog.

Direct primary care enters the mainstream

Burnout among medical professionals has risen sharply, particularly among primary care physicians. A 2014 survey found that more than half of U.S. physicians reported at least one symptom of burnout (depersonalization and/or emotional exhaustion), and nearly as many are dissatisfied with their work-life balance, both worse than a similar survey from 2011. In a recent perspective in the New England Journal of Medicine, primary care internist Suzanne Koven described "the doctor's new dilemma": how to build healing relationships with patients in the face of 15-minute visits and overwhelming electronic documentation burdens:

Do I ask [the patient] what’s really bothering her and risk a time-consuming interaction? Or do I accept what she’s saying at face value and risk missing a chance to truly help her? ... If we ask about the pastry, we fall hopelessly behind in administrative tasks and feel more burned out. If we don’t ask about the pastry, we avoid the kind of intimacy that not only helps the patient, but also nourishes us and keeps us from feeling burned out.

A New York Times editorial by Dr. Robert Wachter (author of The Digital Doctor) stated plainly what I and many other family doctors have felt for some time: quality measurement in medicine and the elaborate documentation required to support it has gone too far. "Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions," Wachter argued. Perhaps the core measures sets announced last week by an alliance of private and public insurers and physician and patient organizations will reduce the measurement burden, but count me as a skeptic.

Larry Bauer, CEO of the Family Medicine Education Consortium, sees direct primary care, or the replacement of insurance intermediaries with a direct financial relationship between patients and primary care physicians, as an exit from "all the administrivia and foolishness" that prevent physicians from serving the unique needs of their patients and communities. It's worth reading through testimonials from physicians in direct primary care practices. My favorite is Dr. Brian Forrest's: "In Direct Primary Care we have pushed all of the things that get between us and our patients out of the exam room. The only thing left in the exam room is the physician/patient relationship and that is at the heart of real quality care and healing relationships."

Compared to just a few years ago, when it was considered a fringe movement with little recognition or support from organized medicine, direct primary care is rapidly moving into the medical mainstream. Direct primary care practices have been featured in NPR/Kaiser Health News, Forbes, Health Affairs, and profiled in the American Academy of Family Physicians' Health Is Primary campaign. Last November, the Journal of the American Board of Family Practice published the first academic study of DPC practice distribution and costs across the nation, and these figures are already out of date.

Courtesy of www.jabfm.org

Although the American College of Physicians has expressed concerns that the spread of direct primary care could exacerbate primary care shortages (though smaller patient panels) and health disparities (by reducing access for low-income persons), direct primary care physician Alex Lickerman, MD believes that both of these obstacles can be overcome:

Unless a viable solution is found to reverse primary care physician dissatisfaction, a critical shortage is already inevitable. What’s required is a new model that attracts physicians into primary care so we can reduce the number of primary care physicians who want to leave the profession and induce more medical students to enter it. ... Savings to government programs like Medicaid and Medicare could be redirected as subsidies for the poor to enable them to enter into direct primary care, or concierge medicine, medical practices. Qliance, in fact, is already experimenting with this model and finding success, having added 14,000 new Medicaid patients in 2014.

Another potential hurdle, the Affordable Care Act's requirement that most persons who are not eligible for public coverage purchase full-service health insurance, has also been removed with the creation of ACA-compliant plans where part of the monthly premium goes directly to the direct primary care practice.

What about quality? How will we know beyond anecdotes that the DPC model is as good for patients as it is for doctors? The nonprofit Consortium for Southeastern Hypertension Control was recently awarded a $15.8 million practice transformation grant from the Centers for Medicare & Medicaid Services that will, in part, support transitioning 600 traditional primary care practices to the direct primary care model over the next 4 years and evaluating their performance on 14 different quality measures.

My current patients can rest easy; I won't be taking the plunge into direct primary care any time soon. However, I am married to another family physician who is - and whose 2013 guest post about how the DPC model could benefit poor patients remains one of the best-read on this blog, for good reason.

Will new adult depression guidelines have an impact?

Major depressive disorder is a common condition that responds to psychotherapy and medications, and several screening tools have been validated for use in primary care. However, screening tools will not work if doctors are unable or unwilling to use them; a 2011 analysis by the Robert Graham Center found that family physicians and general internists screened for depression in only 2 to 4 percent of visits. Also, it is not clear if adults with screen-detected depression benefit from treatment to the same extent as those with clinically evident symptoms. This distinction is important since antidepressants may increase suicide risk, and a recent BMJ analysis suggested that suicidal ideation is underreported in trials of antidepressants.

In this context, the U.S. Preventive Services Task Force recently reiterated a previous recommendation for primary care clinicians to routinely screen adults for depression, and for the first time found sufficient evidence to screen pregnant and postpartum women. In the Task Force's supporting evidence summary, Dr. Elizabeth O'Connor and colleagues reported:

Among pregnant and postpartum women 18 years and older, 6 trials (n = 11,869) showed 18% to 59% relative reductions with screening programs, or 2.1% to 9.1% absolute reductions, in the risk of depression at follow-up (3–5 months) after participation in programs involving depression screening, with or without additional treatment components, compared with usual care.

A new clinical practice guideline from the American College of Physicians (ACP) reviewed the comparative effectiveness of treatment for major depressive disorder and recommended that "clinicians select between either cognitive behavioral therapy or second-generation antidepressants ... after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient." The ACP arrived at this relatively non-specific guidance after finding few differences between multiple comparisons: psychotherapy vs. medications; medications vs. exercise; medications vs. St. John's Wort; and switching medications vs. adding cognitive therapy. Benefits and harms of treatments were similar between men and women and in subgroups defined by race and ethnicity.

In an accompanying editorial, Drs. John Williams, Jr. and Gary Maslow urged generalist physicians to "seize the day" to improve diagnosis and treatment of depression through integrated primary and mental health care models, which they defined as consisting of "support for self-management, follow-up that includes careful assessment of treatment adherence and response, coordination with mental health specialists to increase access to psychological treatments, and more intensive treatment of refractory depression." Whether the new guidelines will inspire more interdisciplinary collaboration and cause real-world impact on adults with depression remains to be seen.

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This post first appeared on the AFP Community Blog.

Can mindful communication protect physicians from burnout?

Are mindful clinicians happier clinicians, and do they communicate better with patients? A pair of studies published in 2013 in Annals of Family Medicine aimed to answer one or the other of these questions. Mindfulness, defined as "purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings," is being increasingly recognized as having a protective effect against clinical burnout. In the first study, an abbreviated mindfulness intervention in 30 primary care clinicians was associated with reduced burnout and improved measures of mental health 9 months later. In the second study, clinicians with higher self-rated mindfulness were found to engage in more patient-centered communication and have higher patient satisfaction scores.

These studies are particularly important to family physicians like me because other surveys have shown that physician burnout is becoming more common, and we (and general internists and emergency physicians) are at much greater risk of experiencing early career burnout than other medical specialists. This isn't only a professional issue, it's a public health issue; since the U.S. primary care shortage is expected to worsen over the next decade due to low student interest, health insurance expansion, and population growth, we need "all hands on deck" now more than ever.

A few years ago, to fulfill the requirements for my Master of Public Health degree, I reviewed the limited literature on interventions to reduce burnout and improve well-being in primary care physicians. The structured abstract is below. Clearly, changes in the way family physicians practice are needed as well. In future posts, I plan to discuss the rapid growth and future potential of direct primary care to improve outcomes for both doctors and patients.

Background: Burnout in primary care physicians may have negative effects on personal health and patient care.

Purpose: To review the prevalence of burnout in primary care in the U.S. and other Western countries; causes, determinants, and negative effects of burnout in primary care physicians; and interventions to reduce burnout.

Data Sources: Electronic searches of PubMed (2003-present) and hand searches of reference lists of key studies and reviews. The full text of 48 citations was reviewed for randomized controlled trials, cohort and cross-sectional studies, and descriptive studies relevant to one of the content areas. 17 studies were included: 4 on prevalence, 6 on causes, determinants, or negative effects, and 7 on interventions.

Data Synthesis: Burnout consists of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. The risk of burnout is higher in the presence of work overload and perceived lack of control over one’s workload. 46 percent of surveyed U.S. physicians reported at least one symptom of burnout; primary care physicians had among the highest rates. Family physicians from 12 European countries commonly reported emotional exhaustion (43%), depersonalization (35%), and reduced personal accomplishment (32%), with higher rates in younger and male physicians. Burnout was associated with a higher frequency of self-reported difficult patient encounters, but was not associated with medical errors, lower quality of care, or patient dissatisfaction.

Descriptive studies of physicians with reputations for “resilience” identified several themes that may prevent burnout. A multi-component intervention to improve physician control over work environment, staff efficiency, and patient care satisfaction was associated with a statistically significant reduction in emotional exhaustion. Limited evidence exists for the effectiveness of individual-level interventions to reduce burnout. A yearlong continuing medical education course in mindful communication was associated with decreases in all 3 burnout dimensions. Short-term cognitive behavioral interventions reduced emotional exhaustion and general psychological distress.

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This post first appeared on Common Sense Family Doctor on September 22, 2013.

Managing hypertension with home blood pressure measurements

Several of my hypertensive patients always have significantly higher blood pressures at the office than at home. Even after verifying the appropriate size cuff, and re-measuring blood pressure several minutes into the visit, the numbers don't change. Since treating these patients based solely on office blood pressures risks overtreatment (prescribing too high a dose or too many drugs), I encourage them to keep logs of their home blood pressures for us to review at each followup visit. However, as outlined in this home blood pressure measurement protocol, interpreting the results can be complex and challenging to carry out in a time-constrained primary care visit.

In a recent study published in the Annals of Family Medicine, a team of Australian researchers monitored 286 patients with uncomplicated hypertension to determine a more efficient method for interpreting home blood pressure measurements. They found that participants with 3 or more of their last 10 home systolic blood pressures greater than or equal to 135 mm Hg were the most likely to have elevated 24-hour ambulatory blood pressures and signs of end organ disease on echocardiography. This correlation held even if patients did not follow the recommended home monitoring protocol. The researchers concluded that using this "3 in 10" threshold may be a more practical way to assess blood pressure control with home measurements.

Although this study only included patients with established hypertension diagnoses, the U.S. Preventive Services Task Force has emphasized the importance of obtaining blood pressure measurements outside of the clinical setting in its 2015 recommendation statement on screening for high blood pressure in adults. According to this Figure, 6 studies found that home blood pressure monitoring confirmed elevated office blood pressure readings only 45 to 84 percent of the time.

In light of the SPRINT trial findings that setting lower blood pressure goals may improve outcomes in patients at high risk for cardiovascular events, it will be even more critical to verify office blood pressure measurements with measurements outside of the office to maximize treatment benefits and minimize adverse effects.

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This post first appeared on the AFP Community Blog.

College tuition and health care costs are unsustainable

Each of my four children has a 529 plan qualified education account into which my wife and I have invested a fixed monthly amount since the month each was born. Despite the impact of the Great Recession (two of my children were born before the fall of 2008) and other market downturns, these investments have grown substantially. Still, with eight and a half years to go until my eldest graduates from high school, we are likely to fall well short of fully financing a four-year college education for any of them due to the skyrocketing costs of college tuition. This will be true whether they aspire to attend my pricey alma mater, Harvard, or practically any other college in the nation. Students need no longer attend graduate or professional school to emerge with large amounts of educational debt; the average debt load of the Class of 2015 was more than $35,000, not counting loans that 17% of parents took out on their children's behalf.

Why have increases in college tuition constantly outpaced rates of inflation? On the New York Times's The Upshot blog, N. Gregory Mankiw recently offered these three reasons:

1) "Baumol's cost disease" - despite minimal advances in college productivity that would warrant our paying more for it, "because society overall is now richer, today's Socrates expects a reasonably high standard of living, and that implies hefty tuition."

2) Rising inequality - "it takes educated people to produce the next generation of educated people," and paying skilled workers is increasingly expensive.

3) Price discrimination - as colleges have raised published prices for the relatively well-off, they have also offered more financial aid based on a family's resources.

Even accounting for the impact of financial aid and subsidies to public universities, tuition costs are rapidly rising out of reach for most families. As Kevin Carey explained in a 2012 article in The New Republic:

Imagine you’re in the business of selling apples that cost $1 on the open market. Then the government decides that more people should have the opportunity to buy apples and society would benefit from a net increase in apple consumption. So it decides to drop the price of apples to 60 cents. Sometimes it does this by giving you 40 cents for every apple you sell, on the condition that you start selling apples for 60 cents. Sometimes it gives people vouchers worth 40 cents that can only be used to purchase apples from approved vendors.

At first, the policy works splendidly. Apples are effectively less expensive so more people buy them and the nation is suffused with apple goodness. But then you, the apple vendor, look at the situation and say “Hey, the market price of an apple is still $1. Wouldn’t it be great if I could charge $1 for apples, but still get 40 cents from the government for every apple I sell?” Raising the price all the way from 60 cents back to $1 in a single year would be too obvious and jeopardize political support for the apple subsidy program. So you start raising prices by three, four, or five percent above inflation annually. When annoyed public officials begin asking why, you explain that apple production is an expensive, labor-intensive business, and that all of the extra money is being used to produce the very best apples money can buy. Since apple quality is substantially a matter of taste, this is a hard claim to refute.

Meanwhile, you use some of your new profits to sponsor crowd-pleasing sports events on weekends, building public goodwill. Other profits are used to hire professional lobbyists to plead for both more subsidies and more freedom to set prices. You also convince the government to allow you and other incumbent apple sellers to form a private organization with the authority to decide whether new sellers can become “approved apple vendors” for the purposes of receiving public subsidies. Unsurprisingly, few new sellers are approved.

But eventually things start to break down. As time passes and price increases accumulate, the public starts to notice that while the taxes they pay to support apple subsidies are staying the same, the price of subsidized apples is creeping closer to the market price. This seems unreasonable. Meanwhile, when the economy turns sour, available tax receipts for apple subsidization decline. Instead of raising taxes to make up the difference, public officials drop the per-apple subsidy to 30 cents. This is bad for you, because it means you either have to spend less money on the exotic orchid greenhouse you’ve built next to the apple orchard—the reason, truth be told, you got into the apple business in the first place—or raise prices even further. Luckily, since you’ve kept new vendors out of the market and prices are still below the market rate, you can get away with raising prices, and so you do.

This is essentially the story of public higher education over the last thirty years. Diplomas are, of course, not apples. But they are more like apples than colleges like to pretend.

This blog is about health care, and college costs are not the same as health care costs. But they are a lot more similar than first meets the eye. Both colleges and health care organizations employ armies of highly skilled workers. Like a college education, access to health care is a good thing (although earning a college diploma improves health more than the best health care money can buy), but measures of quality are hard to find and hotly disputed. Higher prices are often conflated with higher quality (a strong incentive to raise prices), and there is little transparency in how colleges and health institutions come up with price tags beyond what the market will bear. The federal government's response to these rising costs has been to make it easier for students to borrow money for tuition and to subsidize the purchase of health insurance for lower-income persons, but in neither case has it done much to restrain cost growth. Finally, the trajectories of college tuition and health care costs are both unsustainable. These are observations, not solutions - but hopefully solutions to one problem will apply to the other as well.