DISEASE SCREENING

Background

• Definition: Screening intended to identify disease in asx individuals when early detection is feasible & early tx improves outcomes Screening test rarely used to to diagnose dz; instead used to identify persons at ↑ risk → further testing
• Figure 1-2. Characteristics of Screening Test
• Benefits of screening: Can be difficult to compare direct outcomes btw screened & unscreened groups; often established using:
  • Proportion of tested population who test positive
  • Ability of test result to detect disease while still asx
  • Treatment effectiveness in test-positive people
• Harms of screening: False ⊕ can → overdiagnosis & overtreatment, which can have individual & public health costs; screening may identify disease early w/o being able to modify outcome; risks/harms vary based on test & disease

Characteristics of Ideal Screening Test
Disease	High disease prevalence (↑ PPV of ⊕ test) Tx of early disease is effective: can improve outcomes/avoid complications Disease has known asx/early stage which can be identified
Test	Can detect disease while still asymptomatic

• Screening recommendations: Several government agencies (incl US Preventive Services Task Force, or USPSTF; CDC, NCI) periodically undertake systematic reviews of available data to make recommendations; professional societies (ACOG, AUA, ACP, AAFP) & advocacy organizations (ADA, ACS) also offer independent screening recommendations; may refer to www.guidelines.gov to compare
• Applying recommendations: All recommendations are population- based & based on principle of long-term/future benefit; they may not apply to certain individuals, particularly those w/ limited life expectancy
• Patients w/ active sx concerning for disease → testing, not screening (diagnostics may be different: e.g., hx/PE concerning for cervical CA → referral for colposcopy, not Pap)

Evaluation

• During routine visits, consider which screenings are indicated; guidelines typically by age & gender; can be helpful to organize screening by category (below)
• Potential risks & benefits of screening tests should be discussed w/ pt; goal is shared decision-making (NEJM 2012;366:780)

USPSTF Screening Recommendations
Disease	Population, preferred test & interval (if given), & notes
Cancer
Colon Cancer	50–75 y: FOBT (q1y), sigmoidoscopy or FIT-DNA (q1–3y), CT colonoscopy (q5y, requires bowel prep) or colonoscopy (q10y) benefits & burdens greatest w/ colonoscopy (most lives saved, most complications)
Breast Cancer	40–49 y ♀: Consider mammography q2y after discussion w/ pt 50–74 y ♀: Mammography q2y Excludes those at ↑ risk (known genetic mutation, hx chest XRT) ACOG, ACS, ACR recommend more screening (annual mammogram + CBE ± SBE starting at age 40); other groups (AAFP) recommend individual shared decision-making re: screening for ♀ 40–49 y; consider local practice patterns in light of medicolegal risk (JAMA 2013;309:2555)
Cervical cancer	21–29 y ♀: Pap q3y 30–64 y ♀: Pap q3y or (Pap + HPV q5y), n.b. draft 2018 recommendation See “Cervical Cancer Screening”

 

Prostate cancer	See “Prostate Cancer”; most groups recommend pt discussion
Lung cancer)	55–79 y w/ 30 pack-y tobacco hx and smoked w/in past 15 y: Annual low-dose CT, stop 15 y after quit; quitting >> effective in ↓ lung CA than screening CT
Cardiovascular
HTN	All adults: q1y if last SBP 120–139 or last DBP 80–89; q2y if <120/<80
AAA	65–75 yo ♂ ever-smokers: Abd U/S, 1-time screening
Endocrine
Diabetes	Adults w/ BP > 135/80: HbA1c, FPG, glucose tolerance test all ok ADA recommends screening all adults >45 & overwt adults <45 w/ 1 add’l risk factor (e.g., ⊕ FHx or PCOS); see “Diabetes”
Hyperlipidemia	All adults at ↑ risk; all ♂ >35: Total chol, HDL, LDL q5y May ↓ testing interval if borderline; ↑ interval if repeatedly nl
Osteoporosis	All ♀ >65; ♀ <65 at ↑ risk: DXA of hip & lumbar spine For ♀ <65, calculate FRAX score: If 10 y fx risk >9.3%, considered ↑ risk; see “Osteoporosis”
Infectious Disease
HCV	Hx IVDU, blood transfusion, all adults born 1945–1965: Once Pts at ongoing risk (IVDU): More frequent testing
HIV	All adults: Once ↑ Risk (MSM, IVDU): More frequently (see “HIV”)
Chlamydia	Sexually active & (<26 y or ↑ risk): Screen (see “Sexually Transmitted Infection”)
Gonorrhea	Adults at ↑ risk (see “Sexually Transmitted Infection”)
Syphilis	Adults at ↑ risk (see “Sexually Transmitted Infection”)
Social, Ψ,& Substance Use
Depression	All adults: Brief screening, e.g., PHQ-2, if clinic has care support (SW, mental health counselor to assist in depression care)
EtOH abuse	All adults: Brief screening, e.g., AUDIT-C, single question (see “Alcohol Use Disorders”)
Tobacco use	All adults (see “Tobacco”): If screen ⊕, offer counseling
Intimate partner violence	All ♀ of childbearing age: Brief screen; see “Domestic Violence,” if screen ⊕, provide or refer to intervention services

(USPSTF uspstf.org, Diabetes Care 2013;36:S11)

Provider Tools

• USPSTF recommendations available as application for mobile devices at http://epss.ahrq.gov/PDA/index.jsp; enter basic pt info (age, gender) to see list of screening & other recommendations
• National Guidelines Clearinghouse at http://www.guidelines.gov lists recommendations from major government/nongovernment groups, organized by topic

IMMUNIZATIONS

Background 

(Healthy People 2020, cdc.gov, MMWR Surveill Summ 2016;65:1)

• Current US guidelines recommend adults be immunized against up to 14 pathogens w/ the goal of ↓ infectious disease incidence & complications
• Immunization goals:
  • Protect individuals from infection, ↓ complications of infection Reduce transmission to at-risk population (infants, elderly, poor health) Reduce population disease burden: Smallpox eradicated, polio, & diphtheria almost Confer herd immunity: High immunization rates can ↓ the number of susceptible members in a population; this ↓ overall probability of transmission of infection
• Rates improving, but many at risk still inadequately covered
  • Elderly: 61% have adequate pneumococcal coverage, 20.7% VZV, 67% influenza High-risk adults <65: 20.3% have adequate pneumococcal coverage
• CDC estimates that ↑ immunization would → elimination of diphtheria, measles, mumps, rubella in US; 75% reduction in hepatitis A & B incidence since vaccines developed
• Figure 1-3. CDC Vaccine Schedule for Healthy Adults, by Age

Additional Vaccines for Adults >19 y, by Indication (Ann Intern Med 2017;166:209)

Additional Vaccines for Adults >19 y, by Medical Condition/Indication
Diabetes	PPSV23, HepB
ESRD	PCV13, PPSV23*, HepB
Heart or Lung Disease	PPSV23
Liver Disease	PPSV23, HAV, HepB
Asplenia or Complement deficiency	PCV13, PPSV23*, 1 dose each of MenACWY or MPSV4, Hib (>14d pre-splenectomy if possible), MenB
HIV see “HIV”	CD4 < 200: contraindicated: MMR, VZV, HZV All CD4: PCV13, PPSV 23*, MenACWY or MPSV4, extend window of HPV – ♂ series up to age 27
Immunocompromised (other, HIV-)	PCV13, PPSV23* Post-HSCT: add 3 doses Hib contraindicated: MMR, VZV, HZV
EtOH dependency	PPSV23
Healthcare workers	HepB
MSM	HepA, HepB; HPV series extended up to age 27

*2 doses of PPSV23, 5 y apart, prior to age 65

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SPECIFIC VACCINES

 Pneumococcal Immunization

(MMWR 2015;64:944; MMWR 2014;63:822)

• 2 vaccines recommended which protect against different strains: PPSV23 & PCV13
• Goal: Prevention of invasive pneumococcal disease (IPD, e.g., bacteremia, meningitis) & PNA
• Target population: Both vaccines recommended for adults ≥65 or immunocompromised <65 y; PPSV23 also recommended for adults 19–64 y w/ chronic illness
• Dosing: See table for details
• Efficacy: PPSV23: 50–80% reduction in IPD in observational studies; up to 74% effective in meta-analysis of 15 RCTs (MMWR 2010;59:1102); in large RCT of adults >65 y, PCV13 assoc w/ 45%↓ in PNA, 70%↓ in IPD (NEJM 2015;372:1114)

Pneumococcal Vaccine Schedule
Dosing Pearls PPSV23 doses should all be ≥5 y apart if more than 1 dose is needed in lifetime PCV13 single lifetime dose If both indicated, PCV13 should be given 1 y before next dose of PPSV23 For PPSV23, everyone should get exactly 1 dose after age 65; timing depends on prior PCV13 & PPSV23
Clinical Scenario	Schedule
<60 y needs PPSV23	PPSV23 now PCV13 at age 65 2nd PPSV23 once ≥1 y since PCV13 & ≥5 y since 1st PPSV23
<60 y needs PCV13 & PPSV23	PCV13 now PPSV23 1 y later 2nd PPSV23 5 y later 3rd PPSV23 once age 65 & ≥5 y since 2nd PPSV23
60–65 y needs PPSV23	PPSV23 now PCV13 at age 65 2nd PPSV23 once ≥1 y since PCV13 & ≥5 y since 1st PPSV23
60–65 y needs PPSV23 & PCV13	PCV13 now PPSV23 1 y later 2nd PPSV23 once age 65 & ≥5 y since 2nd PPSV23

 

≥65 y no prior pneumococcal vaccine	PCV13 now PPSV23 1 y later
≥65 y prior PPSV23 at age <65	PCV13 now PPSV23 once ≥1 y since PCV13 & ≥5 y since last PPSV23
≥65 y prior PCV13 & PPSV23 at age <65	PPSV23 once ≥1 y since PCV13 & ≥5 y since last PPSV23

Influenza

(MMWR 2010;59:1102; NEJM 2016;375:126; JACI 2016;137:868)

• Goal: Prevention of individual infection & spread of influenza virus
• Strain variability: Flu strains vary by season → each year, vaccines developed to protect against 3 strains of influenza (trivalent: two A & one B; quadrivalent: two A & two B)
• Target population: All adults; esp. pts w/ asthma, DM, chronic lung disease, obesity, people >65
• Dosing: Annually; ASAP once available, optimally before onset of flu to the community; should be offered throughout flu season (Oct–Mar in US); recommended even in pts who already had influenza-like illness this season
• Dosage forms: 2016–17 ACIP guidelines do not recommend one vaccine over another among trivalent, quadrivalent, high or regular dose; these recommendations change annually; visit cdc.gov/flu/professionals/vaccination for latest information

Influenza Vaccines
Forms	Notes
Trivalent inactivated (IM)	Ok for pregnant, HIV⊕; avoid admin during febrile illness Contraindications: h/o GBS after prior immunizations, anaphylactic reaction to egg or vaccine components
Egg-free trivalent inactivated (IM)	Healthy adults <50 y; vaccine not produced in eggs
High-dose trivalent activated (IM)	Approved for ≥65 y; RCT showed 24% ↓ risk of influenza compared to std dose, although some ↑ in mild s/e (NEJM 2014;371:635)
Quadrivalent inactivated (IM)	Adults 18–64 y
Quadrivalent inactivated (intradermal)	All adults

 

Live-attenuated vaccine (intranasal)

Not recommended by ACIP for 2017–2018 2/2 ↓↓ efficacy; when available, for use in healthy adults <50 y; contraindications: chronically ill, immunosuppressed, h/o GBS, egg allergy; s/e can include rhinorrhea, HA

• Egg allergy: Anaphylaxis to flu vaccine extremely rare (1.3/million vaccines given) & not necessarily ↑ in persons with egg allergy; ACIP 2017 recommendations are for:
  • Nonsevere (e.g., hives) egg allergy: any vaccine ok
  • Severe (e.g., anaphylaxis) egg vaccine: any vaccine ok, but monitor for 30 min w/ provider able to manage severe reactions, if they develop
• Efficacy: Variable based on pt, mode of vaccination, & strain: vaccine “fit”; 2 meta-analyses of healthy individuals, inactivated vaccine, good “fit” w/ 59–73% efficacy (Lancet 2012;12:36; Vaccine 2011;29:9159)

Responses to Common Patient Objections to Influenza Vaccination (JAMA 2013;309:881)

“I never get sick”: Even asx pts may then infect contacts at risk for serious complications

“The vaccine does not work”: On a population-wide basis, known to ↓ flu-related illness, abx use, time lost from work, hospitalizations, & deaths

“The vaccine causes the flu”: Misperception can be due to mistaking URI for influenza, acquiring influenza around time of vaccination, mild reaction to vaccine, or ineffectiveness; nearly all providers receive influenza vaccine; use own experience to reassure; “I tested it for you.”

“I am allergic to eggs”: See “Egg allergy” above

“I am pregnant” or “I live w/ an immunocompromised pt”: These groups may receive greatest benefit; obtaining flu shot protects immunocompromised family members

Human Papilloma Virus

(MMWR 2007;56:1, cdc.gov/std/hpv)

• Background: HPV most common STI in US (14 million new infections/y); most resolve spontaneously, but some persist & → cancer (19,000 ♀ & 11,600 ♂ annually)
• HPV strains: low-risk strains (HPV 6,11) assoc w/ low-grade cervical cell changes, genital warts; high-risk strains (HPV 16,18) assoc w/ cervical or anogenital CA (70% cases)
• Goal: Reduce current rates of genital HPV infection & transmission
• Target population: Ideally vaccinate prior to initial sexual activity; however, sexually active individuals should still be vaccinated; also ok if HPV ⊕
• Dosing schedule: if >15 y, standard is 3 doses at 0, 1–2 mos, & 6 mos
  • Pts who did not receive during childhood → 3 doses Pts who received 1 dose before age 15 → 1 more dose
  • Pts who received 2 doses either <5 mos apart or after age 15 → 1 more dose
  • Pts who received 2 doses, >5 mos apart, before age 15 → no further doses necessary
• Dosage forms: All are inactivated; all protect against 16,18
  • HPV9 (Gardasil 9): 9-valent, Gardasil 4 + HPV 31, 33, 45, 52, 58 (contraindication: immediate hypersensitivity rxn to yeast); HPV4 (Gardasil): Quadrivalent against HPV 6,11,16,18
  • HPV2 (Cervarix): Bivalent against HPV 16,18 (contraindication: severe latex allergy)
• Efficacy: Successfully reduces HPV infection; >90% efficacy against CIN2⊕ containing HPV 16/18; also ↓ risk of CIN grade 2/3, & adenoCA in situ (Lancet 2007;369:2161; 2007;369:1861)

Herpes Zoster

(MMWR 2008;57:1; NEJM 2005;352:2271)

• Goal: To prevent zoster or prevent/reduce the severity & duration of postherpetic neuralgia (see “Herpes Zoster”)
• Target population: Pts aged ≥60 y, including those w/ prior episode of zoster (give 6 mos after last episode)
• Contraindications: H/o anaphylaxis to gelatin, neomycin, or previous VZV vaccine; immunocompromised (see table above), including high- dose corticosteroids (≥20 mg/d prednisone ≥2 wks, until ≥1 mo after discontinuation); high-dose immunosuppressives or any immune modulators; persons who received varicella vaccine
• Dosage form: Zoster vaccine is a live, attenuated virus vaccine; safe w/ inactivated influenza, Td, Tdap, PCV13, PPSV23; give 4 wks apart from live, attenuated vaccines
• Efficacy: ↓ Zoster incidence by 51%, ↓ severity by 61%, ↓ postherpetic neuralgia by 66%

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VACCINE ADVERSE REACTIONS 

• Overview: Most pts can receive most vaccinations w/ only local s/e or minor cold sx
• True contraindications: Hx anaphylaxis to a vaccine → avoid only that vaccine; anaphylaxis to egg → avoid MMR, yellow-fever; pregnant or immunosuppressed → avoid all live virus vaccines
• Immunization-specific precautions See MMWR 2011;60(RR02):1
• Safe to admin vaccines to pts w/: Minor URIs, otitis media, (even if febrile), diarrhea, mild–mod local reaction to a previous dose of vaccine, pts on current antimicrobial Rx, or pts in the convalescent phase of an acute illness; not giving immunization → ↑ risk of individual infection → ↑ risk of transmission
• Red flags: Pts should seek medical attention for high fever, unusual behavior, or signs of serious allergic reaction (difficulty breathing, hoarseness, wheezing, hives, paleness, weakness, a fast heart beat or dizziness)
• Reportable reaction (all immunizations): Anaphylaxis (up to 7 d after admin); encephalopathy, encephalitis, or seizures (time limits below); any sequelae of reportable events; s/e listed in package insert as contraindications to future vaccination

Selected Immunization-specific Reportable Reactions
Immunization	Adverse Reactions
Tetanus	Brachial neuritis (w/in 28 d)
Pertussis	Encephalopathy or encephalitis (w/in 7 d)
Measles, mumps, or rubella	Encephalopathy or encephalitis (w/in 15 d)
Rubella	Chronic arthritis (w/in 42 d)
Measles	TTP (7–30 d)

Adverse events: File report via Vaccine Adverse Event Reporting System (VAERS at http://www.vaers.hhs.gov or by calling 1-800-822- 7967

THE PATIENT VISIT

Pre-Visit Preparation

(JAMA 1997;277:350; 2011;305:1802)

• Preparation: Review medical records, health maintenance to create tentative agenda; pre-order any labs (e.g., A1c, BMP); determine your 1–2 top priorities for the visit (e.g., “discuss ⊕ FOBT” or “review home glucose readings”); engage care team in this work to ↓ admin burden and ensure provider practicing at top of license
• Mindfulness: Self-awareness of personal biases, limitations in knowledge, & how provider mood, stress, expectations, & past experiences influence pt care (JAMA 1997;278:502; 1999;282:833; 1999;304:2532; NEJM 2013;368:2445); consider brief pause before knocking to restore focus/reset

In the Visit

• Establishing a provider–patient partnership (Arch Intern Med 2007;167:1172)
  • Greeting: Warmly greet pt by preferred name (default should be w/ title, e.g., Mr. Smith) Introduce yourself: Pts who are new to you prefer hearing your full name and your role Introduce your guests: If any, introduce & ask for permission; “[First Last] is a 1st-y medical student working with me today; is it all right if he joins us?”
  • Introduce yourself to pt guests: Elicit identity in nonjudgmental fashion (e.g., “Hi, I’m Dr. [Lastname]; it’s nice to meet you. How do you know [pt name]”?); ask if pt is comfortable w/ their presence before getting started Rapport-building: Apologize for any delay; begin & end visit w/ small talk, e.g., “How was your Thanksgiving?”
• Technology: Acknowledge computer in room, explain its purpose during your visit, “I am going to write down some notes about what we talk about;” “I am going to order those medications so they can be ready when you pick them up;” share screen, “Here are your A1c values for the past year”
• Agenda-setting: Approach visit w/ own tentative, flexible agenda, but elicit pt agenda up front; asking for pt agenda → improvement in understanding of pt concerns, which can → ↑ pt satisfaction and ↑ pt adherence (JGIM 2005;29:267; Ann Intern Med 2005;143:766)
• Asking about patient “concerns” or topics better than asking if they have “questions” (Patient Educ Couns 2016;99:718)
• Determine agenda for day’s visit vs. future visits; should be shared decision-making: “It sounds like your main concern today is this rash; I’d also like to talk a bit about your blood pressure, and let’s plan to talk about your headaches next time;” (NEJM 2012;366:1653)

History Pearls

• Medications: Include OTC & supplements, pt adherence & s/e Ask patients to bring in their medications to show you (or clinic PharmD, MA, RN)
• Allergies: Ask about details of reaction “What happened (when you took penicillin)?” distinguish btw true hypersensitivity & medication s/e
• Social history: An opportunity to understand pt identity and “life forces” which influence their health and their interaction with medical system; obtained over many visits 

Comprehensive Social History (NEJM 2014;371:1277)

Individual characteristics: Self-defined race/ethnicity, language, education, job history, military (including where s/he served), disability, trauma hx, gender identity/sexual practices, leisure activities, significant travel

Life circumstances: Family structure & living situation (who else is at home), housing environment (home, apt, shelter, street), food security, legal/immigration issues, employment, disability

Emotional health: Social stressors and supports, religious/spiritual beliefs

Perception of health care: Current priorities & how health fits into them; prior significant medical experiences, alternative medicine practices, advance care priorities

Health-related behaviors: Healthy and unhealthy practices and influences (incl tobacco, alcohol, recreational drugs), facilitators and barriers to med adherence, environmental safety (presence/storage of firearms, smoke detectors, seat belts, neighborhood safety)

Access to/utilization of health care: Health insurance status, medication access, health literacy, barriers to appointments (copays, transportation, work allowance, childcare)

• Family history: Age, health status, cause of death; specifically assess for screenable and/or heritable disorders: breast, colon, prostate cancer, cardiac disease, diabetes; FHx is dynamic, should be updated q5–10y in pts 30–50 y (JAMA 2011;306:172, 208)
• Sexual history: Reassure pt: “We ask all patients these questions”; sexual preferences (“Do you have sex w/ men, women, or both?”), practices (“When you have sex, who puts what where?”), number of recent/current partners, incl those outside of current relationship, protection, hx STIs, contraception, sexual dysfunction, hx abuse or IPV
• Advanced directives: See “Advance Care Planning”

Concluding Visit

(stepsforward.org/modules/pre-visit-planning)

• Summarize visit: Verbally and in writing; e.g. med changes, recommendations
• Schedule f/u: Establish appt time & agenda of f/u (“Let’s make an appt in 3 mos to talk about your diabetes…”)
• Order pre-visit labs/studies: For pt to complete before next visit (“… Come a few days early to get your A1c done so we can talk about it then”); this ↓ need for results calls/letters btw visits and helps develop plan during the next visit
• Results: Establish plan for communicating results as well as back-up plan for pt: Obtain permission to leave voicemail, confirm phone number
• Follow-up: Encourage pt to contact w/ any questions or concerns; “If you haven’t heard from me about your CT by next week, please call”; “If your rash doesn’t get better by the end of the week, let me know” Documentation: Include mechanism to organize issues/agenda for future visits; share message or note with consultants when appropriate, cc PCP if an urgent/1× visit
• After difficult visits: Reflecting on experience may help; consider colleagues, Balint groups, Schwartz Center Rounds, Healer’s Art (stepsforward.org/modules/empathetic-listening)

CARE OF THE “DIFFICULT PATIENT”

Background 

(AFP 2013;87:419; Am J Bioeth 2012;12:18; BMJ 1988;297:528; JAMA 2001;285:2629)

• Definition: Pt who engenders a negative reaction from providers (frustration, distress, exasperation), with whom it is difficult to establish a therapeutic relationship, who threatens provider safety, or who fails to assume the “patient role”; pt families may also be perceived as difficult; can → clinical errors, boundary violations, & legal concerns
• Pt characteristics: Pts ↑ likely to have an anxiety d/o, substance use d/o, personality d/o, poor functional status, ↑ affective intensity, ↓ satisfaction with care, & ↑ use of health services (Arch Intern Med 1999;159:1069; J Gen Intern Med 1996;11:1).
• Physician factors: Poor attitude re: psychosocial aspects of pt care, working >55 h/wk; depression/anxiety; ↑ number of patients with psychosocial problems or substance use d/o (BMC Health Serv Res 2006;6:128); lack of understanding/empathy regarding the patient, loneliness, different socioeconomic backgrounds, (NEJM 2012;367:1284); labeling a patient as “difficult” can allow providers to dismiss or blame pt
• Epidemiology: Up to ∼15–30% of primary care encounters; no evidence for association with pt demographics or nature of physical illness (JGIM 1996;11:1)

Management

(AFP 2005;72:2063; J Am Board Fam Med 2006;19:533; JAMA 2011;306:94)

• Safety: Trust your instincts; if feeling uncomfortable or pt begins to escalate behavior, okay to open the door, say “Your shouting is making me uncomfortable,” or simply excuse yourself from the room
• Behavior with staff: Patients may be rude to staff & then kind to you; offer a simple reminder that you & staff are aligned and such behavior is not acceptable
• May need to develop a behavioral plan for pts w/recurrent behavioral issues
• Physician training & factors (Arch Intern Med 1999;159:1069)
  • (1) Increase awareness/compassion for pt psychosocial context
  • (2) Dx & treat comorbid Ψ illness
  • (3) Focus on physician well-being, work-life balance (Balint groups, Schwartz rounds, communication with colleagues) (4) Restore collaboration by prioritizing patient concerns, using a nonjudgmental attitude (5) Set limits & boundaries—be firm but compassionate
  • (6) Mindfulness: Awareness & acknowledgement of own emotional responses
  • (7) Engage others in care of patient (paperwork, forms, letters) to ↓ administrative burden (8) Have security on site at time of appointment (where available) if safety concerns exist (9) Document safety concerns & decision-making
• Empathic interactions: Naming/validating pt emotion (“I can see you are upset”). Active listening (“tell me why X is so upsetting”;) Engage patient (“What may we do to help you feel better?”)

Pt Characteristic	Management Recommendation (AFP 2005;72:2063; NEJM 1978;298:883)
Neediness	Professional behavior, boundaries (e.g., when to call/page), shared decision-making, regular f/u, reassure pt they will not be abandoned; set small, achievable goals; enlist family if pt willing; schedule longer visits; address one concern/visit
Entitlement	Mindfulness, address specific pt emotion; inform pt they deserve to get good medical care & team is working in their best interest; apologize for legitimate grievances (e.g., wait times)
Pessimism “Eeyore”	Engage by sharing disappointment at poor results; offer realistic expectations; focus on symptom control rather than cure
Self-destructive	Realistic expectations; celebrate small successes; examine cause of nonadherence; respect autonomy; motivational interviewing (see “Counseling Patients”)

COUNSELING PATIENTS

BEHAVIORAL COUNSELING

Background

• Definition: A form of therapy that seeks to change behavior(s); general approach includes discussion of pt’s awareness of behavior pattern & its effects, soliciting pt’s perspective on behavior & reasons for change, & engage pt in planning for change
• Strategy: Different techniques available; important to find a strategy that is a good fit for the topic, the provider, & the individual; avoid arguments & confrontation, which can ↑ pt defensiveness & resistance to change; changing most of these behaviors are long-term goals & benefit from a therapeutic relationship; nonjudgmental listening is key
• Efficacy: Most counseling shows a “dose–response” relationship; ↑ success at changing behavior w/ recurrent discussions; providers can effect change despite their time limitations, but should also consider referral to others trained in this approach as local resources & situation allow (e.g., social workers, chemical dependency specialists, therapists)

Motivational Interviewing

(AFP 2009;79:277)

• Pt-centered technique proven helpful in tx of substance, EtOH use d/o; can help develop therapeutic relationship & set individual goals (Cochrane Data System Rev 2011;5:CD008063; Motivational interviewing: Helping People Change, Miller & Rollnick, 2013)
• Idea that arguments for & against change already exist within the pt; frame conversation so that pt voicing reason for change to provider, not vice versa; goal is a guided, collaborative conversation that engages & empowers pt, strengthen’s pt’s motivation/commitment to change
• Encourage pt to envision him/herself in the future, when they are successful & look back at what made them successful; use past success as a template for future success—what worked before, how could they use that now?

Sample Process of Motivational Interviewing (Adapted from Miller WR, Rollnick S, Butler CC. Motivational Interviewing in Health Care. 2008)

(1)  What would motivate you to make this change? (2)  What are the 3 best reasons to do it? (3)  How important is it to you to make this change, & why? (4)  How would you go about it in order to succeed? (5)  Reflect answers back to pt (6)  So what do you think you’ll do?

R: RESIST telling patients what to do U: UNDERSTAND patient motivators to change & not to change L: LISTEN to your patient E: EMPOWER your patient to make good decisions

• Transtheoretical: Behavioral changes occur in stages; provider assessment of pt readiness for change
  • Precontemplation: Not interested in change; advise pt of risks & ask for their thoughts Contemplation: Considering change; “What are the pros/cons of quitting?”
  • Preparation: “Do you think you could start making those changes next week?”
  • Action: Support & reflect on what they are doing well/personal strengths they are using
• 5 As: See “Tobacco Use”
• 5 Rs: Designed for smoking cessation, but may be useful in other circumstances
• Relevance: Why changing behavior is personally relevant (e.g., children’s health) Risks: Negative consequences of behavior (e.g., shortness of breath, cancer) Rewards: Potential benefits of changing behavior (e.g., improved health, saving money) Roadblocks: Barriers to changing behavior (e.g., fear of wt gain, withdrawal sx) Repetition: Approach these issues on a regular basis

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PSYCHOSOCIAL COUNSELING

(AFP 2009;79:277)

• Epidemiology: >50% of mental health visits are to PCPs; supportive counseling may be therapeutic for pt mood & physical sx (Prim Care Clin Office Pract 2007;34:551)
• Challenges: Providing supportive counseling in a busy primary care practice is challenging, esp if pts p/w numerous other medical problems; The BATHE technique may provide therapeutic counseling in a time-efficient manner (1–5 mins)

BATHE Protocol (Stuart MR, Lieberman JA. The 15-Minute Hour. 2008)

B: BACKGROUND: Elicit stressors, “You seem upset; what’s going on in your life (or how is life treating you)?” A: AFFECT: “How do you feel about it?” T: TROUBLES: Identifying a specific part of a problem makes it manageable & provides something PCP may assist w/, “What troubles you most about losing your job?” H: HANDLING: Assess coping mechanisms; “How are you handling the divorce?” E: EMPATHY: Validate pt emotions; “That sounds very difficult for you”; try to address main issue, e.g., “Would you like to talk to our social worker about housing resources?”

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GRIEF 

(JAMA 2013;310:416)

•  Definition: Grief is bereavement after a loss, often the death of a loved one, typically lasting 6–12 mos; Complicated grief: Yearning for/preoccupation w/ the loss, preoccupation w/ surrounding circumstances, intense sorrow/anger/self-blame, and/or denial/avoidance that impairs function, causes significant distress, & does not improve w/ time
• Risk factors: ♀, pre-existing psych d/o (anxiety, depression), childhood trauma, nature of death/loss, death of spouse, social support/resources available, EtOH/illicit use
• Epidemiology: ∼7% of pts experience complicated grief
• Diagnosis: Clinical; Ddx includes depression, anxiety, PTSD, all of which may coexist
• Treatment: Bereavement support groups, mgmt of comorbid d/o, targeted psychotherapy
• Patient information: JAMA 2005;293:2686

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BREAKING  BAD NEWS

• Providers often have responsibility for sharing potentially upsetting news; wide ranges in nature of pt–provider relationship & in emotional impact of news
• Providers can often have significant positive impact on encounter by preparing & supporting the pt appropriately
• Consider SPIKES protocol; for further discussion of pt wishes in setting of poor prognosis, see “Advance Care Planning” 

SPIKES Protocol (Adapted from Oncologist 2000;5:302)

Setting: Private area, tissues ready, pager/phone set to silent; let pt decide who is present; sit down w/ pt, establish rapport Perception: Assess pt understanding of medical situation/nature of conversation Invitation: Ask pt what information they wish to know Knowledge: Share 2–3 key facts, as simply as possible, & w/ pauses to allow pt to digest/process info; “I’m sorry to tell you that the cancer has spread” – PAUSE – “There are new lesions in the liver” – PAUSE – “This is why your skin is yellow” Empathy: Recognize & respond to pt emotion, goals, & hopes; “We were all hoping for a different result;” sometimes helpful to name pt emotion, e.g., “You seem upset” Respond to pt cues; try moving closer to pt & offering an empathic gesture (e.g., offering tissue) while being silent until pt speaks Align provider goals w/ pt (“I wish…”) while acknowledging situation (“…but”) Invite pt response: “I imagine this is really difficult to hear” Strategy/Summary: Discuss next 1–2 steps – referrals, studies, f/u plan for PCP “I’ve set you up to talk w/ the surgeons about this, & I’ll see you back in 2 wks”

OBESITY

Background

(NEJM 2017;376:254)

• Obesity is a multifactorial, chronic disease affected by social, behavioral, cultural, metabolic, & genetic factors
• Body mass index: (weight [kg]/height [m2]); serves as proxy for amount of relative body fat; however, this is indirect, & ↑ BMI may reflect higher lean mass for certain pts (e.g., athletes)
• Classification: Obese: BMI ≥30; overweight: BMI >25
• Comorbidities: Health risks assoc w/ obesity include prediabetes & DM2, HTN, HLD, CVD, gallstones, NAFLD, GERD, OA, cancer, OSA, stroke, mood/anxiety/eating d/o, disability, ↑ mortality (obesity itself accounts for ~5–15% US deaths/y) (NEJM 2009;361:2252)
• Epidemiology: >1/3 US adults obese, >2/3 overweight or obese; dramatic (>2×) ↑ prevalence in past 30 y, now leveling off (JAMA 2016;315:2284)
• Risk factors: Assoc w/ ↑ age; race/ethnicity: non-Hispanic black >Mexican-Americans > any Hispanic race/ethnicity; ↓ socioeconomic status; ↓ education (♀ only)

Evaluation

• Screening: All adults by BMI & waist circumference at periodic health visits
• History: Complications (as above), RFs for complications (tobacco use, ⊕ FHx CAD); Contributing factors: (Mood d/o, hypothyroidism); Meds: Especially those w/ wt-related s/e (atypical antipsychotics, antidepressants, antiepileptics, diabetes medications, glucocorticoids); Social hx: Support system, resources (time, money), motivations for wt loss, barriers to wt loss; stressful life events
• Weight history: Past wt loss attempts (incl meds, surgery), diet (esp fast food, sugary beverages, snacks, portion size, timing of eating), physical activity, ⊕ FHx obesity
• Physical exam: Height, weight, waist circumference, BP; look for signs of insulin resistance (acanthosis nigricans), hypothyroidism, & Cushing syndrome
  • Visceral abdominal adiposity strongly associated w/ obesity complications: Waist circumference >40″ (♂)/>35″ (♀) independently ↑ health risks in pts w/ BMI <35 (note ↓ cut-offs in people of East Asian descent: >35″ (♂)/ >31″ (♀) (AHRQ 2011; 11- 05159-EF-1)
• Lab: Chem 7 (Cr for HTN/DM-related renal disease screening), LFTs (NAFLD screening), TFTs (r/o underlying hypothyroidism), HbA1c (DM screening), fasting lipids (HLD screening); consider Vit D (frequently comorbid Vit D deficiency)

Treatment

(Obesity 2014;22(S2):S1)

• General approach: Goals are (1) prevent further wt gain, (2) reduce body wt, (3) maintain wt loss over long term; gradual wt loss (rate = 1–2 lb/wk) w/ initial goal of 5–10% wt loss recommended
• Indications for weight loss: Recommended if BMI > 25 kg/m2 or high- risk (waist circumference plus ≥2 CV RFs)
• Benefits: Health benefits seen w/ any wt loss, even if pt remains above ideal body wt (↓ risk DM, HTN, CVD, HLD, disability; ↓ HbA1c for pts w/ DM)

Lifestyle Modification

• Comprehensive behavioral change = cornerstone of therapy; may encourage small steps toward change if not ready for lifestyle overhaul; see “Counseling Patients”; set goals/metrics for success to keep motivated
• Energy balance equation: Net body balance (wt) = Energy input (food) – Energy output (metabolism, physical activity)
• Diet: Low-calorie diet essential; recommend ∼1200–1500 kcal/d ♀,
• 1500–1800 kcal/d ♂; reduction of 500 kcal/d results in wt loss of 1 lb/wk; nutritionist can offer more precise calc.
• Low carbohydrate, low fat, Mediterranean diet, DASH diet, & other diets all effective → patient preference & adherence key factor (NEJM 2009;360:859)
• Recommend ↓ soda & sugary beverage consumption as appropriate (25% of US consumes >200 kcal/d of soda) (NCHS Data Brief 2011;71:1); reframe as “liquid candy”
• Recommend ↓ EtOH intake as appropriate (20% of men consume >300 kcal/d of EtOH ≈ 2 beers) (cdc.gov, NHANES 2013)
• Exercise: Exercise alone may not → significant wt loss (Obesity 2011;19:100), but important for prevention of wt gain & ↓ CV/DM risk independent of wt loss (Arch Int Med 2008;168:2162); AHA recommends ≥150 min/wk moderate to vigorous activity (e.g., 30 min/d 5 d/wk)
• Weight Self-Monitoring: Encourage weighing at home ≥1×/wk, both for wt loss & wt maintenance
• Behavioral therapy: offer referral to high-intensity comprehensive lifestyle intervention (14 visits in first 6 mos), where pt will have regular feedback & support from trained healthcare professional, complete behavior change curriculum, & monitor food/exercise/wt
• Group programs: YMCA diabetes prevention program (AJPH 2015;105:2328) & commercial wt loss programs like Weight Watchers (JGIM 2013;28:12) effective for some patients

Pharmacotherapy

(J Clin Endocrinol Metab 2015;100(2):342)

• Indications: Obese or BMI ≥27 w/ CV RFs who have failed lifestyle modifications alone
• General considerations: Always prescribe in combination w/ ongoing lifestyle modification counseling (AHRQ 2011; 11–05159-EF-1); titrate ↑ from lowest dose; wt loss effect often lost after medication d/c; newer nongenerics costly & usually not covered by insurance
• Orlistat (Xenical, Alli): FDA-approved for chronic wt mgmt
  • Mechanism: Lipase inhibitor → ↓ fat digestion/absorption
  • S/e: Bloating, flatulence, oily stools, ↓ fat-soluble vitamin absorption Contraindications: Pregnancy, chronic malabsorption, gallbladder disease Notes: Less costly ½ strength OTC formulation available (Alli); Rx w/ multivitamin
• Phentermine/Topiramate ER (Qsymia): FDA-approved for chronic wt mgmt
  • Mechanism: (P) Inhibits NE/5HT reuptake & (T) enhances GABA activity, glutamate antagonist → ↓ appetite, ↓ food intake S/e: (P) Tachycardia, HTN → monitor BP/HR; (T) teratogenic, cognitive dysfunction, metabolic acidosis, constipation, dysgeusia Contraindications: Pregnancy, hyperthyroidism, MAOI use, glaucoma Notes: Qsymia more effective than phentermine alone (CONQUER, Lancet 2011;377:1341); phentermine alone is generic, FDA-approved for wt mgmt for ≤ 3 mos
• Lorcaserin (Belviq): FDA-approved for chronic wt mgmt
  • Mechanism: 5HT 2C receptor agonist → early satiety, ↓ food intake S/e: HA, nausea, fatigue, constipation, hypoglycemia (if DM) Contraindications: Pregnancy, serotonergic drug Rx (SSRI, SNRI)
  • Notes: No effect on 5HT 2B receptor (which in fenfluramine → valvular disease)
• Bupropion SR/Naltrexone SR (Contrave): FDA-approved for chronic wt mgmt
  • Mechanism: (B) Inhibits NE/dopamine reuptake & (N) opioid antagonist → ↓ food intake S/e: Tachycardia, HTN → monitor BP/HR; HA, nausea, vomiting, dizziness, insomnia Contraindications: Pregnancy, seizures, uncontrolled HTN, chronic opioid use, MAOI use Notes: Helpful for pts w/ frequent thoughts of food & food cravings
• Liraglutide (Saxenda): FDA-approved for chronic wt mgmt
  • Mechanism: GLP-1 agonist → early satiety, ↓ food intake
  • S/e: nausea, vomiting, diarrhea, pancreatitis
  • Contraindications: Pregnancy, hx pancreatitis, hx medullary thyroid cancer or MEN2
  • Notes: Liraglutide FDA-approved for DM (Victoza) w/ lower max dose (1.8 mg/d) vs. max dose 3.0 mg/d for Saxenda

Bariatric Surgery

(Cochrane Database Syst Rev 2014;8:CD003641; NEJM 2007;357:741; Ann Int Med 2005;142:547)

• Indications: Pts w/ BMI ≥40 or BMI ≥35 w/ related comorbidities (HTN, OA, OSA) who have failed conventional Rx or BMI ≥30 w/ DM
• Contraindications: Tobacco/nicotine use, Ψ d/o not well treated for 1 y, eating d/o
• Efficacy: Surgery more effective at ↓ wt & ↓ comorbidities (DM, HLD, HTN, OSA) than medical Rx for pts w/ BMI >30
• When referring, document prior wt loss attempts, medical necessity, pt comprehension & accountability; refer to experienced ctr → ↓ surgical risk (Can Fam Physician 2010;56:873)
• Laparoscopic sleeve gastrectomy: Most common procedure (Obes Surg 2013;23:427; asmbs.org); typical wt loss 25–30%; mortality 0.2–0.5%; shorter operative time & decreased malabsorption complications compared to RnY
• Laparoscopic Roux-en-Y gastric bypass: 2nd most common procedure; Gold standard bariatric surgery → greatest improvement in GERD, type 2 DM, & HTN; typical wt loss 30–50%; mortality 0.5–0.9%; complications include wound infection/dehiscence, stromal stenosis, hernias, gallstones, vitamin deficiencies, dumping syndrome
• Other procedures: Laparoscopic adjustable gastric banding less commonly performed in the US due to ↓ effectiveness & complications (band slippage/erosion, pouch dilatation); Investigational & uncommon procedures include intragastric balloon, biliopancreatic diversion, duodenojejunal bypass sleeve, & transoral surgical approaches
• Weight Regain After Bariatric Surgery: Common (≥20% prevalence; Nutrition 2008;24:832); DDx includes dietary nonadherence, fistula, gastric pouch enlargement, anastomosis dilation. Refer to bariatric center for evaluation & consideration of EGD
• Monitoring After Bariatric Surgery: patients should continue to be monitored for pre-existing comorbid conditions (HTN, HLD, NAFLD, DM), as well as nutritional deficiencies, depression, & complications of malabsorption (e.g., osteoporosis)

CHRONIC PAIN

Background 

(J Pain 2008;9:883; cdc.gov/nchs 2010 Nat’l Health Statistics; Pain 2011;152:1219)

• Definition: Pain persisting beyond timeframe of expected healing or due to ongoing/recurrent insult; generally, >3–6 mos in duration
• Classification: Neuropathic pain: Damage or malfunction of nerves; may be peripheral (e.g., diabetic neuropathy, postherpetic neuralgia; see “Peripheral Neuropathy”) or central (e.g., spinal cord injury, multiple sclerosis, stroke); Nociceptive pain: Initiated by inflammation or tissue damage; may be superficial (burns, abrasions), deep somatic (arthritis, sprain), or visceral (IBD, bowel obstruction)
• Pathophysiology: Can be due to mechanisms at many levels of peripheral & central nervous systems including abnormal neuroplasticity (nl stimuli processed along pain pathway → perceived as painful); biochemical imbalance (5HT + NE both shown to ↓ peripheral pain signals); severity of pain does not correlate w/ degree of tissue damage
• Epidemiology: Often not assessed separately from other conditions, but affects 20% of ♀ & 17% of ♂ in US; may be 40% in older adults (MMWR Weekly 2013;62:342): LBP, arthritis, & HA all common; many people have pain at multiple sites; chronic pain more prevalent among pts w/ ↑ social stressors, ↓ SES, older age, poorer physical health
• Treatment disparities: Evidence that nonwhite pts may receive ↓ analgesics, ↓ pain specialist referrals, & have ↓ PCP trust even when similar rates of opioid misuse/illicit drug use (Pain 2013;154:36; JGIM 2011;26:846)
• Risk factors/comorbidities (Gen Hosp Psych 2009;31:206)
  • Depression: Up to 1/2 of pts w/ MDD have chronic pain; >25% of pts w/ chronic pain have MDD; often underdiagnosed (Arch Intern Med 2003;163:2433); ↑ disability, ↓ coping, ↓ response to tx Anxiety: Pts w/ chronic pain more likely to have anxiety & panic d/o (Depress Anxiety 2008;25:593) PTSD: Higher rates of chronic pain (up to 80% of Vietnam combat veterans) (J Psychosom Res 1997;43:379) SUD: In primary care, rates of SUD in pts w/ chronic pain range from 3– 34%; may be higher in pts on chronic opioids (Ann Intern Med 2007;146:116; Pain 2011;152:488) Injury: 15% of those w/ mod–severe traumatic injury → chronic pain 1 y later; ↑ risk if: severe injury, severe pain at presentation, belief in future need for pain meds, hopelessness re: ability to relieve pain (Pain Med 2010;11:1599)

Evaluation

• General approach: A thorough initial hx can be therapeutic; even if unable to determine etiology, listening helps reassure pt & provider that a search for potential causes has been appropriately undertaken
• Pain history: In addition to evaluating/identifying any medical condition responsible for the pain, focus on impact of pain rather than its intensity (NEJM 2015;22:2209)
  • Impact: What has been the effect on pt QoL, activity level, occupation, social life?
  • Assoc sx: Depression, anxiety, stress
  • Beliefs: Pt’s understanding of dx studies & responses to specific tx, including Rx & OTC medications (noting dosage, duration), CAM, & nonpharmacologic approaches
• Past medical history: Assess for comorbidities that may impact tx plan: mood d/o, SUD, mobility restrictions, advanced chronic disease (e.g., CHF, COPD)
• Social history: What is current & prior level of functioning? Assess recreational & fitness activities, occupational hx; ask about social supports (see “The Patient Visit”)
• Exam: Complete PE recommended, w/ particular focus on MSK & neuro exam; additionally, observe for pain behaviors (e.g., moaning, facial expressions)
• Diagnostics: As per clinical scenario

Nonpharmacologic Treatment

(BMJ 2017;357:j1284)

• General approach: Identify & definitively treat underlying cause whenever possible; if pain persists, focus on function; multimodal is best (Rheumatology (Oxford) 2008;47:670)
  • If cause known: Tx of cause & exacerbating factors as able; review of available tx options & periodic reassessment of tx course appropriate (see “Peripheral Neuropathy,” “Fibromyalgia,” “Inflammatory Bowel Disease,” “Herpes Zoster,” “Pelvic Pain,” “Headache,” “Jaw & Dental Pain,” Musculoskeletal ch., “Depression,” “Anxiety”) If cause unknown after complete eval: Provide reassurance (pts w/ chronic pain often have ↑ level of health anxiety) & periodically reassess, consider further eval as indicated (J Psychosom Res 2006;60:155)
• Discuss: Validate experience (“I hear that this has really been affecting your life”)
  • Expectations: Chronic pain is a complicated problem; currently available therapies rarely result in complete resolution of sx (often not “curable”); establish function as tx goal, not resolution of pain Goal setting: “How will we define improvement?” —should be SMART (Specific, Measurable, Achievable, Relevant, & Time- bound) (Pain Med 2009;10:S101) Follow-up: Needs assessment over time, focusing on function: Ask “How does the pain interfere w/ enjoyment of life/general activity?” (JGIM 2009;24:733)
• Safety/side effects: Most nonpharmacologic interventions are low/no risk

Nonpharmacologic Interventions for Chronic Pain
Intervention	Conditions Recommended	Evidence
Exercise	Fibromyalgia, LBP, hip/knee OA	Beneficial for most chronic pain (Cochrane Database Syst Rev 2017;4:CD011279); specific benefit for fibromyalgia (BMJ 2002;325:185); chronic low back pain (Ann  Intern Med 2008;148:247); consider low- impact (swimming, tai chi, gentle yoga) for pts w/ knee or hip OA (Arthritis Care Res 2012;64:465)
Psychotherapy	Fibromyalgia, neuropathic pain, LBP	Cognitive Behavioral Therapy (CBT): ↓ disability & improve mood; ↓ chronic low back pain (Ann Intern Med 2008;148:247; Cochrane Data Syst Rev 2012;11:CD007407; Pain 2013;154:824) Acceptance and Commitment Therapy (ACT): Awareness of experiences & movement toward personal goals; ↓ functional limitation & ↓ pain- related anxiety (Pain 2011;152:2098)
Mind-body medicine (biofeedback, meditation, yoga, tai chi)	LBP, neck pain, headaches, fibromyalgia	Improved function, decreased pain, & disability (JAMA 2016;315:1240; J Pain 2012;13:1; NEJM 2010;363:743)
Acupuncture	Fibromyalgia, neck, & LBP	Improved pain/reduced stiffness; true acupuncture better than sham acupuncture (Cochrane Database Syst Rev 2013;5:CD007070; Arch Intern Med 2012;172:1444; JAMA 2014;311:955)
Manual (massage, chiropractics)	MSK pain, HA, fibromyalgia	Benefit in LBP, shoulder pain, HA, fibromyalgia (Lancet 2011; 377:2226; Evid Based CAM 2007;4(2):165)
Transcutaneous electric nerve stimulation (TENS)	Neuropathic pain, MSK pain	Limited RCT evidence (Cochrane Database Syst Rev 2008;16 (3):CD003222)
Sleep	All	Poor sleep assoc w/ ↑ incidence of pain, ↓ pain threshold, ↑ emotional response to pain (Eur J Pain 2012;16:522; Pain 1996;68:363; J Sleep Research 2007;16: 185); no studies re: sleep interventions, but reasonable to review sleep hygiene
Thermal (heat/ice)	All	Limited RCT evidence

Pharmacotherapy

(ICSI 2011 Chronic Pain Guidelines, icsi.org)

• General approach: Many classes available; studies of efficacy often restricted to certain causes, prescribing choices based on type(s)/source(s) of pain & s/e profile
• For short-acting agents, consider prescribing PRN specific scenario (before a walk, before making dinner) rather than simply time-based (e.g., “q4h PRN”) to emphasize function
• Antidepressants: Treat comorbid mood or anxiety d/o; antidepressants ↓ pain & MDD sx simultaneously (Arch Int Med 2003;163:2433); can also help pts w/o depression by Δ how brain interprets painful stimuli (Pain 1999;83(3):389)

Pharmacotherapy for Chronic Pain by Pain Type
Pain Type	Treatment
Neuropathic pain (Mayo Clin Proc 2015;90:532)	1st-line: TCAs, gabapentin (see “Neuropathy”) Adjunct: Topicals (lidocaine, capsaicin)
Fibromyalgia & myofascial pain (JAMA 2014;311:1547)	1st-line: SNRIs, TCAs 2nd-line: Non-BZD muscle relaxants, gabapentin (see “Fibromyalgia”)
OA (knee, hip, hand) (Arthritis Care Res 2012;64:465)	1st-line: APAP, topical NSAIDs (knee, hand) 2nd-line: NSAIDs 3rd-line: Tramadol, intra-articular corticosteroids 4th line (should be used rarely): opioids; see “Chronic Opioid Use”
Low back pain (Spine J 2008;8:173; AFP  2009;79:1067)	1st-line: APAP, NSAIDs 2nd-line: TCAs, SSRIs (see “Low Back Pain”)
Localized MSK pain	Topical agents (lidocaine, capsaicin, topical NSAIDs)
Complex regional pain syndrome (Pain Med 2013;14:180)	NSAIDs, TCAs, gabapentin, topical agents; tx similar to neuropathic pain (above)
Pharmacotherapy for Chronic Pain by Medication Type
Medication	Conditions Recommended	Notes
TCAs	Neuropathic pain, fibromyalgia, low-back pain, HA, & IBS	↑ Risk CV events, ↑ QT
SNRIs	Fibromyalgia, consider for knee/hip OA (2nd-line), neuropathy	S/e: Nausea, ↑ BP; caution if liver disease, HTN

 

Gabapentin, pregabalin	Fibromyalgia, neuropathic pain	S/e: Sedation, dizziness, edema, wt gain; renally cleared, caution if ↓ GFR
NSAIDs	OA, RA, LBP; Topical NSAIDs for hand, shoulder, knee, back pain	No evidence for fibromyalgia or neuropathic pain; risk gastritis, AKI/ESRD, hepatitis; s/e may be ↓ w/ topical NSAIDs
APAP	OA (1st-line)	Use as NSAID or opiate-sparing adjunct; preferred over NSAIDS in pts w/ CAD; S/e: ↑ LFTs, drug rash
Tramadol	↓ Pain substantially in OA, fibromyalgia, & neuropathic pain	SNRI + opioid agonist; ↑ risk of 5HT syndrome if used w/ SSRI, cyclobenzaprine
Capsaicin	For neuropathic & MSK pain (incl OA) when limited to focal area	Applied BID, max efficacy not reached until ∼2 wks 2/2 substance P depletion
Lidocaine patch	Postherpetic neuralgia	12 h on, 12 h off; may have local or (rare) systemic s/e
Muscle relaxant (cyclobenzaprine)	Fibromyalgia; no evidence for chronic MSK pain	Sedating; avoid carisoprodol 2/2 risk of dependency
α2-agonist (tizanidine)	Antispasticity agent, used for tension HA, LBP	HoTN, sedation, dizziness
Opioids	Not routinely recommended	See “Chronic Opioid Use”

(Adapted from Arthritis Care Res 2012;64:465; JAMA 2004;292:2388; Lancet 2011;377:2226)

When to Refer

• Referral threshold dependent on local resources; multiple disciplines may be helpful
• Pain specialist: Consideration of interventional therapies, such as injectables (e.g., nerve block), implantable device (e.g., spinal cord stimulation, controversial); pain may also be able to suggest tx plans which can be administered by PCP
• Other specialist: Severe/refractory pain which is potentially correctable w/ intervention should be referred to appropriate discipline (e.g., knee OA → orthopedics)
• Therapist: Can assist w/ pain-related distress-coping techniques, mgmt of mood or SUD
• Palliative care: Co-mgmt of sxs in pts w/ life-limiting illness

CHRONIC OPIOID USE

Background 

(MMWR 2011;60:1487; JAMA 2013;309:657; cdc.gov/drugoverdose/epidemic/)

• Definition: An opioid is any substance that binds to opioid receptors (found in CNS, PNS, & GI tract); opiates are naturally derived from poppy (e.g., morphine, opium)
• Epidemiology: 3–4% of US adults receive chronic opioid tx (Pharmacoepidemiol Drug Saf 2009;18:1166)
• Efficacy: No long-term (>1 y) studies of opioids for chronic pain; dose- dependent risk of adverse effects; a select subset of individuals can safely use opioids for long-term pain relief (Cochrane Database Syst Rev 2010;1:CD006605; Ann Intern Med 2015;162:276)
• Side effects: Nausea, constipation, somnolence, ↑ fall risk in elderly, hyperalgesia (paradoxical ↓ pain tolerance), hypogonadism, medication misuse (5% of US adults have used opioid Rx for nonmedical reasons, in excessive dose, or via unauthorized routes), addiction (up to 25% of pts receiving chronic opioids in primary care have opioid use d/o) (J Pain 2007;8:573; Ann Intern Med 2007;146:116; AFP 2012;85:49; Drug Alcohol Depend 2008;94:38)
• Risks: Opioids responsible for 61% of drug O/D deaths, usually unintentional (MMWR Weekly 2016;65:1445); for chronic pain, opioid Rx assoc w/1.64× ↑ risk of death when compared with nonopioid regimens (JAMA 2016;316:2415); since 1999, 4× ↑ in no. of US opioid Rx’s & 4× ↑ in no. of US Rx opioid O/D deaths; recent slowing in rate (excluding illicit fentanyl) due to restricted prescribing (drugabuse.gov/related-topics/trends- statistics/overdose-death-rates)

Evaluation

Should a trial of chronic opioids be initiated?

1. Have other agents w/ more favorable s/e profiles been tried?
2. What is the risk of misuse? (See “Risk Assessment”, below)
3. What are potential benefits & tx goals? Do these outweigh the risks?

Risk Assessment: Multiple screening tools exist; not intended to supplement clinical judgment (J Pain 2009;10:131); (see “Opioid Use Disorder”)

Opioid risk tool: 5-question survey; predicts risk of aberrant behavior (early refills, unauthorized dose escalation, hx O/D, abnl utox, soliciting opioid Rx from other providers); available at opioidrisk.com/node/887 (Pain Med 2005;6:432) DIRE score: Diagnosis, Intractability, Risk, Efficacy → helps predict opioid efficacy (↓ pain & ↑ function) & risk of aberrant behavior requiring d/c of Rx; available at opioidrisk.com/node/517, mobile app at opioidrisk.com/node/2404 (J Pain 2006;7:671)

Treatment

(MMWR 2016;65:1)

• Deciding not to prescribe opioids: “Based on my medical opinion, I would not recommend using opioids for this pain;” or “Opioids are not a safe option for your pain, but there are some other txs I would recommend;” acknowledge pt frustration; discuss other tx, offer reassurance; consider referral to pain specialist
• High-risk patients: Avoid opioid use; very close monitoring if Rx opioids; consider referral to pain specialist
• Initiation of opioid therapy as part of a comprehensive tx plan (see “Chronic Pain”)
  • Start as a trial (e.g., 7–30 d); establish mutually accepted, specific, measurable outcomes in advance (see “Goal setting” in “Chronic Pain”): “How will we know if this is working? Not working?”
  • Use short-acting initially, not long-acting opioids; avoid escalating above 50 morphine-equivalents (MED) per day (e.g. ~30 mg oxycodone) 3. Write prescriptions with partial fill option, in case patients do not want to accept the full prescription (particularly for initiation trial) 4. Create & review opioid tx agreement for all pts; frame as informed consent & chance to be explicit about expectations, avoid term “contract” (tx decisions bound by provider’s best judgment of benefit & safety, rather than by written document) Follow-up: Review the 4 As (Adv Ther 2000;17:70; Pain Med 2005;6:107):
    • Analgesia: Effectiveness of medications at ↓ pain
    • ADLs: Has this tx ↑ functioning?
    • Adverse events: Any s/e or toxicities of the medication
    • Aberrant behavior: Any signs of abuse of the medication?
• Efficacy: If some progress toward goals, continue Rx; if lack of benefit or significant s/e → taper off; express shared frustration at lack of efficacy (JAMA 2013;309:919)

Recommended Components of Opioid Treatment Agreement
Component	Sample Details
Indications	Type/location of pain, other tx which have been tried
Time frame	E.g., initial 7–30 d trial
Goals of Rx	Agreed upon w/ pt
Potential risks	S/e, med interactions (other sedating Rx, EtOH), activity restrictions/hazards (driving, other activities that put self/others at risk), physical dependence, addiction
Comprehensive tx plan	E.g., other activities for pain mgmt (exercise, PT), tx for substance use or mood d/o
Provider expectations	Obtaining opioids from one (named) provider, one (named) pharmacy, no unauthorized ↑ in dose; limits on early refills or replacing lost/stolen medications, rules of requesting refills, offer partial fill option
Monitoring to reduce risk of harm	Urine drug testing, pill counts, assessment of efficacy, & s/e
Indications for changing or stopping opioids	When risks/harms may outweigh benefits (not meeting tx goals, s/e, aberrant behavior, safety concerns, lack of efficacy)
(American Academy of Pain Medicine clinical guidelines, J Pain 2009;10:113; US Substance Abuse & Mental Health Services Administration, Treatment Improvement Protocol 54 www.samhsa.gov) Sample agreement: www.aapainmanage.org/literature/Articles/OpioidAgreements.pdf

• Monitoring: Avoid paradigm of “catching” pt; many Rx require monitoring due to safety risks (e.g., isotretinoin “iPLEDGE”); combined chemical + behavioral monitoring ↑ effective at detecting misuse (Pain Med 2009;10: Suppl 2:S101); explain that provider cannot provide risky medications w/o the pt’s participation in ↓ risk Chemical: Planned & random urine testing, risk determines freq (↑ risk = ↓ freq)
  • Prescription Drug Monitoring Program: one in every US state; review at least q 3 mo
  • Behavioral: Aberrant behavior assessment, pill counts, corroborative reports of others
• Preventing overdose: Consider naloxone Rx to prevent O/D in pts prescribed chronic opioids, particularly if prior O/D, higher doses (≥50 MED), concurrent sedatives (Ann Intern Med 2016;165:245)
• Preventing constipation: Persistent s/e; ensure bowel regimen (stool softeners, laxatives, GI-specific opioid antagonists) (Am J Gastroenterol 2013;108:1566)
• Approach to aberrant behavior (J Pain 2009;10:131; Pain Med 2009;10: Suppl 2:S101)
  • Confirm findings
  • State findings to pt in nonjudgmental way “I notice that your last urine toxicology test was positive for cocaine. Can you tell me what happened?”
  • Listen to pt; express concerns that such behavior is problematic
  • Consider potential causes of aberrant behavior & treat the causes as able 5. therapeutic structure; more frequent visits, urine drug testing (incl at time of behavior when feasible) remind pt that aberrant behavior signals increased risk If behavior continues, taper to alternative meds; if addiction suspected, recommend eval/tx (see “Substance Use Disorders”)

Aberrant Behaviors which Predict Addiction or Opioid Use Disorder
Selling meds or falsifying Rx Obtaining medications from nonmedical sources Resistance to changing medications despite ↓ in function or significant s/e Lack of control over substance use Recurrent episodes of: Rx loss or theft, obtaining opioids from other providers, unauthorized dose escalation, early refill requests
Behaviors Which Arouse Suspicion for Addiction, But Are Less Predictive
Asking for more or specific medication Stockpiling medications during times when pain is less severe Use of the pain medications to treat other sx Reluctance to ↓ opioid dosing once stable In earlier stages of tx: Unauthorized dose escalation, obtaining opioids from other providers, sharing or borrowing similar meds from friends/family
Differential Diagnosis of Behaviors Suggestive of Addiction
Inadequate pain mgmt	Stable condition but inadequate pain control Progressive condition/pathology, tolerance to opioids
Inability to comply w/ tx	Cognitive impairment, Ψ conditions, self-medication of Ψ or sleep d/o, diversion by pt/others

(Minimizing Misuse of Rx Opioids in Chronic Nonmalignant Pain. 2010; drugabuse.gov; Clin J Pain 2002;18:S28)

• Discontinuing opioids: Frame it as the medication, not the pt, that has failed; Present the evidence for lack of efficacy &/or ↑ riskiness or harm of the drug, citing objective evidence & pt’s own reports; plan taper & discuss alternative tx; consider specialist referral for add’l recommendations; continue tx of chronic pain using other Rx/modalities

ADVANCE CARE PLANNING

Background 

(Ann Intern Med 2010;153:256; 2012;156:ITC2-1; NEJM 2004;350:7)

• Identifying pt values, end-of-life wishes, & surrogate decision makers in advance of critical illness can ↑↑ chance of following pt wishes at end of life, ↓ pt & family stress, & ↑ pt & family satisfaction (BMJ 2010;340:c1345)
• Multiple ways of helping pts ensure their wishes carried out: eliciting pt values, offering recommendations, documenting wishes, identifying preferred decisional surrogates, referring to other healthcare providers for additional support
• Who should have ACP discussion: Medicare reimburses for advance care planning & considers (optional) part of annual wellness visits; discuss w/ elderly or poor prognosis, but helpful to get a sense of values & identify surrogates in all pts; ↑ depth/frequency of discussion with ↑ age &/or ↓ prognosis
• Pt culture influences end-of-life discussions (AFP 2005;71:515); some pts prefer to partially or fully defer prognosis discussion and/or tx decisions to family members; confirm beforehand: “Some people want to be very involved in their medical decisions, & others prefer I talk with their [family]. What’s your preference?”
• Prior to discussion of ACP: assess decision-making capacity & pt understanding of medical conditions; assess pt’s desired involvement in medical decisions vs. deferring to family surrogates; if preference for family involvement, invite them for ACP discussions; if relevant, communicate prognosis (see “Breaking Bad News” in “Counseling Patients”)

Definitions

• Capacity: Ability to communicate choices, understand/retain relevant info & use it rationally, appreciate situation & benefits/consequences of offered txs (NEJM 1988;319:1635; 2007;357:1834); may be determined by any treating provider & does not require legal determinations; psych input often useful if Ψ d/o affects pt decision-making
• Competence: legal right of a pt to make decisions; determined by a judge
• Surrogate decision-maker: also known as health care proxy (HCP); person(s) designated to make pt’s medical decisions if they are no longer capable; jurisdiction often includes all medical decisions, not just life-sustaining tx
  • Pt-assigned: does not require lawyer or judge; can ask pt “If you were sick who would make decisions for you?” (AFP 2012;85:461) & document their response; members of healthcare team cannot be surrogate decision-maker; encourage pt to complete HCP form & share wishes re: decision-makers w/ family Court-assigned: If not identified by pt, assignment order varies by state, but order of priority usually spouse, then adult children, then parents, then siblings; if pt has court-appointed guardian, guardian usually takes precedent
• Durable power of attorney: Legally assigned agent who may make medical, financial, & other decisions on pt’s behalf; must be assigned w/ assistance of a lawyer
• Advance directive: written document describing pt’s wishes re: medical care, incl guidance for future care should s/he be unable to make own decisions; made by pt, often in consultation with family & PCP
  • Living will: Legal advanced directive—becomes valid only when pt unable to make wishes known for him/herself & is terminally ill or permanently unconscious; many states use “Five Wishes” forms: http://www.agingwithdignity.org/five-wishes.php
  • MOLST/POLST: Medical (or Provider) Orders for Life-sustaining Treatment; form outlines preferences for life-sustaining tx (specifics vary by state), includes pre-hospital resuscitation/transfer preferences; signed form = legally binding medical orders w/in state
• Hospice: Comprehensive care for pts w/ limited life expectancy (<6 mos); enrollment → full coverage (for Medicare beneficiaries) of nursing, meds, hospital equipment, social work, palliative tx, bereavement support for survivors (AFP 2008;77:807); may be provided at home or in SNF; open hospice/“bridge to hospice” allows life-prolonging tx (e.g., chemotherapy) & some add’l hospice support services (JCO 2001;19:2057); eligibility varies by insurance provider & disease; recommendations for language during discussion of hospice also available (Ann Intern Med 2007;146:443)
• Palliative care: Focus on symptom mgmt, quality of life, goals of care regardless of prognosis in pts w/ serious illness

Advance Care Discussion

(AFP 2005;72:1263; 2008;77:167; NEJM 2004;350:2582; JAMA Intern Med 2014;174:1994)

• For healthier patients (e.g., Medicare AWV):
  • Introduce topic: “Have you thought about what kinds of care you would want if you were to become seriously ill?
  • Explain rationale for discussion: “It’s helpful to think about this now while you are relatively healthy, so we can keep your goals & wishes in mind over time”
  • Elicit pt values and goals: “If you were to become very ill, what is most important to you in your care? Are there situations you want to avoid? What does QOL mean to you?”
  • Review pt information annually & PRN
• For sicker patients:
  • Assess pt understanding of condition/prognosis: “So that we are on the same page, what is your understanding of your medical condition(s)?”
  • Introduce topic: “Have you thought about what care you would want if you became seriously ill/if things got worse?”
  • Acknowledge emotions: Expect that discussion may elicit strong emotions; acknowledge feelings & use as opportunity for discussion “I can see this really worries you—is it okay if we talk more about this? What is it that worries you the most?
  • Elicit pt values and goals: “As we talk about your health/illness, what is most important to you in your care? Are there situations you would like to avoid?”
• Review risks & benefits of tx options: Discuss options & align w/ pt’s values & goals “Based on what you’ve shared, it sounds like QoL is the most important issue; knowing what types situations you’d like to avoid, let’s talk about what tx options make sense.”
• Share prognostics of resuscitation: Use the GO-FAR “Good Outcome Following Attempted Resuscitation” calculator at www.gofarcalc.com to help pt understand prognosis after CPR (JAMA Intern Med 2013;173:1872); 17% of adults w/ in-hospital resuscitation survive to discharge; rates lower w/ elderly, ESRD, liver disease, cancer patients (Resuscitation 2010;81:302)
• Give a recommendation: If pt & family seem ready: “I’ve heard about what is important to you, we’ve talked about what tx options would make sense for you, & I agree with you that we will do/not do the following (CPR, intubation, dialysis, feeding tubes, pressors, noninvasive respiratory support); based on what you’ve told me, I would recommend (         )”
• Complete living will/advanced directives & document: Key elements to document include: (1) Who was present for the discussion, (2) Who was the decision-maker, (3) Estimated prognosis, (4) Pt’s stated values & goals, (5) Clinician’s recommendations, & (6) Patient’s decision; sample forms by state at com/formslist.shtm
• Encourage pt to share decisions/goals w/ family: especially identified surrogate
• Patient information: AFP 2004;70:725; 2008;77:817; 2012;85:467; JAMA 2012;308:200; caringinfo.org (state-specific HCP & living will forms)

FALL PREVENTION

Background 

(NEJM 2003;348:42; JAMA 2010;303:258; MMWR 2016;65:993; BMJ 2016;353:1419)

• Epidemiology: Falls are leading cause of fatal & nonfatal injuries among adults ≥65 y; in 2014, 28.7% of older adults reported falling; 2.8 million older adults req’d treatment for fall-related injuries, w/ 800K hospitalizations & 27K deaths 2/2 falls
• Increased injuries in elderly 2/2 ↑ frequency of falls + more risk of harm from falls (↓ protective reflexes, ↓BMD, ↑ risk of SDH, prolonged recovery)
• Risk factors: ↑ age, recent falls, fear of falling, weakness, gait, or balance problems, LE/foot pain, visual or sensory deficits (incl neuropathy), orthostasis, incontinence, dementia, ↓ functional status, polypharmacy or ↑-risk meds, EtOH use d/o

Evaluation

(NEJM 2003;348:42; AFP 2010;82:81; J Am Geri Soc 2011;59:148; BMJ 2016;353:1419)

• Screening: Ask about (1) recent fall, (2) ≥2 falls in prior 12 mos, (3) difficulty w/ walking or balance; if any ⊕ → multifactorial fall assessment below
• Fall History: Determine nature of & precipitants for fall, assess risk factors
  • Circumstances: place, time, activity being performed
  • Complications: injury, head trauma, time down (need for medic alert bracelet) Assoc sx: prodrome (orthostasis or cardiac), syncope (see “Syncope”) Mechanical triggers: poor footwear, use/absence of eyeglasses, assistive device Environmental triggers: rugs, lighting, cluttered floors, stairs, curbs
• Medical History: Vision problems, joint pain/arthritis, EtOH use, neuropathy, PD, incontinence (running to bathroom), nocturia, hx stroke, diabetes, weakness, orthostatic hypotension
• Medications: New meds or recent dose changes, timing of meds in relation to falls; High-risk meds: sleep aids (1.4–1.6× ↑ risk for hypnotics, trazodone 1.2× ↑ risk), antidepressants (1.7–2×↑ risk, incl TCAs, SSRIs), antipsychotics (1.6× ↑ risk) BZDs (1.6×), also concern w/ diuretics, antihypertensives, antiarrhythmics, βB, hypoglycemic agents (NEJM 1998;339:875; Arch Intern Med 2010;170:477)
• Exam: VS: Assess for orthostasis; Gen: Notice footwear, presence/absence of assistive device; HEENT: Visual acuity & visual fields; CV: Arrhythmias, valvular disease: See “Valvular Heart Disease”); Neuro: Mental status, strength, LE sensation (neuropathy); gait, Romberg (balance), coordination
• Timed up and go test (TUG): Requires stopwatch & line on floor 10 ft away from armchair where pt is sitting; pt may use assistive device for support
• Instructions: When I say “Go,” I want you to:
  • Stand up from the chair
  • Walk to the line on the floor at your normal pace
  • Turn
  • Walk back to the chair at your normal pace
  • Sit down again
    >12 sec to complete = ⊕ test = 13.5× ↑ in fall risk (BMJ 2016;353:1419); test can also reveal deficits to target

• Workup: Consider HCT, B₁₂, Chem-7, TFTs, 25OH-VitD, med levels; additional tests (event monitor, TTE, brain, & spine imaging) should be guided by Hx/PE

Management

(J Am Geri Soc 2011;59:148; Ann Intern Med 2012;157:197; BMJ 2016;353:1419)

• General principles: Exercise program & Vit D supplementation recommended for all pts >65 w/ increased risk of fall; for pts at ↑ risk, using multidisciplinary approach (AFP 2011;84:1287)
• Exercise program: Balance, gait, & strength training; at least 12 wks duration w/ 30–90 min sessions occurring 1 to 3 times/wk (AFP 2011;84:1287); early mobilization after a fall (JAMA 2012;308:2573); Tai chi may be esp beneficial for balance (Gait Posture 2007;25:205–214)
• Vitamin D: Prevents fractures (NEJM 2012;387:40); may prevent falls by ↓muscle atrophy; goal 25OHVit D level >30; AGS recommends a supplemental vitamin D dose of 1000 units daily (J Am Geri Soc 2014;62:147)
• Pts at ↑ risk: Tx varies by cause of fall; may include PT eval (for balance, strength, gait), home safety assessment by VNA/OT, assistive devices (walker, cane); med review (incl ↓ & d/c of high-risk meds if possible); pain management; eval & tx of osteoporosis; grab bars in bathroom; ophthalmology referral; podiatry referral; nonskid, well-fitted footwear; bedside commode or urinal; medic alert bracelet (esp if pt lives alone)
• Warfarin: H/o falls is not an absolute contraindication for anticoagulation: risk of SDH is so low that a patient w/ avg risk of embolic CVA on AC must fall 300×/yr for risks of AC to outweigh benefits; shared decision-making & risk eval advised (Arch Intern Med 1999;159:677; Am Heart J 2011;161:241)
• Head trauma while on systemic anticoagulant therapy: Due to ↑ risk of ICH or SAH, imaging recommended on all anticoagulated pts w/ even mild/minor head trauma (Lancet 2001;357:771; J Emerg Med 2015;48:137); some advocate for 24-h obs followed by a 2nd CT scan to detect delayed bleeds (Ann Emerg Med 2012;59:451)

Patient Information

JAMA 2010;303:288; www.cdc.gov/steadi/patient.html (English and Spanish patient education material)

PERIOPERATIVE EVALUATION

Background (Ann Intern Med 2016;165:ITC81; J Hosp Med 2012;7:697; BMJ 2011;343:d4331)

Epidemiology: 27 million pts undergo surgery in US each yr; complication rates vary by site, surgery, surgeon, & pt population; some estimates 12–21% of surgeries → post-op complications which prolong hospital stay or ↓ pt functional status (Arch Surg 2002;137:611)

Ambulatory preoperative risk assessment may ↓ length of stay, complications, & mortality

Goals of preoperative eval: Assess risk & offer recommendations to å risk

Pathogenesis of perioperative MI: (1) Volume shifts; (2) ↑ O₂ demand (stress), incl 2/2 blood loss; (3) Post-op ↑ PLT reactivity

Perioperative MI affects ∼3.3% of surgeries in pts >45 y at risk; CV complications leading cause of death <30 d after noncardiac surgery

Stepwise Surgical Evaluation

(1) Surgical emergency? → proceed to OR

(2) Cardiac contraindications present? → delay surgery Unstable/severe angina, recent MI (<6 wks), decompensated, worsening, new-onset, or class IV HF, high-grade AV block, symptomatic arrhythmias, new VT, severe AS or symptomatic MS

(3) Low-risk surgery? → proceed to OR

(4) Vascular surgery? → consider β & stress test if it will Δ mgmt

(5) nonemergent, moderate–high risk surgery without cardiac contraindications → See below

Moderate–High Risk Surgery Evaluation

Evaluation (Ann Intern Med 2009;151:ITC1; Circulation 2009;120:e169; JACC 2007;50:e159)

History: PMHx w/ thorough eval of current/prior cardiac & pulmonary disease, incl h/o toxic meds/tx (e.g., chest XRT, doxorubicin, bleomycin); bleeding disorder

Exercise/functional capacity (see below)

Meds incl antihypertensives, diabetes meds, potentially renotoxic meds (NSAIDs, diuretics), antiplatelet or anticoagulants, herbals, OTCs, pain meds, psychiatric meds Substances (alcohol, tobacco, drug use)

Functional Capacity (Circulation 1981;64:1227)

1 MET: Independently eat, dress, toilet 4 METs: Climb flight of stairs or hill, walk 4 mph, sex 4–10 METs: Heavy housework (scrubbing floors), moving heavy furniture, jog 5 mph >10 METs: Swimming, tennis, basketball

Exam: BP, HR, SaO2, evidence of PAD (carotid bruits, peripheral pulses), pulmonary disease, liver disease, bleeding/bruising, mental status, any wounds

Studies: ✓ β-hCG in premenopausal ♀; other pre-op lab testing, incl coags, generally not indicated in healthy pts <50 y undergoing low-risk elective surgery (Lancet 2003;362:1749); “specific tests by indication below”

Creatinine in pts undergoing mod–high risk surgery

Hgb/HCT in elderly or pts undergoing surgery w/ significant anticipated blood loss PTT, PT, PLT in surgery w/ ↑ bleeding risk (i.e., prostate, neurosurgery, ophthalmic, intrabdominal/thoracic, mastectomy, laparoscopy, arthroscopy) ECG in high-risk pts (hx DM, CHF, CAD, stroke, PAD, CKD) undergoing high-/intermed- risk surgery or pts w/o risk factors undergoing vascular surgery CXR if obese, hx cardiopulmonary disease, or if >50 y undergoing thoracic/abdominal surgery (Ann Intern Med 2006;144:581) PFTs in pt w/ dyspnea of unclear origin, hx COPD or asthma; consider TTE if pt has dyspnea of unclear origin, pathologic murmur, hx valvular disease, pulm HTN or CHF w/ change in clinical status & no echo in past 12 mos BNP or NT-proBNP: Consider ✓ in patients with CHF w/ change in clinical status. BNP ≥92 ng/l or NT pro-BNP

≥300 ng/l predictive of ↑ risk of death or MI (NEJM 2015;373:2258; JACC 2014;63:170)

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CARDIAC RISK ASSESSMENT

 CV Risk assessment includes pt Hx/PE & predictors of cardiac risk: RCRI class or NSQIP, functional capacity, surgery-specific risk, & (if appropriate) results of stress testing/TTE (Circulation 2009;120:e169; JACC 2007;50:e159; NEJM 2015;373:2258)

CV Risk by Type of Surgery (cardiac death, nonfatal MI, nonfatal cardiac arrest)
High risk (≥5%): Aortic/major vascular surgery, peripheral arterial surgery
Intermed (1–5%): CEA, head & neck, intraperitoneal/thoracic, orthopedic, prostate
Low risk (≤1%): Outpt surgery, endoscopy, cataract & breast surgery, dental procedures
RCRI Risk Factors
(1)  Diabetes treated w/ insulin (2)  Hx HF (3) Cr > 2.0 (4)  Hx CVD (5)  High-risk surgery (intrathoracic/peritoneal, suprainguinal vascular) (6)  Hx MI or ⊕ ETT, current nitrate Rx, CP due to CAD, ECG w/ pathologic Q-wave**
# RCRI Risk Factors                              Class                                CV Risk* (95% CI)

 

0	I   II III IV	0.4% (0.05–1.5%)
1		0.9% (0.3–2.1%)
2		6.6% (3.9–10.3%)
≥3		11% (5.8–18.4%)

*Major cardiac complications included acute MI, pulmonary edema, VF, cardiac arrest, complete heart block

**Hx coronary revasc does not count unless other criteria for CAD present (Circulation 1999;100:1043)

RCRI limitations: Does not predict all-cause mortality, excludes emergency surgery; less sensitive methods (CK-MB) were used in MI dx; ↓ accuracy for AAA, vascular surgery, elderly

NSQIP/Gupta risk calculator: surgicalriskcalculator.com/miorcardiacarrest; outperforms RCRI based upon improved C statistic (Circulation 2011;124:381)

Consideration of Additional Testing (AFP 2012;85:239; JACC 2007;50:e159; JACC 2009;54:2102)

Stress testing: Generally, stress testing has a high NPV/low PPV for peri-op CV events; see “CP & Noninvasive Testing” for details; not appropriate if no cardiac sx, functional capacity ≥4 METS & undergoing low-or intermed-risk surgery; pre-op testing has not been shown conclusively to change outcomes & may lead to unnecessary testing & intervention for stable CAD; if indicated, ETT preferred over pharmacologic

Angiography: Decision based on results of stress test/echo, or if pt has an indication independent of need for surgery (e.g., ACS, uncontrolled angina)

Revascularization: Considered in pts w/ left main/3v disease, or 2v disease w/ proximal LAD stenosis, LV dysfunction/ischemia on stress testing; benefit weighed against risk of delaying surgery, d/c’ing (or continuing) anti-PLT agent peri-op

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RISK MANAGEMENT 

Cardiovascular Disease

Recent PCI: Delay surgery if at all possible to >14 d s/p balloon angioplasty, >30 d s/p BMS, & >6 m (>1 y is safer) s/p DES (JACC 2016;68:182)

CHF: Typically, continue ACEI & diuretics; consider short-acting ACEI (i.e., captopril)

HTN: Avoid elective surgery if poorly controlled HTN; continue BB or clonidine; consider holding ACEI/ARB, CCB on AM of surgery if BP well controlled

Pacemakers: Consult EP (programming during surgery, post-op interrogation)

Statins, ASA, BB: See “Medication management” below

Type 2 Diabetes Mellitus

Glucose goals: Generally, less intensive control preferred; ↑ hypoglycemia w/ intensive (<120–150 mg/dl) perioperative targets (Cochrane Database Syst Rev 2012;(9):CD002752)

Surgery timing: Pre 9 AM surgery ideal to prevent prolonged NPO. PO med mgmt: Hold most meds the morning of surgery (see above) Insulin med mgmt: Consider reducing PM insulin night before surgery if h/o AM hypoglycemia; hold short/rapid acting insulin AM of surgery; take ∼½ of total usual AM dose (short+long) in intermed/long acting form only

Insulin pump: Continue usual basal rate; endocrine c/s

Liver Disease (Ann Surg 2005;244:242)

Pts w/ cirrhosis have ↑bleeding, infection risk; abd surgery, decompensation ↑↑ risk; suggest hepatology involvement, avoid nephrotoxic meds

Risk assessment: MELD score ∼ post-op mortality, with ↑↑ as MELD ↑ (e.g., MELD 5 = 5%, MELD 25 = 25%, MELD 35 = 50%) or Child Class (A∼10%, B ∼30%, C 75%, portal HTN ≥30%); ↓ albumin → ↑ morbidity/mortality (Arch Surg 1999;134:36–42)

Tobacco (Arch Surg 2012;147:373)

Smoking assoc w/ ∼2× ↑ risk of post-op dehiscence, wound complication, hernia, & surgical site infection; tobacco cessation prior to surgery ↓ post-op complications by 41%, incl wound healing & pulmonary complications (Am J Med 2011;124:144)

Chronic Corticosteroid Use

Generally, pts on chronic steroids should continue on day of surgery; consider stress dosing if >20 mg prednisone/equiv for >3 wks & major surgery

Steroid stress dosing (Ann Intern Med 2009;151:ITC-1)

Major surgery (CT surg, oncologic, intra-abd): Hydrocortisone 100 mg IV q8h × 3 doses → 50 mg IV q8h × 3 doses → 25 mg IV q8h × 3 doses → outpt dosing Intermediate-risk surgery (orthopedic, urologic, ENT): Hydrocortisone 50 mg IV q8h × 3 doses → 25 mg IV q8h × 3 doses → outpt dosing Low-risk surgery (e.g., cataract): Outpt dosing day of surgery, double 1st post-op dose

H/o Stroke (NEJM 2007;256:706)

Incidence of peri-op stroke varies w/ type of surgery (0.08–0.7% general surgery to 8.7% aortic repair); prior stroke major RF; surgery should be delayed until >2 wks after stroke

Rheumatoid Arthritis, Ankylosing Spondylitis, or Chronic Steroids Risk of C-spine injury during intubation 2/2 atlantoaxial instability; consider flex/ext C-spine films (Ann Intern Med 2009;151:ITC-1)

Delirium Prevention (NEJM 1999;340:669)

Common post-op in elderly (15–60%) & often unrecognized, esp if hypoactive; assoc w/ ↑ morbidity/mortality/LOS/institutional placement; prevention w/ behavioral protocols (mobilization, timely d/c of Foley, orientation, family at bedside) can ↓ incidence (60% risk reduction, NNT = 20); limit opioids, sleep aids, benzos post-op

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MEDICATION MANAGEMENT

 CV Medications (Chest 2008;133:299; 2012;141:e326S; NEJM 1997;336:1506; Circulation 2014;130:2215)

Statins: Continue if pt already on; initiate early in surgery in pts who should be on (see “Dyslipidemia”); consider initiating in pts undergoing vascular surgery regardless of risk factors

Antihypertensives: Generally continued until time of surgery; clonidine & βB assoc w/ withdrawal syndrome (JAMA 2002;287:2043)

Beta-blockers: Controversial due to variety of Rx intensity & outcomes studied in trials (Circulation 2014;130:2246; JAMA 2010;303:551); ↓ peri-op MI but ↑ stroke & total mortality (esp if high dose BB leading to ↓ BP); POISE, Lancet 2008;371:1839); in retrospective cohort of pts undergoing noncardiac, nonvascular surgery, peri-op βB ↓ all-cause mortality in pts w/ >2 RCRI risk factors; for RCRI = 2, NNT = 105, RCRI = 3, NNT = 41, RCRI = 4 NNT = 18 (JAMA 2013;309:1714); continue βB in pts already on; consider initiating 1–4 wks prior to surgery in pts who should be on a βB or who have CAD, stable angina, or those w/ >1 RCRI risk factor undergoing intermed or high-risk surgery (NEJM 2005;353:349); discuss risks/benefits w/ pt & document; titrate to HR 60–70 bpm; continue for 1 mo after & taper carefully if discontinuing; β1 selective agents preferred due to less HoTN; outcomes worse if βB stopped abruptly pre-op or if initiated on day of surgery

Antithrombotic Management

ASA & P₂Y₁₂ inhibitors (clopidogrel, prasugrel, etc.) irreversibly inhibit platelet function; each day they are held → 10–14% restoration of platelet function; platelets not fully restored to nl function until 7–10 d after d/c

Aspirin: Pts w/ recent coronary stenting (<90 d s/p BMS, <1 y s/p DES) should delay surgery or remain on ASA; for others, even w/prior PCI, ASA of unclear perioperative benefit in noncardiac surgery (NEJM 2014;370:1494) though withdrawal may ↑ risk; generally safe to continue in ↓ bleeding risk (see below); hold for surgery w/ ↑ bleeding risk (see below); d/c ASA 5–7 d prior to surgery; resume >24 h after surgery if sufficient hemostasis (Chest 2008;133:299; Chest 2012;141:e326S)

P₂Y₁₂ inhibitors (e.g., clopidogrel): Pts w/ recent coronary stenting (<90 d s/p BMS, <6 mos s/p DES) should delay surgery or remain on DAPT; consider d/c of DAPT 3–6 mos s/p DES if risk of surgical delay > thrombotic risk (Circulation 2016;134:e123; 2014;130:2215); pts at low risk of CV events can d/c clopidogrel 7–10 d prior to surgery; resume 24 h after surgery if sufficient hemostasis; MI risk after discontinuation of thienopyridine mostly unrelated to sites of prior stent (Circulation 2017;135:1720)

Herbal meds: ↑ Bleeding w/ garlic, ginkgo, ginseng; ↓ glucose w/ ginseng; CV complications w/ ephedra; interaction w/ sedatives & other drugs by kava, valerian, St. John’s Wort (JAMA 2001;286:208)

Anticoagulant Management (Chest 2012;141:e326S; JACC 2017)

Decisions to continue vs. interrupt anticoagulation, & if interrupted, whether or not to bridge, based on balance of (1) pt’s thromboembolic risk (2) pt & procedural risk of bleeding

For AF at low or moderate thrombotic risk (see above) bridging generally not needed; ↑ bleeding risk w/o benefit (BRIDGE, NEJM 2015;373:823); individualized risk assessment & recommendations from ACC: tools.acc.org/bridgeanticoag/ (JACC 2015;66:1392)

Higher thrombosis risk:

AF & 1 of following: CHADSVASc > 6, valvular heart disease, stroke/TIA <3 mos Mechanical valves: Any mitral, any caged-ball valves, any stroke/TIA <3 mos; aortic & any add’l thrombotic risk factors (AF, CHF, hx stroke/TIA) CAD: Stent in last y, recent MI, nonstented PCI after MI (Gastrointest Endosc 2009;70:1060) Stroke: Recent (<6 mos) stroke or TIA

VTE: Recent (<3mos) or recurrent VTE, malignancy-associated VTE

Other: Severe/multiple thrombophilia; protein C/S/antithrombin deficiency, APLAS, h/o intracardiac clot, stroke/TIA/VTE w/prior interruption of anticoagulants

Lower thrombosis risk: Distant (>12 mos) VTE; AF w/o valvular disease or risk factors above; bioprosthetic valves

Higher bleeding risk: Abnl renal or liver function, bleeding diathesis, elderly, abnl number/fxn of PLT, bleeding w/ prior procedures or w/ prior bridging

Procedures w/ ↑ bleeding risk: NSG, urologic/renal procedures, cardiac/vascular

Procedures w/ å bleeding risk: Arthrocentesis, cataract surgery, outpt dental surgery, minor dermatologic procedures

Novel anticoagulants (NOACs): Assess procedural bleed risk; suggested timetable (based on ACC 2017 nonvalvular AF guidelines) below

Timeframe for Witholding NOACs Prior to Procedure, by GFR
	DTI: low bleeding risk	DTI: other/unk bleeding risk	FXa inhibitor: low bleeding risk	FXa inhibitor: other/unk bleeding risk
CrCl ≥80	≥24 h	≥48 h	≥24 h	≥48 h

Warfarin: Usually held 5 d prior to surgery; may consider 3–4 d if INR

<2, >5 d if INR >3; for VTE disease, recommended to resume 12–24h later if adequate hemostasis

Minor dental procedure: Continue or stop 2–3 d prior to procedure

Minor dermatologic procedure, cataract surgery: continue Heparin bridging recommendations:

Unfractionated heparin: d/c 4–6 h prior to surgery

LMWH: Stop 24 h prior to surgery; resume 24 h after surgery (if bridging to warfarin or continuing on LMWH)

Other Medications

IBD medications: Hold 5-ASA & 6-MP on day of surgery; resume 3 d post-op if nl renal function (Mayo Clin Proc 2011;86:748)

Stimulants: Hold on AM of surgery

NSAIDs: Can ↑ bleeding risk; hold 4–5 d prior to surgery

Commenting on Perioperative Risk

[Pt’s name] is seen for preoperative eval. [Pt] reports no sx of CP at rest or w/ exertion, dyspnea at rest or w/ exertion, PND, LE edema, claudication, or palpitations. [Pt] has no h/o (ischemic heart disease, CHF, CVD, diabetes, recent anticoagulant or antithrombotic use, personal or FHx of coagulopathy). [Pt] reports no h/o (stress test, cardiac cath, or coronary revascularization). [Pt] reports being able to achieve      METs of activity during (          describe activities).

This pt’s cardiac risk factors include (high risk surgery, ischemic heart disease, h/o CHF, h/o CVD, IDDM, SCr >2). According to the RCRI, this number of risk factors stratifies the pt to Class    , which carries a      percent risk of major CV complications (Circulation 1999;100:1043). In this case, however, the RCRI potentially (over/under) estimates the pt’s true cardiac risk given the h/o  . It also does not take into account comorbid conditions such as        .

The risks of        were discussed w/ the pt, in light of the benefits of possible surgery. This assessment was conveyed to the surgery & anesthesia teams.