Excepting a few countries like Denmark that have managed to flatten their infection curve, primary and secondary schools around the world have now been closed for a month or more due to the public health imperative to slow the spread of COVID-19 through physical distancing. Parents and guardians, many of whom have lost jobs or recently transitioned to telework themselves, have struggled to keep track of and connect their children with online educational activities designed to replace in-person learning. I know - I'm one of those parents.
Unfortunately, evidence suggests that distance learning, no matter how carefully designed, does not fully replace in-person instruction. A 2016 report from the National Alliance of Public Charter Schools found that students who attended full-time virtual public charter schools had consistently lower engagement, academic gains, and performance than those in traditional public schools, regardless of demographics. Worse, a considerable proportion of U.S. students have not participated in online learning due to not having personal computers or home Internet access.
Extrapolating from studies of summer learning loss, the educational nonprofit Northwest Evaluation Association recently projected that relative to a typical academic year, students returning to school this fall may only retain 70 percent of reading gains and 50 percent or less of math gains. To make up for these losses, some school districts are planning to extend school into the summer, shrink their curricula, or repeat some of last year's lessions next year. Another controversial idea for high-poverty schools is having all students repeat their current grade, given the potential for further interruptions due to a second or third wave of COVID-19 in the fall.
Prior to COVID-19, chronic absenteeism (defined as missing at least 10 percent of the academic year, or about 18 days) already affected about 14% of American students from kindergarten through 12th grade. According to an American Family Physician article on school absenteeism, it not only has negative effects on academic performance and graduation rates, but also worsens future social functioning, health status, and life expectancy. Reasons for absenteeism vary from chronic or serious illness (including mental illness) to academic challenges, parenting problems, bullying and victimization, and other social stressors such as food insecurity and homelessness. Family physicians and pediatricians can help by performing an assessment of students with frequent absences and referring students and families to one or more appropriate interventions.
**
This post first appeared on the AFP Community Blog.
Tuesday, April 28, 2020
Tuesday, April 21, 2020
Don't miss these important prostate and lung cancer screening studies
In a time when the most common cause of death in older Americans is COVID-19, it seems nearly old-fashioned to write about screening for prostate and lung cancers, which, respectively, account for a small proportion of overall deaths in men (prostate) and only in smokers rivals mortality from heart disease (lung). But while the pandemic has riveted media attention on COVID-19 studies of questionable value, including non-peer reviewed preprints and uncontrolled case series, I think it's still important to highlight two notable recent publications on pitfalls of cancer screening.
I generally advise my average-risk patients not to have prostate cancer screening. Even viewing the evidence in the most optimistic light, few men are helped and many more are harmed. Notably, for this linked graphic the U.S. Preventive Services Task Force used the prostate cancer mortality risk reduction estimated in the European screening trial, the only one of three major PSA screening trials (the others were conducted in the U.S. and United Kingdom) to show any benefit whatsoever. And, as I explained in an earlier blog post, relying on observational trends in prostate cancer mortality to deduce benefits from screening is fraught with problems.
In a new analysis in the New England Journal of Medicine, Drs. Gil Welch and Peter Albertsen dive deeper into the prostate cancer mortality data and its implications for screening. They propose an explanation for a trend that I had always found puzzling: before starting to decline in the early 1990s (which some experts attribute to the effect of screening, but Welch and Albertsen argue convincingly must also be the result of improved treatment), mortality rose between 1970 and 1990 by more than 30 percent. This earlier mortality increase likely resulted from "sticky diagnosis bias," which occurred because transuretral resections of the prostate (TURP) procedures were widely used to treat benign prostatic hyperplasia (BPH) in older men, leading to many more incidental diagnoses (or overdiagnoses) of prostate cancer that ended up on death certificates. Welch and Albertsen go on to explain why "decreasing prostate cancer mortality may be a misleading metric in evaluating PSA screening":
Screening may more easily change the distribution of causes of death (trading off one cause for another) than extend life (as implied by promises to “save lives”). This issue is particularly relevant to PSA screening, since the median age at death due to prostate cancer is so high — 80 years (as compared with 72 for lung cancer and 68 for breast cancer). For the elderly, the combination of a high burden of competing risks for death and high rates of intervention-related complications conspires to limit any reduction in all-cause mortality offered by screening.
Of course, length of life is not the only relevant outcome; quality of life is equally important. If screening helped avert the pain that can be associated with metastatic disease, that would change the calculus, but it is not clear that it often does. Furthermore, the quality-of-life question has two sides. Prostate cancer treatment itself results in substantial morbidity: surgery and radiation can produce impotence and bowel and bladder problems; antiandrogen therapy leads to hot flashes, decreased stamina, and metabolic syndrome. Which group of men — the treated or the untreated — feels a bigger effect on quality of life can be debated.
From a statistical perspective, screening for lung cancer has always held more promise than screening for prostate cancer, since many more people (men and women) die prematurely from the former. Based on consistent results from several randomized trials, the medical consensus is that low-dose CT screening in carefully selected older smokers (or former smokers) reduces lung cancer mortality, and, possibly, all-cause mortality. However, as I've argued in the past, the potential harms of LDCT make it essential that clinicians discuss the pros and cons of screening with patients first, rather than universally recommending it.
A study in JAMA Internal Medicine assessed the informational content of 162 lung cancer screening program websites, half at academic medical centers and half at community medical centers. The authors found that 98 percent of web sites described potential benefits, but only 48 percent described potential harms, with community centers being even less likely (40 percent) to mention any harms. Overdiagnosis, which is arguably the most substantial harm since it usually leads to unnecessary invasive treatment, was mentioned by only 14% of academic centers and none of the community centers. Granted, going to a website is only the first step toward actually being screened for lung cancer, but it's discouraging that this content is so unbalanced.
On the Lown Institute blog, Judith Garber pointed out one reason for the "big benefit, little or no harm" messages that these websites send:
It is important to acknowledge the profit motive behind screening. If we reimbursed hospitals not for the volume of procedures done, but the outcomes for patients, we would likely a much greater effort to target individuals who would most benefit from screening, rather than hospitals trying to persuade as many people as possible to get screened.
I generally advise my average-risk patients not to have prostate cancer screening. Even viewing the evidence in the most optimistic light, few men are helped and many more are harmed. Notably, for this linked graphic the U.S. Preventive Services Task Force used the prostate cancer mortality risk reduction estimated in the European screening trial, the only one of three major PSA screening trials (the others were conducted in the U.S. and United Kingdom) to show any benefit whatsoever. And, as I explained in an earlier blog post, relying on observational trends in prostate cancer mortality to deduce benefits from screening is fraught with problems.
In a new analysis in the New England Journal of Medicine, Drs. Gil Welch and Peter Albertsen dive deeper into the prostate cancer mortality data and its implications for screening. They propose an explanation for a trend that I had always found puzzling: before starting to decline in the early 1990s (which some experts attribute to the effect of screening, but Welch and Albertsen argue convincingly must also be the result of improved treatment), mortality rose between 1970 and 1990 by more than 30 percent. This earlier mortality increase likely resulted from "sticky diagnosis bias," which occurred because transuretral resections of the prostate (TURP) procedures were widely used to treat benign prostatic hyperplasia (BPH) in older men, leading to many more incidental diagnoses (or overdiagnoses) of prostate cancer that ended up on death certificates. Welch and Albertsen go on to explain why "decreasing prostate cancer mortality may be a misleading metric in evaluating PSA screening":
Screening may more easily change the distribution of causes of death (trading off one cause for another) than extend life (as implied by promises to “save lives”). This issue is particularly relevant to PSA screening, since the median age at death due to prostate cancer is so high — 80 years (as compared with 72 for lung cancer and 68 for breast cancer). For the elderly, the combination of a high burden of competing risks for death and high rates of intervention-related complications conspires to limit any reduction in all-cause mortality offered by screening.
Of course, length of life is not the only relevant outcome; quality of life is equally important. If screening helped avert the pain that can be associated with metastatic disease, that would change the calculus, but it is not clear that it often does. Furthermore, the quality-of-life question has two sides. Prostate cancer treatment itself results in substantial morbidity: surgery and radiation can produce impotence and bowel and bladder problems; antiandrogen therapy leads to hot flashes, decreased stamina, and metabolic syndrome. Which group of men — the treated or the untreated — feels a bigger effect on quality of life can be debated.
From a statistical perspective, screening for lung cancer has always held more promise than screening for prostate cancer, since many more people (men and women) die prematurely from the former. Based on consistent results from several randomized trials, the medical consensus is that low-dose CT screening in carefully selected older smokers (or former smokers) reduces lung cancer mortality, and, possibly, all-cause mortality. However, as I've argued in the past, the potential harms of LDCT make it essential that clinicians discuss the pros and cons of screening with patients first, rather than universally recommending it.
A study in JAMA Internal Medicine assessed the informational content of 162 lung cancer screening program websites, half at academic medical centers and half at community medical centers. The authors found that 98 percent of web sites described potential benefits, but only 48 percent described potential harms, with community centers being even less likely (40 percent) to mention any harms. Overdiagnosis, which is arguably the most substantial harm since it usually leads to unnecessary invasive treatment, was mentioned by only 14% of academic centers and none of the community centers. Granted, going to a website is only the first step toward actually being screened for lung cancer, but it's discouraging that this content is so unbalanced.
On the Lown Institute blog, Judith Garber pointed out one reason for the "big benefit, little or no harm" messages that these websites send:
It is important to acknowledge the profit motive behind screening. If we reimbursed hospitals not for the volume of procedures done, but the outcomes for patients, we would likely a much greater effort to target individuals who would most benefit from screening, rather than hospitals trying to persuade as many people as possible to get screened.
Thursday, April 9, 2020
Learning health policy during a pandemic
Last week marked my first major foray into virtual teaching. At Georgetown, the first-year medical student class was told to stay home after Spring Break in order to slow the spread of COVID-19 in Washington, DC and its suburbs. The week of teaching health policy went about as well as I could have expected - my home wireless network held up, no one Zoom bombed any lectures or large group activities, I figured out how to use Panopto, and with fewer distractions than during a normal year, few students missed learning sessions. I also updated my podcast from last year, recording a new conclusion to the episode (embedded below) on health care reforms since the Affordable Care Act.
We are living in unprecedented times, with our health care system under enormous stress from the COVID-19 pandemic and little relief in sight. At this time last year, I predicted that incremental health care reforms would be the most likely outcome of the upcoming Presidential and Congressional elections, regardless of who won. But the evolving U.S. response to the novel coronavirus has exposed glaring deficiencies in our national preparedness, as well as the organization of the health care workforce and the usual way we practice medicine. It’s forced us to re-examine questions such as: how much health care really needs to be provided in person? Does our current physician-centered payment system discourage developing innovative models of care? And perhaps most importantly, in the face of a highly contagious disease, is excluding 25 or more million uninsured persons from the health care system no longer justifiable, if it ever was?
As the COVID-19 curve begins to show signs of flattening in New York and New Jersey after a staggering death toll, the pandemic continues to expand rapidly in Illinois, Michigan and Louisiana. And public health observers are starting to realize that this novel coronavirus does, indeed, discriminate, hitting majority-minority communities much harder than others. Perhaps that explains why Alabama, whose population is 26 percent African American, was projected just a few days ago to have the highest COVID-19 mortality rate in the nation - even greater than New York's? (A revised projection now places it in the middle of the pack.)
Coincidentally, there's a feature article in this week's New Yorker about another deadly health disparity in Alabama that disproportionately affects minorities. Cervical cancer is one of clinical prevention's great success stories. Women who have periodic Pap smears and, more recently, tests for cancer-causing subtypes of human papillomavirus (HPV), can have precancerous lesions identified and treated long before they progress to cancer. Vaccines against high-risk HPV subtypes, when administered before exposure through sex, prevent infections in the first place, and are routinely recommended for women and men between the ages of 11 and 26. So nearly all of the 13,000 U.S. women who are diagnosed with cervical cancer and the 4,000 who die from it each year have one thing in common: it's been too long since they saw a gynecologist or family doctor.
Why is this tragedy more likely to occur in Alabama, as compared to New York City (25% African American) or Washington, DC (47%)? In Alabama, to qualify for Medicaid as a parent in a family of four, one's household income must be below 18% of the federal poverty level - that is, less than $393 per month. Try to house, feed and clothe a family of four and pay for health insurance or health care of any type (including inexpensive direct primary care) on $400 or $500 a month! The numbers don't even come close to adding up.
Enter health policy. In 2014, a key provision of the Affordable Care Act went into effect that provided at least 90% federal matching funds to states that expanded Medicaid eligibility to 138% of the poverty level. Alabama said no, and it and 13 other states - including most of the solid South, continue to say no, even though studies suggest that additional budgetary costs to states from Medicaid expansion would be more than offset by improvements in the health and earning potential of their residents and the financial footing of their health care institutions.
Developing preventable cancers while being poor and uninsured in Alabama and 13 other states is not only a problem for African Americans, but for persons of all races and backgrounds. If Alabama expanded Medicaid today, the expansion "would provide coverage for roughly three hundred and forty thousand additional Alabamians. About half of the newly insured would be low-income whites." Among other benefits, these newly insured persons could then access coronavirus testing and treatment. Social distancing, widespread testing, contact tracing, and vaccine development won't be enough to halt the pandemic if we leave millions of Americans behind; it's no wonder that Medicaid expansion has been proposed as a potent policy tool for mitigating the health and economic impact of COVID-19.
We are living in unprecedented times, with our health care system under enormous stress from the COVID-19 pandemic and little relief in sight. At this time last year, I predicted that incremental health care reforms would be the most likely outcome of the upcoming Presidential and Congressional elections, regardless of who won. But the evolving U.S. response to the novel coronavirus has exposed glaring deficiencies in our national preparedness, as well as the organization of the health care workforce and the usual way we practice medicine. It’s forced us to re-examine questions such as: how much health care really needs to be provided in person? Does our current physician-centered payment system discourage developing innovative models of care? And perhaps most importantly, in the face of a highly contagious disease, is excluding 25 or more million uninsured persons from the health care system no longer justifiable, if it ever was?
As the COVID-19 curve begins to show signs of flattening in New York and New Jersey after a staggering death toll, the pandemic continues to expand rapidly in Illinois, Michigan and Louisiana. And public health observers are starting to realize that this novel coronavirus does, indeed, discriminate, hitting majority-minority communities much harder than others. Perhaps that explains why Alabama, whose population is 26 percent African American, was projected just a few days ago to have the highest COVID-19 mortality rate in the nation - even greater than New York's? (A revised projection now places it in the middle of the pack.)
Coincidentally, there's a feature article in this week's New Yorker about another deadly health disparity in Alabama that disproportionately affects minorities. Cervical cancer is one of clinical prevention's great success stories. Women who have periodic Pap smears and, more recently, tests for cancer-causing subtypes of human papillomavirus (HPV), can have precancerous lesions identified and treated long before they progress to cancer. Vaccines against high-risk HPV subtypes, when administered before exposure through sex, prevent infections in the first place, and are routinely recommended for women and men between the ages of 11 and 26. So nearly all of the 13,000 U.S. women who are diagnosed with cervical cancer and the 4,000 who die from it each year have one thing in common: it's been too long since they saw a gynecologist or family doctor.
Why is this tragedy more likely to occur in Alabama, as compared to New York City (25% African American) or Washington, DC (47%)? In Alabama, to qualify for Medicaid as a parent in a family of four, one's household income must be below 18% of the federal poverty level - that is, less than $393 per month. Try to house, feed and clothe a family of four and pay for health insurance or health care of any type (including inexpensive direct primary care) on $400 or $500 a month! The numbers don't even come close to adding up.
Enter health policy. In 2014, a key provision of the Affordable Care Act went into effect that provided at least 90% federal matching funds to states that expanded Medicaid eligibility to 138% of the poverty level. Alabama said no, and it and 13 other states - including most of the solid South, continue to say no, even though studies suggest that additional budgetary costs to states from Medicaid expansion would be more than offset by improvements in the health and earning potential of their residents and the financial footing of their health care institutions.
Developing preventable cancers while being poor and uninsured in Alabama and 13 other states is not only a problem for African Americans, but for persons of all races and backgrounds. If Alabama expanded Medicaid today, the expansion "would provide coverage for roughly three hundred and forty thousand additional Alabamians. About half of the newly insured would be low-income whites." Among other benefits, these newly insured persons could then access coronavirus testing and treatment. Social distancing, widespread testing, contact tracing, and vaccine development won't be enough to halt the pandemic if we leave millions of Americans behind; it's no wonder that Medicaid expansion has been proposed as a potent policy tool for mitigating the health and economic impact of COVID-19.
Monday, March 30, 2020
Breast cancer screening is likely to be harmful after age 75
To increase acute care capacity during the COVID-19 pandemic, hospitals have suspended elective surgical procedures, and family medicine practices have postponed visits for preventive care and monitoring of stable chronic diseases - particularly in patients older than 70 years, whose risk of developing serious illness from SARS-CoV-2 contracted in a health care setting likely outweighs potential benefits. For example, women in this age group should cancel or postpone screening mammograms.
Even in the best of times, though, it's not known if screening mammography beyond 75 years of age is helpful or harmful. The U.S Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of breast cancer screening after age 75, and decision tools have been developed to help women decide whether or not to continue to be screened, relying on limited evidence and the patient's predicted life expectancy. As the authors of a recent American Family Physician editorial observed, though, discussing the clinical implications of life expectancy with older patients can be challenging and fraught with pitfalls.
Since it is unlikely that a randomized controlled trial of screening mammography in older women will be performed, researchers recently used observational data from the U.S. Medicare program to emulate such a trial in more than 1 million beneficiaries aged 70 to 84 years with a life expectancy of at least 10 years and no previous breast cancer diagnosis. The primary outcome was eight-year risk of breast cancer mortality.
While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years. Although guidelines already discourage screening for cancer in adults with a life expectancy of less than 10 years, this study suggested that stopping breast cancer screening after age 75 may be the right decision for all women, regardless of health status.
**
This post first appeared on the AFP Community Blog.
Even in the best of times, though, it's not known if screening mammography beyond 75 years of age is helpful or harmful. The U.S Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of breast cancer screening after age 75, and decision tools have been developed to help women decide whether or not to continue to be screened, relying on limited evidence and the patient's predicted life expectancy. As the authors of a recent American Family Physician editorial observed, though, discussing the clinical implications of life expectancy with older patients can be challenging and fraught with pitfalls.
Since it is unlikely that a randomized controlled trial of screening mammography in older women will be performed, researchers recently used observational data from the U.S. Medicare program to emulate such a trial in more than 1 million beneficiaries aged 70 to 84 years with a life expectancy of at least 10 years and no previous breast cancer diagnosis. The primary outcome was eight-year risk of breast cancer mortality.
While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years. Although guidelines already discourage screening for cancer in adults with a life expectancy of less than 10 years, this study suggested that stopping breast cancer screening after age 75 may be the right decision for all women, regardless of health status.
**
This post first appeared on the AFP Community Blog.
Sunday, March 22, 2020
Curiosity: what makes a doctor truly great
I have never been invited to give a commencement address. The closest I came was my own high school graduation, when I was the unofficial valedictorian. Since my school did not have a tradition of the highest-ranked student addressing the class on graduation day, though, I didn't get the chance. Our commencement speaker, a television news anchor and former graduate, delivered a great speech that I still remember more vividly than the addresses by bigger names at my college, medical school, and public health graduation ceremonies.
Obviously, I have not had the good fortune of hearing Dr. Atul Gawande speak at a commencement. (Atul, if you're reading this, Georgetown University School of Medicine would be delighted to have you address a future graduating class.) In 2018 he delivered a profoundly insightful address at UCLA that went viral on social media. It's worth reading in its entirety, but the point he drove home is that in a time when discrimination and unequal treatment have become as socially acceptable in some circles as in the pre-American Civil Rights era, it remains the sacred calling of medicine to recognize that all lives have equal worth, and that doctors and patients share a "common core of humanity":
Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.
Curiosity. If medicine were only about the science of the human body in health and disease, I would never have become a family doctor. Fortunately, that isn't so; in fact, after years of practice I often feel that the science has become incidental to doctoring. Yes, the knowledge base for medicine is always expanding, but as I tell students, regardless of what field of medicine you choose, the technical aspects eventually become routine. Even emergency and family physicians, who encounter the largest variety of symptoms and diagnoses, get acclimated to bread-and-butter encounters: back pain, chest pain, respiratory infections, the management of common chronic conditions under or out of control.
What keeps my work meaningful is learning about the details of my patients' lives that aren't strictly medical. As Dr. Faith Fitzgerald wrote in a classic article two decades ago:
What does curiosity have to do with the humanistic practice of medicine? ... I believe that it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients—to empathize—one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past, and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.
Obviously, I have not had the good fortune of hearing Dr. Atul Gawande speak at a commencement. (Atul, if you're reading this, Georgetown University School of Medicine would be delighted to have you address a future graduating class.) In 2018 he delivered a profoundly insightful address at UCLA that went viral on social media. It's worth reading in its entirety, but the point he drove home is that in a time when discrimination and unequal treatment have become as socially acceptable in some circles as in the pre-American Civil Rights era, it remains the sacred calling of medicine to recognize that all lives have equal worth, and that doctors and patients share a "common core of humanity":
Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.
Curiosity. If medicine were only about the science of the human body in health and disease, I would never have become a family doctor. Fortunately, that isn't so; in fact, after years of practice I often feel that the science has become incidental to doctoring. Yes, the knowledge base for medicine is always expanding, but as I tell students, regardless of what field of medicine you choose, the technical aspects eventually become routine. Even emergency and family physicians, who encounter the largest variety of symptoms and diagnoses, get acclimated to bread-and-butter encounters: back pain, chest pain, respiratory infections, the management of common chronic conditions under or out of control.
What keeps my work meaningful is learning about the details of my patients' lives that aren't strictly medical. As Dr. Faith Fitzgerald wrote in a classic article two decades ago:
What does curiosity have to do with the humanistic practice of medicine? ... I believe that it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients—to empathize—one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past, and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.
Then, as now, pressures to be efficient in evaluating patients threatened to suppress natural curiosity. Dr. Fitzgerald bemoaned an educational system that produces medical students who were too un-curious to ask a patient how he had been bitten in the groin by a snake ("How could one not ask?"), or to question the "BKA (below-knee amputation) times two" description in the chart of a patient who obviously had legs. Finally, she mentioned one patient who had been deemed by the housestaff to be the "dullest" (least interesting) on the service: an old woman who (upon further inquiry) turned out to have survived the sinking of the Titanic.
2020 graduates, I am delighted that many of you will be entering family medicine this year, but regardless of the medical specialty you've chosen, don't ever stop being curious - especially about the most "difficult" patients and the ones you least understand. It is that skill, more than any other, that will sustain you in your work and that separates the merely competent doctors from the truly great ones.
**
This post first appeared on Common Sense Family Doctor on June 4, 2018 and in a slightly different form as "What Makes A Doctor Truly Great" in the November/December 2018 FPM.
**
This post first appeared on Common Sense Family Doctor on June 4, 2018 and in a slightly different form as "What Makes A Doctor Truly Great" in the November/December 2018 FPM.
Monday, March 16, 2020
Insomnia and sleep apnea in adults: evidence-based treatments
At an American Family Physician editors' meeting several years ago, a colleague, who marveled at the amount of academic and clinical activities that I cram into a typical workweek, asked half-seriously, "Do you sleep?" Yes, I answered, not only do I need at least seven hours of uninterrupted sleep each night, I don't feel the least bit guilty about making it a priority. As Dr. Jennifer Middleton wrote in a previous blog post, the negative health consequences of chronic sleep deprivation are legion. Unfortunately, a recent survey found that nearly half of U.S. military personnel report poor sleep quality. From 2003 to 2011, the incidence of insomnia and obstructive sleep apnea (OSA) in active duty U.S. Army soldiers increased by 652% and 600%, respectively.
Concerns about these two common sleep disorders led the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) to develop a joint clinical practice guideline for their diagnosis and management; a synopsis was published last month in Annals of Internal Medicine. Key recommendations for treating chronic insomnia (insomnia occurring for three or more nights per week for three or more months) generally agree with those from a 2016 American College of Physicians guideline and Agency for Healthcare Research and Quality review: offer cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and reserve short-term pharmacologic therapy (low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists, such as zolpidem) for patients who are unable to access or complete CBT-I.
The VA/DoD panel suggests not using antipsychotic drugs, benzodiazepines, or trazodone for chronic insomnia due to harms outweighing benefits or lack of benefit. It also advises against two common ingredients in over-the-counter sleep aids, diphenhydramine and melatonin. The panel suggests that clinicians not use sleep hygiene education as a standalone treatment due to its limited effectiveness and potential to discourage patients from pursuing the more effective CBT-I.
For OSA, the VA/DoD guideline suggests using the STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure) to stratify risk in patients who report sleep symptoms and performing home sleep apnea testing rather than in-laboratory polysomnography in patients with a high pretest probability of OSA. Although continuous positive airway pressure (CPAP) therapy is recommended for persons with severe OSA, mandibular advancement devices may be used as an alternative in mild or moderate cases. The VA/DoD panel did not evaluate positional therapy (techniques to promote side sleeping) for OSA. However, a recent Cochrane review found that patients are more likely to tolerate and adhere to positional therapy than CPAP, compensating somewhat for the former's lesser effectiveness.
**
This post first appeared on the AFP Community Blog.
Concerns about these two common sleep disorders led the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) to develop a joint clinical practice guideline for their diagnosis and management; a synopsis was published last month in Annals of Internal Medicine. Key recommendations for treating chronic insomnia (insomnia occurring for three or more nights per week for three or more months) generally agree with those from a 2016 American College of Physicians guideline and Agency for Healthcare Research and Quality review: offer cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and reserve short-term pharmacologic therapy (low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists, such as zolpidem) for patients who are unable to access or complete CBT-I.
The VA/DoD panel suggests not using antipsychotic drugs, benzodiazepines, or trazodone for chronic insomnia due to harms outweighing benefits or lack of benefit. It also advises against two common ingredients in over-the-counter sleep aids, diphenhydramine and melatonin. The panel suggests that clinicians not use sleep hygiene education as a standalone treatment due to its limited effectiveness and potential to discourage patients from pursuing the more effective CBT-I.
For OSA, the VA/DoD guideline suggests using the STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure) to stratify risk in patients who report sleep symptoms and performing home sleep apnea testing rather than in-laboratory polysomnography in patients with a high pretest probability of OSA. Although continuous positive airway pressure (CPAP) therapy is recommended for persons with severe OSA, mandibular advancement devices may be used as an alternative in mild or moderate cases. The VA/DoD panel did not evaluate positional therapy (techniques to promote side sleeping) for OSA. However, a recent Cochrane review found that patients are more likely to tolerate and adhere to positional therapy than CPAP, compensating somewhat for the former's lesser effectiveness.
**
This post first appeared on the AFP Community Blog.
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