With more than 50 percent of doctor’s visits in the United States involving primary care physicians, no year is ever a quiet one in the life of a general practitioner, and 2016 is no exception. The past 12 months have seen a number of changes to medical guidelines, and scientific research has raised questions about certain practices in healthcare.
Typically, new developments in primary care are more likely to translate into extra work for physicians’ offices. However, 2016 saw some exceptions.
Back in May came the news that there is no longer any need to ask patients to fast in preparation for cholesterol checks, while other stories revealed some techniques that could make a doctor’s job much easier when it comes to patient diagnoses.
However, the past year in primary care has not been without flaws. According to one study, the burden of medical error should be measured as if it were a disease.
In this article, we take a look at the top news stories that have had the biggest impact on general practitioners (GPs) in 2016.
Flu prevention in children
The American Academy of Pediatrics used the September publication of Pediatrics to make their recommendations on flu prevention in children.
Recent research had shown that the flu shot gave “significantly better protection” than the nasal spray vaccine.
The organization also championed inoculation of healthcare professionals themselves, even adding that they should brag about the merits of protection in acting as vaccine guardians:
“HCPs [healthcare providers] should act as role models for both their patients and colleagues by receiving influenza vaccination annually and by letting others know that they have received vaccine, highlighting the safety and effectiveness of annual influenza vaccination.”
Tackling antimicrobial resistance
Meanwhile, inappropriate antimicrobial prescribing has persisted, leading the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) to issue advice in the Annals of Internal Medicine in January.
Common colds, uncomplicated bronchitis, sore throats, and sinus infections may create a lot of demand in primary care, but the organizations offer some advice in an effort to combat antibiotic resistance and drug spending.
To help with patient information, the paper suggests the use of the “symptomatic prescription pad.” The CDC have print-ready examples on their website.
Another tool that might improve antibiotic prescription is an office test that distinguishes viral infections from bacterial ones – but how practical and cost-effective would this be?
Researchers at Duke Medicine in Durham, NC, published results of such a test in January.
They are working to priorities established by President Barack Obama in 2014 to improve diagnostics, and they say that their gene expression blood test is a step toward this goal. However:
“The technical hurdle to transfer these targets to a reliable, timely, affordable, and accessible platform remains.”
ISDA update guidelines for aspergillosis diagnosis, management
In July, the Infectious Diseases Society of America (IDSA) updated their guidelines for the diagnosis and treatment of aspergillosis – an umbrella term for a variety of diseases caused by the fungus Aspergillus.
The new guidelines focused on three types of aspergillosis: allergic, chronic pulmonary, and invasive. Each recommendation was given a classification of “weak” or “strong” based on the quality of evidence.
For example, the guidelines make a strong recommendation that invasive aspergillosis should be treated with voriconazole, based on high-quality evidence that this drug is effective.
Still, the IDSA say that they consider adherence to the guidelines to be voluntary, “with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.”
Updating the doctor’s bag
If you have had enough of being told how to manage common presentations by people who have never sat through a block of winter appointments, perhaps a digital spruce up for the stethoscope and other devices could be a welcome distraction.
According to The Journal of mHealth‘s editor, the doctor’s bag is getting a digital makeover.
How about a stethoscope attachment that can transcribe heart sounds to the medical record? Or smartphone technology that can create images from the otoscope?
New app to detect early-stage skin cancer
Skin cancer is the most common cancer for both men and women in the United States, with around 5.4 million basal and squamous cell skin cancers diagnosed annually, as well as more than 76,000 melanomas.
In July came the news of a new app, called Dermofit, that promises to help doctors better detect skin cancer in its early stages.
“Thirty percent of doctors will automatically send a patient to a hospital if they have signs of a skin growth,” notes Dermofit developer Prof. Jonathan Rees, of the University of Edinburgh in the United Kingdom. “But the evidence is that the vast majority of people who are seen and referred do not have skin cancer or anything serious at all.”
The new app consists of a library of more than 1,300 skin lesion photos that have been grouped together based on their color and texture.
“Practitioners can click on the image of a lesion of interest which then leads to further similar lesions. As lesions are selected, further sets of similar lesions are displayed,” explains Prof. Rees. “This gives familiarity with the different skin lesion types and allows users to differentiate between lesions that look similar, but that are from different skin lesion classes.”
Fasting for cholesterol testing ‘redundant’
In May came a study that claimed the fasting requirement for cholesterol testing is redundant.
Using an article in the European Heart Journal in April, the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine made a joint consensus statement.
“Since 2009, non-fasting lipid testing has become the clinical standard in Denmark,” and is appropriate more widely, say the authors, offering a chance to simplify testing for patients and GPs.
The consensus, however, does include the recommendation that non-fasting plasma triglyceride concentrations above 5 millimoles per liter (440 milligrams per deciliter) might be repeated after fasting.
Blood pressure drugs may do more harm than good
“The linear relation between blood pressure and cardiovascular disease seen in some observational studies cannot be extrapolated to assumed benefit of treatment,” conclude the authors of a February paper published in The BMJ.
The authors suggest that blood pressure drugs prescribed below a certain threshold are likely to not only lack benefit in this way, but they may also be harmful.
They recommend that blood pressure drugs be used in people with diabetes if systolic blood pressure is above the 140 milligrams of mercury threshold. Treating for readings below this may be harmful, they conclude.
They confirm that antihypertensives used above this threshold are important in cutting mortality and cardiovascular disease in diabetes patients.
Medical error third leading cause of death in U.S.
In another paper in The BMJ that was published in May, researchers find that the third leading cause of death in the U.S. is medical error.
One of the authors discusses the issue in an audio interview, saying that the issue has been “vastly underestimated.” The paper also adds: “Death certificates in the U.S., used to compile national statistics, have no facility for acknowledging medical error.”
The estimate of 250,000 deaths is “very conservative,” says Prof. Martin Makary, of the Department of Surgery at the Johns Hopkins University School of Medicine in Baltimore, MD.
The solution, according to the paper, is to share data about medical error in the same way as data is shared about disease – medical error “should not be exempt” from the approach of scientific inquiry.
The dangers of undiagnosed dementia
It might seem obvious that undiagnosed dementia presents danger, but is there evidence relating to these risks?
Some numbers appeared in a study published in the Journal of the American Geriatrics Society in June.
People who had probable dementia but no diagnosis were more likely to drive, prepare hot meals, manage finances and medications, and attend medical visits alone, compared with seniors who had been diagnosed.
The authors conclude: “Understanding the prevalence of potentially unsafe activities and living conditions can help clinicians focus safety screening and counseling in older adults with diagnosed or suspected dementia.”
Obviously, the problem of dementia is a major and growing one in society, and the authors confirm that over half of seniors living in the community who are suspected of having dementia do not have a physician’s diagnosis of it.
Measures against the problem, say the authors, include assisting patients and their families to “accept, understand, and adapt to a dementia diagnosis.”
Study suggests doctors ignore women’s heart health
As a physician, you always want to do the best for each patient. Therefore, a study published in March is likely to have come as a blow to many GPs, after finding that many women feel that doctors ignore their heart health.
Presented at the American College of Cardiology’s 65th Annual Scientific Session, the study surveyed more than 1,000 women, asking them what health advice they received from their physicians.
Around 34 percent of the women had been told by their doctor to lose weight, while only 16 percent were informed that they were at risk of heart disease – despite 74 percent of them having at least one risk factor for the condition.
Study co-author Dr. C. Noel Bairey Merz, of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Heart Institute in California, says that the findings are a concern.
“Women feel stigmatized. They are most often told to lose weight rather than have their blood pressure and blood cholesterol checked,” he notes.
“If women don’t think they’re going to get heart disease, and they’re being told by society and their doctors that everything would be fine if they just lost weight, that explains the paradox of why women aren’t going in for the recommended heart checks. Who wants to be told to lose weight?”
Helping patients manage their medications
On the subject of older adults, a study characterized many elderly patients who may need help managing medications.
A brief scale can help to identify those who may need help with medication, found researchers who were publishing in the Journal of the American Geriatrics Society in June.
The factors that proved predictive were an age of 75 years or older, male sex, memory problems, and problems with daily living tasks.
The factors are based on the finding that people aged 80 and over were up to three times more likely to need help with medicines than 65- to 69-year-olds. Men were up to twice as likely to need help as women, while memory problems increased the likelihood by up to fivefold.
Included among the research questions asked of 4,106 older residents of five counties in North Carolina was simply: “Are you able to take your medicine without help (in the right doses at the right time)?”
Among factors associated with reduced need for help was patients reporting four or more chronic conditions.
To identify the need for medication help, the authors suggest a five-item scale:
- At least 75 years of age
- Four or more errors on the short portable mental status questionnaire
- One or more problems with self-reported activities of daily living
- One or more problems with instrumental activities of daily living
Such a test identifies need for help with 77.1 percent sensitivity and 87.9 percent specificity, they conclude.
Given what 2016 has brought to primary care, it will certainly be interesting to see what lies ahead for 2017.