Escaso impacto del programa de detección del cáncer de mama mediante mamografía en Inglaterra

Escaso impacto del programa de detección del cáncer de mama mediante mamografía en Inglaterra -> Este gran estudio poblacional británico no ha detectado una asociación entre la aplicación de un programa de cribado de cáncer de mama y la mortalidad relacionada con el cáncer de mama.

J R Soc Med, 06/2013 "Breast cancer mortality trends in England and the assessment of the effectiveness of mammography screening: population-based study".

Objetivo: Investigar si las estadísticas de mortalidad muestran un efecto del cribado mamográfico en la población, basadas en la mortalidad por cáncer de mama en Inglaterra. Diseño: Análisis de regresión Joinpoint y otros análisis, los datos de mortalidad basados en la población. Configuración: Análisis de las tasas de mortalidad en la región de Oxford, Reino Unido (1979-2009), ya que, a diferencia del resto de Inglaterra, se mencionan en cada certificado de defunción todas las causas de muerte para sus residentes (no sólo la causa subyacente), que están disponibles antes del comienzo en el English National Breast Screening Programme (NHSBSP). Además, el análisis de las tasas nacionales de mortalidad por cáncer de mama inglesas (1971-2009). Las participantes mujeres que murieron de cáncer de mama en la región de Oxford (1979 - 2009) e Inglaterra (1971 - 2009). Variables principales: Las tasas de mortalidad específicas por edad y las tasas de mortalidad estandarizadas por edad. Se utilizó el análisis de regresión de puntos de intersección para estimar los años ('joinpoints') en la que las tendencias cambian, y la variación porcentual anual entre joinpoints, con intervalos de confianza. Resultados: En la región de Oxford, las tendencias de la mortalidad por cáncer de mama sobre la base de la causa subyacente y en menciones fueron muy similares. Para todas las edades combinadas, la mortalidad alcanzó su punto máximo a la vez la causa subyacente y menciones en 1985 y luego comenzó a declinar, antes de la introducción del NHSBSP en 1988. Entre 1979 y 2009, la mortalidad medida como causa subyacente, las tasas se redujeron en -2,1% (IC -2,7 a -1,4 95%) por año para las mujeres de 40-49 años (sin cribado), y en el mismo porcentaje por año (- 2,1% [-2,4 a -1,7]) para las mujeres de 50-64 años (cribadas en el programa). En Inglaterra, los primeros cambios estimados en la tendencia se produjeron antes de la introducción de la detección, o antes de la probabilidad de haber tenido un efecto (entre 1982 y 1989). A partir de entonces, la tendencia a la baja fue mayor en las mujeres menores de 40 años: 2,0% por año (-2,8 a -1,2) en 1988-2001 y -5,0% anual (-6,7 a -3,3) en 2001-2009. No hubo pruebas de que la disminución de las tasas de mortalidad fueran consistentemente mayores en las mujeres en los grupos de edad y las cohortes que habían sido cribadas o seleccionados en varias ocasiones, que en otras mujeres (no cribadas), en los mismos períodos de tiempo. Conclusiones: Las estadísticas de mortalidad no muestran un efecto del cribado mamográfico en la población para la prevención de la mortalidad por cáncer de mama en Inglaterra.

http://jrs.sagepub.com/content/106/6/234.full

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No hay pruebas suficientes que apoyen el reposo en cama para prevenir el aborto

No hay pruebas suficientes que apoyen el reposo en cama para prevenir el aborto, ni tampoco para decir que no es efectivo. 

Posted on febrero 18, 2011 porrafafabravo B cama para el riesgo de aborto?

Respuesta: No hay evidencia suficiente de que el reposo en cama bien en el hospital o en el hogar prevenga el aborto involuntario en mujeres con viabilidad fetal confirmada y hemorragia vaginal en la primera mitad del embarazo. En un ensayo se produjo un mayor riesgo de aborto en las mujeres en el grupo de reposo en cama que en las de un grupo de terapia de gonadotropina coriónica humana sin reposo en cama.

Advertencia: El pequeño número de participantes en los estudios revisados es un factor importante que contribuye a resultados poco concluyentes. Actualmente no hay pruebas que puedan apoyar la recomendación de reposo en cama en la prevención del aborto involuntario, ya que ninguno de los estudios evaluaron los efectos secundarios potenciales de reposo en cama (eventos tromboembólicos, estrés materno, la depresión y el coste).

Contexto: El aborto involuntario sucede en el 10 a 15% de los embarazos en función de la edad materna y la paridad previa. Se asocia con anomalías cromosómicas en aproximadamente la mitad o dos tercios de los casos. Muchas intervenciones se han utilizado para prevenir el aborto involuntario, pero el reposo en cama es probablemente la más comúnmente prescrita en casos de amenaza de aborto y para aquellas con una historia previa de abortos.

Revisión Sistemática Cochrane:
Aleman A et al. Bed rest during pregnancy for preventing miscarriage. Cochrane Reviews, 2010, Issue 10. Article No. CD003576. DOI: 10.1002/14651858.CD003576.pub2.
Esta revisión incluyó 2 estudios con 84 participantes

PERLA N º 288, noviembre 2010
Escrita por Brian R McAvoy. Traducida por Google y Rafael Bravo

No hay pruebas suficientes que apoyen el reposo en cama para prevenir el aborto 

Posted on febrero 18, 2011 porrafafabravo B cama para el riesgo de aborto?

Respuesta: No hay evidencia suficiente de que el reposo en cama bien en el hospital o en el hogar prevenga el aborto involuntario en mujeres con viabilidad fetal confirmada y hemorragia vaginal en la primera mitad del embarazo. En un ensayo se produjo un mayor riesgo de aborto en las mujeres en el grupo de reposo en cama que en las de un grupo de terapia de gonadotropina coriónica humana sin reposo en cama.

Advertencia: El pequeño número de participantes en los estudios revisados es un factor importante que contribuye a resultados poco concluyentes. Actualmente no hay pruebas que puedan apoyar la recomendación de reposo en cama en la prevención del aborto involuntario, ya que ninguno de los estudios evaluaron los efectos secundarios potenciales de reposo en cama (eventos tromboembólicos, estrés materno, la depresión y el coste).

Contexto: El aborto involuntario sucede en el 10 a 15% de los embarazos en función de la edad materna y la paridad previa. Se asocia con anomalías cromosómicas en aproximadamente la mitad o dos tercios de los casos. Muchas intervenciones se han utilizado para prevenir el aborto involuntario, pero el reposo en cama es probablemente la más comúnmente prescrita en casos de amenaza de aborto y para aquellas con una historia previa de abortos.

Revisión Sistemática Cochrane:
Aleman A et al. Bed rest during pregnancy for preventing miscarriage. Cochrane Reviews, 2010, Issue 10. Article No. CD003576. DOI: 10.1002/14651858.CD003576.pub2.
Esta revisión incluyó 2 estudios con 84 participantes

PERLA N º 288, noviembre 2010
Escrita por Brian R McAvoy. Traducida por Google y Rafael Bravo

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Cribado de cancer de prostata - Screening of prostaste cancer

Image via Wikipedia

Editorial del NEJM 26 de Marzo 2009


In the United States, most men over the age of 50 years have had a prostate-specific–antigen (PSA) test,¹ despite the absence of evidence from large, randomized trials of a net benefit. Moreover, about 95% of male urologists and 78% of primary care physicians who are 50 years of age or older report that they have had a PSA test themselves,² a finding that suggests they are practicing what they preach. And indeed, U.S. death rates from prostate cancer have fallen about 4% per year since 1992, five years after the introduction of PSA testing.³ Perhaps the answer to the PSA controversy is already staring us in the face. At the same time, practice guidelines cite the unproven benefit of PSA screening, as well as the known side effects,^4,5 which largely reflect the high risks of overdiagnosis and overtreatment that PSA-based screening engenders.⁶
The first reports from two large, randomized trials that many observers hoped would settle the controversy appear in this issue of the Journal. In the U.S. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, Andriole et al.⁷ report no mortality benefit from combined screening with PSA testing and digital rectal examination during a median follow-up of 11 years.⁸ In the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial, Schröder et al.⁸ report that PSA screening without digital rectal examination was associated with a 20% relative reduction in the death rate from prostate cancer at a median follow-up of 9 years, with an absolute reduction of about 7 prostate cancer deaths per 10,000 men screened.⁸ The designs of the two trials are different and provide complementary insights.
First, one must ask, "Why were these results published now?" Neither set of findings seems definitive; that is, there was neither a clear declaration of futility in the PLCO trial nor an unambiguous net benefit in the ERSPC trial. Both studies are ongoing, with future updates promised. The report on the ERSPC trial follows a third planned interim analysis, which found a marginally significant decrease in prostate-cancer mortality after adjustment of the P value for the two previous looks in an attempt to avoid a false positive conclusion (yet apparently preserving no alpha for the planned final analysis). On the other hand, the investigators in the PLCO trial made the decision to publish their results now because of concern about the emerging evidence of net harm compared with potential benefits associated with PSA screening. Both decisions to publish now can be criticized as premature, leaving clinicians and patients to deal with the ambiguity.
The ERSPC trial is actually a collection of trials in different countries with different eligibility criteria, randomization schemes, and strategies for screening and follow-up. The report by Schröder et al. is based on a predefined core group of men between 55 and 69 years of age at study entry. Subjects were generally screened every 4 years, and 82% were screened at least once. Contamination of the control group with screening as part of usual care is not described. Biopsies were generally recommended for subjects with PSA levels of more than 3.0 ng per milliliter. It is unclear whether the clinicians and hospitals treating patients with prostate cancer differed between the two study groups.
Adjudications of causes of death were made by committees whose members were unaware of study-group assignments, though not of treatments. This point is important, since previous research has suggested that the cause of death is less likely to be attributed to prostate cancer among men receiving attempted curative treatment.⁹ Misattribution might then create a bias toward screening, since the diagnosis of more early-stage cancers in the ERSPC trial led to substantially more attempted curative treatments.
The ERSPC interim analysis revealed a 20% reduction in prostate-cancer mortality; the adjusted P value was 0.04. The estimated absolute reduction in prostate-cancer mortality of about 7 deaths per 10,000 men after 9 years of follow-up, if real and not the result of chance or bias, must be weighed against the additional interventions and burdens. The 73,000 men in the screening group underwent more than 17,000 biopsies, undoubtedly many more than did men in the control group, though the latter is not reported. Men had a substantially higher cumulative risk of receiving the diagnosis of prostate cancer in the screening group than in the control group (820 vs. 480 per 10,000 men). Diagnosis led to more treatment, with 277 versus 100 per 10,000 men undergoing radical prostatectomy and 220 versus 123 per 10,000 undergoing radiation therapy with or without hormones, respectively (tentative estimates given the unknown treatments in both groups).
Although estimates of the benefit of screening were somewhat greater for men who actually underwent testing (taking into account noncompliance) than for those who were not tested, the side effects would be proportionately higher as well. Given these trade-offs, the promise of future ERSPC analyses addressing quality of life and cost-effectiveness is welcome indeed. The ERSPC results also reemphasize the need for caution in screening men over the age of 69 years, given an early trend toward higher prostate-cancer mortality with screening in this age subgroup, although this finding may well be due to chance alone.
A final point to make about the ERSPC trial is that to the extent that the diagnosis and treatment of prostate cancer in the screening group differed from those in the control group, it becomes difficult to dissect out the benefit attributable to screening versus improved treatment once prostate cancer was suspected or diagnosed. A similar distribution of treatments among seemingly similar patients with cancer is only partially reassuring in this regard.
Despite a longer median follow-up, the PLCO trial was smaller and therefore less mature than the ERSPC trial, with 174 prostate-cancer deaths driving the power of the study, as compared with 540 such deaths in the ERSPC trial. The screening protocol was homogeneous across sites with an enrollment age of 55 to 74 years and annual PSA tests for 6 years and digital rectal examinations for 4 years, with about 85% compliance. Subjects in the screening group who had a suspicious digital rectal examination or a PSA level of more than 4.0 ng per milliliter received a recommendation for further evaluation. This strategy helped to ensure that any difference in outcome was attributable to screening, rather than downstream management. The effectiveness of screening, of course, will be determined by the effectiveness of subsequent "usual care," but this is the same usual care that many practitioners assume has been responsible for the falling U.S. death rate from prostate cancer. Adjudication of causes of death was similar to that in the ERSPC trial.
Though the PLCO trial has shown no significant effect on prostate-cancer mortality to date, the relatively low number of end points begets a wide confidence interval, which includes at its lower margin the point estimate of effect from the ERSPC trial. Other likely explanations for the negative findings are high levels of prescreening in the PLCO population and contamination of the control group. Contamination was assessed by periodic cross-sectional surveys, with about half the subjects in the control group undergoing PSA testing by year 5. It is unclear whether these estimates reflect testing that year or since trial inception; if the former, the cumulative incidence may be even higher. The smaller difference in screening intensity between the two study groups in the PLCO trial, as compared with the ERSPC trial, is reflected in a smaller risk of overdiagnosis (23% vs. more than 70%) and a less impressive shift in cancer stage and grade distributions. Given that study-group contamination from the use of digital rectal examination was less problematic (only about 25%), ongoing results from both of these trials may necessitate rethinking the role of digital rectal examination in cancer screening.
After digesting these reports, where do we stand regarding the PSA controversy? Serial PSA screening has at best a modest effect on prostate-cancer mortality during the first decade of follow-up. This benefit comes at the cost of substantial overdiagnosis and overtreatment. It is important to remember that the key question is not whether PSA screening is effective but whether it does more good than harm. For this reason, comparisons of the ERSPC estimates of the effectiveness of PSA screening with, for example, the similarly modest effectiveness of breast-cancer screening cannot be made without simultaneously appreciating the much higher risks of overdiagnosis and overtreatment associated with PSA screening.
The report on the ERSPC trial appropriately notes that 1410 men would need to be offered screening and an additional 48 would need to be treated to prevent one prostate-cancer death during a 10-year period, assuming the point estimate is correct. And although the PLCO trial may not have the power as yet to detect a similarly modest benefit of screening, its power is already more than adequate to detect important harm through overdiagnosis. However, the implications of the trade-offs reflected in these data, like beauty, will be in the eye of the beholder. Some well-informed clinicians and patients will still see these trade-offs as favorable; others will see them as unfavorable. As a result, a shared decision-making approach to PSA screening, as recommended by most guidelines, seems more appropriate than ever.
Finally, despite these critiques, both groups of investigators deserve high praise for their persistence and perseverance: to manage such monstrous trials is a herculean task, made no easier when so many observers think the results are self-evident. Further analyses will be needed from these trials, as well as from others — such as the Prostate Cancer Intervention Versus Observation Trial (PIVOT) in the United States (ClinicalTrials.gov number, NCT00007644 [ClinicalTrials.gov] )¹⁰ and the Prostate Testing for Cancer and Treatment (PROTECT) trial in the United Kingdom (Current Controlled Trials number, ISRCTN20141297 [controlled-trials.com] )¹¹ — if the PSA controversy is finally to sleep the big sleep.
No potential conflict of interest relevant to this article was reported.

Source Information
From Massachusetts General Hospital and Harvard Medical School, Boston.

This article (10.1056/NEJMe0901166) was published at NEJM.org on March 18, 2009.
References

1. Ross LE, Berkowitz Z, Ekwueme DU. Use of the prostate-specific antigen test among U.S. men: findings from the 2005 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2008;17:636-644. [Free Full Text]
2. Chan EC, Barry MJ, Vernon SW, Ahn C. Brief report: physicians and their personal prostate cancer-screening practices with prostate-specific antigen: a national survey. J Gen Intern Med 2006;21:257-259. [CrossRef][ISI][Medline]
3. Ries LAG, Melbert D, Krapcho M, et al. SEER cancer statistics review, 1975–2005. Bethesda, MD: National Cancer Institute, 2008. (Accessed March 6, 2009 at http://seer.cancer.gov/csr/1975_2005/.)
4. Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues. CA Cancer J Clin 2008;58:161-179. [Free Full Text]
5. U. S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:185-191. [Free Full Text]
6. Barry MJ. Why are a high overdiagnosis probability and a long lead time for prostate cancer screening so important? J Natl Cancer Inst (in press).
7. Andriole GL, Grubb RL III, Buys SS, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-1319. [Free Full Text]
8. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:1320-1328. [Free Full Text]
9. Newschaffer CJ, Otani K, McDonald MK, Penberthy LT. Causes of death in elderly prostate cancer patients and in a comparison nonprostate cancer cohort. J Natl Cancer Inst 2000;92:613-621. [Free Full Text]
10. Wilt TJ, Brawer MK, Barry MJ, et al. The Prostate cancer Intervention Versus Observation Trial: VA/NCI/AHRQ Cooperative Studies Program #407 (PIVOT): design and baseline results of a randomized controlled trial comparing radical prostatectomy to watchful waiting for men with clinically localized prostate cancer. Contemp Clin Trials 2009;30:81-87. [CrossRef][ISI][Medline]
11. Donovan J, Hamdy F, Neal D, et al. Prostate Testing for Cancer and Treatment (ProtecT) feasibility study. Health Technol Assess 2003;7:1-88. [Medline]

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Antigeno Prostatico Especifico: inutil para el cribado de cancer de prostata

Todavia desconozco en que idioma hay que escribir esto, pero por enesima  vez sale otro articulo que dice que la PSA,  no tiene ninguna utilidad en el cribado de cáncer de próstata y que sólo sirve para el seguimiento de pacientes con Cáncer de prostata. El tema es simple. Se trata de una prueba inespecifica, y el famoso antigeno es volumen-dependiente del tamaño de la prostata. Por ende, en la natural evolucion que tenemos los hombres la prostata se agranda con la edad. Por tanto, ningun valor sirve para diferenciar si ese agrandamiento se  debió a la hipertrofia prostática benigna, que también es muy común luego de los 65 años. Por otro lado, un viejo anatomista,  Testut, ya escribia en su tratado que data del año 1900, que en sus autopsias encontraba un 100% de cáncer de prostata en hombres  mayores de 80 años. En otras palabras, y aunque los urólogos se empeñen en poner al cancer de próstata como un grave problema de salud, colocandolo entre las primeras causas de muerte, la realidad indica, que nos morimos más con cáncer de próstata que por el cáncer mismo. Por ende es un buen marcador de la evolución del cáncer pero no tiene ninguna utilidad, escrito en Inglés (también ha sido escrito en castellano, catalán, portugues, francés, ruso, y seguramente en esperanto) por el  British Medical Journal.
Por ende tendremos que seguir lidiando con los expertos que aparecen en la prensa de todo el mundo, e intentan convencer a la gente de hacerse estos estudios desde los 50 años. 

Utilizando una cohorte grande Seuca relacionada con un registro nacional de cáncer, los investigadores compararon los valores iniciales de PSA de aquellos que desarrollaron cáncer de próstata en el curso de 7 años post escrutinio, con otros hombres de similares características que no desarrollaron cáncer de próstata. La sobreposición de los valores de PSA frustraron los esfuerzos de los investigadores de encontrar un valor que tenga alta especificidad así como una sensibilidad del 50%. Sin embargo, notaron que un valor de PSA menor de 1 ng/mL virtualmente descarta el diagnóstico durante el período de seguimiento.

Debido a los resultados de este estudio, se podría decir que los datos sobre los costos y beneficios de las pruebas de PSA permanecen insuficientes para apoyar el escrutinio masivo.

Referencia: Benny Holmström, et al. Prostate specific antigen for early detection of prostate cancer: longitudinal study. BMJ. Septiembre 2009;339:b3537.

Antigeno Prostatico Especifico: inutil para el cribado de cancer de prostata

Todavia desconozco en que idioma hay que escribir esto, pero por enesima  vez sale otro articulo que dice que la PSA,  no tiene ninguna utilidad en el cribado de cáncer de próstata y que sólo sirve para el seguimiento de pacientes con Cáncer de prostata. El tema es simple. Se trata de una prueba inespecifica, y el famoso antigeno es volumen-dependiente del tamaño de la prostata. Por ende, en la natural evolucion que tenemos los hombres la prostata se agranda con la edad. Por tanto, ningun valor sirve para diferenciar si ese agrandamiento se  debió a la hipertrofia prostática benigna, que también es muy común luego de los 65 años. Por otro lado, un viejo anatomista,  Testut, ya escribia en su tratado que data del año 1900, que en sus autopsias encontraba un 100% de cáncer de prostata en hombres  mayores de 80 años. En otras palabras, y aunque los urólogos se empeñen en poner al cancer de próstata como un grave problema de salud, colocandolo entre las primeras causas de muerte, la realidad indica, que nos morimos más con cáncer de próstata que por el cáncer mismo. Por ende es un buen marcador de la evolución del cáncer pero no tiene ninguna utilidad, escrito en Inglés (también ha sido escrito en castellano, catalán, portugues, francés, ruso, y seguramente en esperanto) por el  British Medical Journal.
Por ende tendremos que seguir lidiando con los expertos que aparecen en la prensa de todo el mundo, e intentan convencer a la gente de hacerse estos estudios desde los 50 años. 

Utilizando una cohorte grande Seuca relacionada con un registro nacional de cáncer, los investigadores compararon los valores iniciales de PSA de aquellos que desarrollaron cáncer de próstata en el curso de 7 años post escrutinio, con otros hombres de similares características que no desarrollaron cáncer de próstata. La sobreposición de los valores de PSA frustraron los esfuerzos de los investigadores de encontrar un valor que tenga alta especificidad así como una sensibilidad del 50%. Sin embargo, notaron que un valor de PSA menor de 1 ng/mL virtualmente descarta el diagnóstico durante el período de seguimiento.

Debido a los resultados de este estudio, se podría decir que los datos sobre los costos y beneficios de las pruebas de PSA permanecen insuficientes para apoyar el escrutinio masivo.

Referencia: Benny Holmström, et al. Prostate specific antigen for early detection of prostate cancer: longitudinal study. BMJ. Septiembre 2009;339:b3537.

Cuidados dentro de la casa para pacientes con gripe

Fuente: OPS

Cómo cuidar a los demás
La mayoría de los pacientes con gripe podrá permanecer en sus casas y podrán ser atendidos por otros integrantes de la familia o personas que habiten en el hogar. Estos corren el riesgo de contagiarse gripe durante el período de incubación y enfermedad del paciente.

Manejo del paciente con gripe
Aleje físicamente al paciente lo más posible de todo el resto de las personas no enfermas que habitan en una casa. Si es posible, arme un cuarto aparte.
Es importante que el aire de la habitación circule hacia el exterior y que no vuelva a ingresar en la casa.
Sólo deben entrar a la habitación del enfermo las personas que estrictamente necesitan atenderlo, y deben lavarse bien las manos al salir.
Usar barbijos puede ser útil.
Los pacientes no deben salir de sus hogares durante el período en que es más probable que puedan contagiar a otros.

Medidas para controlar la infección en el hogar
Todas las personas en la casa deben lavarse las manos con agua y jabón o utilizar líquido de limpieza de manos con alcohol luego de entrar en contacto con un paciente que tiene gripe.
No es necesario separar los cubiertos utilizados por un paciente con gripe.
No es necesario lavar por separado la ropa de cama y otra ropa utilizada por el paciente con gripe. Hay que manejar la ropa sucia con cuidado para evitar la contaminación. Deben higienizarse las manos luego de manipular la ropa sucia.
Los pañuelos usados por un paciente enfermo deben colocarse en una bolsa y descartarse con el resto de los desechos hogareños.
Considere la posibilidad de colocar una bolsa exclusiva para ello al lado de la cama.

Manejo de otras personas en el hogar
Aquellas personas/visitantes que no han estado expuestos a la gripe y que no resultan esenciales para cuidar al paciente no deberían ingresar a la casa.
Si hay personas que no han estado expuestas y que deben ingresar a la casa, deben evitar el contacto estrecho con el paciente.
Las personas que habitan en la misma casa que el paciente con gripe deben limitar el contacto con él en la medida de lo posible; considere la posibilidad de designar una persona como cuidadora principal del paciente.
Los convivientes de dicho hogar deben estar atentos a cualquier aparición de los síntomas de la gripe

Cuidados dentro de la casa para pacientes con gripe

Fuente: OPS

Cómo cuidar a los demás
La mayoría de los pacientes con gripe podrá permanecer en sus casas y podrán ser atendidos por otros integrantes de la familia o personas que habiten en el hogar. Estos corren el riesgo de contagiarse gripe durante el período de incubación y enfermedad del paciente.

Manejo del paciente con gripe
Aleje físicamente al paciente lo más posible de todo el resto de las personas no enfermas que habitan en una casa. Si es posible, arme un cuarto aparte.
Es importante que el aire de la habitación circule hacia el exterior y que no vuelva a ingresar en la casa.
Sólo deben entrar a la habitación del enfermo las personas que estrictamente necesitan atenderlo, y deben lavarse bien las manos al salir.
Usar barbijos puede ser útil.
Los pacientes no deben salir de sus hogares durante el período en que es más probable que puedan contagiar a otros.

Medidas para controlar la infección en el hogar
Todas las personas en la casa deben lavarse las manos con agua y jabón o utilizar líquido de limpieza de manos con alcohol luego de entrar en contacto con un paciente que tiene gripe.
No es necesario separar los cubiertos utilizados por un paciente con gripe.
No es necesario lavar por separado la ropa de cama y otra ropa utilizada por el paciente con gripe. Hay que manejar la ropa sucia con cuidado para evitar la contaminación. Deben higienizarse las manos luego de manipular la ropa sucia.
Los pañuelos usados por un paciente enfermo deben colocarse en una bolsa y descartarse con el resto de los desechos hogareños.
Considere la posibilidad de colocar una bolsa exclusiva para ello al lado de la cama.

Manejo de otras personas en el hogar
Aquellas personas/visitantes que no han estado expuestos a la gripe y que no resultan esenciales para cuidar al paciente no deberían ingresar a la casa.
Si hay personas que no han estado expuestas y que deben ingresar a la casa, deben evitar el contacto estrecho con el paciente.
Las personas que habitan en la misma casa que el paciente con gripe deben limitar el contacto con él en la medida de lo posible; considere la posibilidad de designar una persona como cuidadora principal del paciente.
Los convivientes de dicho hogar deben estar atentos a cualquier aparición de los síntomas de la gripe

Cuidados dentro de la casa para pacientes con gripe

Fuente: OPS

Cómo cuidar a los demás
La mayoría de los pacientes con gripe podrá permanecer en sus casas y podrán ser atendidos por otros integrantes de la familia o personas que habiten en el hogar. Estos corren el riesgo de contagiarse gripe durante el período de incubación y enfermedad del paciente.

Manejo del paciente con gripe
Aleje físicamente al paciente lo más posible de todo el resto de las personas no enfermas que habitan en una casa. Si es posible, arme un cuarto aparte.
Es importante que el aire de la habitación circule hacia el exterior y que no vuelva a ingresar en la casa.
Sólo deben entrar a la habitación del enfermo las personas que estrictamente necesitan atenderlo, y deben lavarse bien las manos al salir.
Usar barbijos puede ser útil.
Los pacientes no deben salir de sus hogares durante el período en que es más probable que puedan contagiar a otros.

Medidas para controlar la infección en el hogar
Todas las personas en la casa deben lavarse las manos con agua y jabón o utilizar líquido de limpieza de manos con alcohol luego de entrar en contacto con un paciente que tiene gripe.
No es necesario separar los cubiertos utilizados por un paciente con gripe.
No es necesario lavar por separado la ropa de cama y otra ropa utilizada por el paciente con gripe. Hay que manejar la ropa sucia con cuidado para evitar la contaminación. Deben higienizarse las manos luego de manipular la ropa sucia.
Los pañuelos usados por un paciente enfermo deben colocarse en una bolsa y descartarse con el resto de los desechos hogareños.
Considere la posibilidad de colocar una bolsa exclusiva para ello al lado de la cama.

Manejo de otras personas en el hogar
Aquellas personas/visitantes que no han estado expuestos a la gripe y que no resultan esenciales para cuidar al paciente no deberían ingresar a la casa.
Si hay personas que no han estado expuestas y que deben ingresar a la casa, deben evitar el contacto estrecho con el paciente.
Las personas que habitan en la misma casa que el paciente con gripe deben limitar el contacto con él en la medida de lo posible; considere la posibilidad de designar una persona como cuidadora principal del paciente.
Los convivientes de dicho hogar deben estar atentos a cualquier aparición de los síntomas de la gripe

Cribado de cancer de prostata

Editorial del NEJM 26 de Marzo 2009

In the United States, most men over the age of 50 years have had a prostate-specific–antigen (PSA) test,¹ despite the absence of evidence from large, randomized trials of a net benefit. Moreover, about 95% of male urologists and 78% of primary care physicians who are 50 years of age or older report that they have had a PSA test themselves,² a finding that suggests they are practicing what they preach. And indeed, U.S. death rates from prostate cancer have fallen about 4% per year since 1992, five years after the introduction of PSA testing.³ Perhaps the answer to the PSA controversy is already staring us in the face. At the same time, practice guidelines cite the unproven benefit of PSA screening, as well as the known side effects,^4,5 which largely reflect the high risks of overdiagnosis and overtreatment that PSA-based screening engenders.⁶

The first reports from two large, randomized trials that many observers hoped would settle the controversy appear in this issue of the Journal. In the U.S. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, Andriole et al.⁷ report no mortality benefit from combined screening with PSA testing and digital rectal examination during a median follow-up of 11 years.⁸ In the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial, Schröder et al.⁸ report that PSA screening without digital rectal examination was associated with a 20% relative reduction in the death rate from prostate cancer at a median follow-up of 9 years, with an absolute reduction of about 7 prostate cancer deaths per 10,000 men screened.⁸ The designs of the two trials are different and provide complementary insights.

First, one must ask, "Why were these results published now?" Neither set of findings seems definitive; that is, there was neither a clear declaration of futility in the PLCO trial nor an unambiguous net benefit in the ERSPC trial. Both studies are ongoing, with future updates promised. The report on the ERSPC trial follows a third planned interim analysis, which found a marginally significant decrease in prostate-cancer mortality after adjustment of the P value for the two previous looks in an attempt to avoid a false positive conclusion (yet apparently preserving no alpha for the planned final analysis). On the other hand, the investigators in the PLCO trial made the decision to publish their results now because of concern about the emerging evidence of net harm compared with potential benefits associated with PSA screening. Both decisions to publish now can be criticized as premature, leaving clinicians and patients to deal with the ambiguity.

The ERSPC trial is actually a collection of trials in different countries with different eligibility criteria, randomization schemes, and strategies for screening and follow-up. The report by Schröder et al. is based on a predefined core group of men between 55 and 69 years of age at study entry. Subjects were generally screened every 4 years, and 82% were screened at least once. Contamination of the control group with screening as part of usual care is not described. Biopsies were generally recommended for subjects with PSA levels of more than 3.0 ng per milliliter. It is unclear whether the clinicians and hospitals treating patients with prostate cancer differed between the two study groups.

Adjudications of causes of death were made by committees whose members were unaware of study-group assignments, though not of treatments. This point is important, since previous research has suggested that the cause of death is less likely to be attributed to prostate cancer among men receiving attempted curative treatment.⁹ Misattribution might then create a bias toward screening, since the diagnosis of more early-stage cancers in the ERSPC trial led to substantially more attempted curative treatments.

The ERSPC interim analysis revealed a 20% reduction in prostate-cancer mortality; the adjusted P value was 0.04. The estimated absolute reduction in prostate-cancer mortality of about 7 deaths per 10,000 men after 9 years of follow-up, if real and not the result of chance or bias, must be weighed against the additional interventions and burdens. The 73,000 men in the screening group underwent more than 17,000 biopsies, undoubtedly many more than did men in the control group, though the latter is not reported. Men had a substantially higher cumulative risk of receiving the diagnosis of prostate cancer in the screening group than in the control group (820 vs. 480 per 10,000 men). Diagnosis led to more treatment, with 277 versus 100 per 10,000 men undergoing radical prostatectomy and 220 versus 123 per 10,000 undergoing radiation therapy with or without hormones, respectively (tentative estimates given the unknown treatments in both groups).

Although estimates of the benefit of screening were somewhat greater for men who actually underwent testing (taking into account noncompliance) than for those who were not tested, the side effects would be proportionately higher as well. Given these trade-offs, the promise of future ERSPC analyses addressing quality of life and cost-effectiveness is welcome indeed. The ERSPC results also reemphasize the need for caution in screening men over the age of 69 years, given an early trend toward higher prostate-cancer mortality with screening in this age subgroup, although this finding may well be due to chance alone.

A final point to make about the ERSPC trial is that to the extent that the diagnosis and treatment of prostate cancer in the screening group differed from those in the control group, it becomes difficult to dissect out the benefit attributable to screening versus improved treatment once prostate cancer was suspected or diagnosed. A similar distribution of treatments among seemingly similar patients with cancer is only partially reassuring in this regard.

Despite a longer median follow-up, the PLCO trial was smaller and therefore less mature than the ERSPC trial, with 174 prostate-cancer deaths driving the power of the study, as compared with 540 such deaths in the ERSPC trial. The screening protocol was homogeneous across sites with an enrollment age of 55 to 74 years and annual PSA tests for 6 years and digital rectal examinations for 4 years, with about 85% compliance. Subjects in the screening group who had a suspicious digital rectal examination or a PSA level of more than 4.0 ng per milliliter received a recommendation for further evaluation. This strategy helped to ensure that any difference in outcome was attributable to screening, rather than downstream management. The effectiveness of screening, of course, will be determined by the effectiveness of subsequent "usual care," but this is the same usual care that many practitioners assume has been responsible for the falling U.S. death rate from prostate cancer. Adjudication of causes of death was similar to that in the ERSPC trial.

Though the PLCO trial has shown no significant effect on prostate-cancer mortality to date, the relatively low number of end points begets a wide confidence interval, which includes at its lower margin the point estimate of effect from the ERSPC trial. Other likely explanations for the negative findings are high levels of prescreening in the PLCO population and contamination of the control group. Contamination was assessed by periodic cross-sectional surveys, with about half the subjects in the control group undergoing PSA testing by year 5. It is unclear whether these estimates reflect testing that year or since trial inception; if the former, the cumulative incidence may be even higher. The smaller difference in screening intensity between the two study groups in the PLCO trial, as compared with the ERSPC trial, is reflected in a smaller risk of overdiagnosis (23% vs. more than 70%) and a less impressive shift in cancer stage and grade distributions. Given that study-group contamination from the use of digital rectal examination was less problematic (only about 25%), ongoing results from both of these trials may necessitate rethinking the role of digital rectal examination in cancer screening.

After digesting these reports, where do we stand regarding the PSA controversy? Serial PSA screening has at best a modest effect on prostate-cancer mortality during the first decade of follow-up. This benefit comes at the cost of substantial overdiagnosis and overtreatment. It is important to remember that the key question is not whether PSA screening is effective but whether it does more good than harm. For this reason, comparisons of the ERSPC estimates of the effectiveness of PSA screening with, for example, the similarly modest effectiveness of breast-cancer screening cannot be made without simultaneously appreciating the much higher risks of overdiagnosis and overtreatment associated with PSA screening.

The report on the ERSPC trial appropriately notes that 1410 men would need to be offered screening and an additional 48 would need to be treated to prevent one prostate-cancer death during a 10-year period, assuming the point estimate is correct. And although the PLCO trial may not have the power as yet to detect a similarly modest benefit of screening, its power is already more than adequate to detect important harm through overdiagnosis. However, the implications of the trade-offs reflected in these data, like beauty, will be in the eye of the beholder. Some well-informed clinicians and patients will still see these trade-offs as favorable; others will see them as unfavorable. As a result, a shared decision-making approach to PSA screening, as recommended by most guidelines, seems more appropriate than ever.

Finally, despite these critiques, both groups of investigators deserve high praise for their persistence and perseverance: to manage such monstrous trials is a herculean task, made no easier when so many observers think the results are self-evident. Further analyses will be needed from these trials, as well as from others — such as the Prostate Cancer Intervention Versus Observation Trial (PIVOT) in the United States (ClinicalTrials.gov number, NCT00007644 [ClinicalTrials.gov] )¹⁰ and the Prostate Testing for Cancer and Treatment (PROTECT) trial in the United Kingdom (Current Controlled Trials number, ISRCTN20141297 [controlled-trials.com] )¹¹ — if the PSA controversy is finally to sleep the big sleep.

No potential conflict of interest relevant to this article was reported.

Source Information

From Massachusetts General Hospital and Harvard Medical School, Boston.

This article (10.1056/NEJMe0901166) was published at NEJM.org on March 18, 2009.

References

1. Ross LE, Berkowitz Z, Ekwueme DU. Use of the prostate-specific antigen test among U.S. men: findings from the 2005 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2008;17:636-644. [Free Full Text]
2. Chan EC, Barry MJ, Vernon SW, Ahn C. Brief report: physicians and their personal prostate cancer-screening practices with prostate-specific antigen: a national survey. J Gen Intern Med 2006;21:257-259. [CrossRef][ISI][Medline]
3. Ries LAG, Melbert D, Krapcho M, et al. SEER cancer statistics review, 1975–2005. Bethesda, MD: National Cancer Institute, 2008. (Accessed March 6, 2009 at http://seer.cancer.gov/csr/1975_2005/.)
4. Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues. CA Cancer J Clin 2008;58:161-179. [Free Full Text]
5. U. S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:185-191. [Free Full Text]
6. Barry MJ. Why are a high overdiagnosis probability and a long lead time for prostate cancer screening so important? J Natl Cancer Inst (in press).
7. Andriole GL, Grubb RL III, Buys SS, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-1319. [Free Full Text]
8. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:1320-1328. [Free Full Text]
9. Newschaffer CJ, Otani K, McDonald MK, Penberthy LT. Causes of death in elderly prostate cancer patients and in a comparison nonprostate cancer cohort. J Natl Cancer Inst 2000;92:613-621. [Free Full Text]
10. Wilt TJ, Brawer MK, Barry MJ, et al. The Prostate cancer Intervention Versus Observation Trial: VA/NCI/AHRQ Cooperative Studies Program #407 (PIVOT): design and baseline results of a randomized controlled trial comparing radical prostatectomy to watchful waiting for men with clinically localized prostate cancer. Contemp Clin Trials 2009;30:81-87. [CrossRef][ISI][Medline]
11. Donovan J, Hamdy F, Neal D, et al. Prostate Testing for Cancer and Treatment (ProtecT) feasibility study. Health Technol Assess 2003;7:1-88. [Medline]

Quien tiene tiempo para Medicina Familiar?

Interesante articulo en el que se comenta sobre el exceso de guias de practicas clinicas y la cantidad de horas que llevaria llevar adelante las practicas preventivas que se proponen. Al menos en America del Norte, esto implicaria unas 10,5 horas por dia, cuando el promedio de horas laborables por estos medicos es de casi 8 horas.

Nicholas Pimlott, MD CCFP
Associate Professor in the Department of Family and Community Medicine at the University of Toronto, Research Director of the Family Practice Health Centre at Women’s College Hospital in Toronto, Ont., and Associate Editor of Canadian Family Physician

Correspondence to: Dr Nicholas Pimlott, 60 Grosvenor St, Toronto, ON M5S 1B6; telephone 416 323–6065; fax 416 323–6335; e-mail nick.pimlott@utoronto.ca

Recently a number of articles in the medical literature have discussed the many dissatisfactions of primary care physicians, including family physicians.

Bodenheimer¹ has clearly documented the growing pressures on primary care physicians in the United States. Patients are dissatisfied as they experience longer wait times and perceive the quality of care they receive to be inadequate. Physicians are dissatisfied because they feel they are paid for volume, not quality; they earn half the income of specialists and the gap is widening; and they find that the workload is becoming impossible to sustain. The situation is similar in Canadian primary care.

Time pressures

The first published evidence examining family physician workload appeared in 2003. Yarnall et al² used published and estimated times per service to determine the physician time required to provide all of the services recommended by the US Preventive Services Task Force, at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population. They found that to fully satisfy the US Preventive Services Task Force recommendations, a physician would have to spend 1773 hours per year, or 7.4 hours per working day, providing preventive services.

Recently, using similar methods, Østbye et al³ applied guideline recommendations for 10 common chronic diseases to a panel of 2500 primary care patients (with an age and sex distribution and chronic disease prevalence similar to those of the general population) and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician. They found that 823 hours per year, or 3.5 hours a day, were required to provide care for the 10 most common chronic diseases, provided the diseases were stable and in good control. They recalculated this estimate based on increased time requirements for uncontrolled disease. The estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2484 hours per year or 10.6 hours a day. The authors concluded that meeting current practice guidelines for only 10 chronic illnesses requires more time than primary care physicians have available for patient care overall.

When we combine the results of these 2 studies, the average American family physician will spend between 10.9 and 18 hours per day delivering preventive and chronic illness care. Such estimates fail to account for time spent in the delivery of acute care for common conditions, such as upper respiratory tract infections and urinary tract infections, that make up much of a typical day. They also fail to account for time spent outside the examination room answering telephone calls, filling out forms, making referrals, and so on, which takes up a substantial part of the day.^4,5

The situation begs some obvious questions. How did expectations for family physicians outstrip the number of hours in the day? Since even the most conscientious family physician is not working 24 hours a day,⁶ how do family physicians cope with such expectations and demands on their time? Finally, how can expectations of family physicians be made more realistic without compromising the quality of patient care?

Guideline explosion

Several factors have contributed to the time crunch for family physicians, but I believe one factor in particular has had an enormous effect—the explosion of clinical practice guidelines (CPGs) over the past decade. Clinical practice guidelines emerged in the 1970s in most of the industrialized world, beginning with the Canadian Task Force on the Periodic Health Examination in Canada and the US Preventive Services Task Force in the United States. The task forces had an admirable purpose and necessary goals: to evaluate the scientific evidence behind preventive care and to make evidence-based recommendations for practice. These task forces established clear evidence hierarchies and a clear process for the evaluation and the dissemination of clinical evidence. Their recommendations continue to guide primary preventive care today.

Since that time there has been an explosion of CPGs aimed at family physicians. There are more than 2000 guidelines available from the website of the National Guidelines Clearinghouse (www.guideline.gov) in the United States (although not all of them are relevant to family physicians). At last count there were 124 CPGs posted on the website (http://gacguidelines.ca) of the Ontario-based Guidelines Advisory Committee (GAC), an organization dedicated to the evaluation and dissemination of guidelines relevant to family physicians; the GAC’s mission is "to promote better health for the people of Ontario by encouraging physicians and other practitioners to use evidence-based clinical practice guidelines and clinical practices based on best available evidence. In particular, to increase awareness and use of best available evidence, [they] identify, evaluate, endorse and summarize guidelines for use in Ontario."

While the GAC evaluates and rates CPGs according to criteria for quality, there are many problems with CPGs, including many of those that the GAC has favourably evaluated. First, there is strong evidence that guidelines are not developed according to stringent criteria. Shaneyfelt has demonstrated that "Guidelines published in the peer-reviewed medical literature during the past decade do not adhere well to established methodological standards. While all areas of guideline development need improvement, greatest improvement is needed in the identification, evaluation, and synthesis of the scientific evidence."⁷ Second, guidelines follow the clinical research paradigm and are often developed with only one condition or disease in mind. Patients seen by family physicians usually present with several chronic and interacting conditions, making the application of guideline recommendations more difficult.⁸ Third, guidelines often do not take into account patient preferences for care, something that family physicians are explicitly trained to do. Fourth, even high-quality guidelines fall short in the way they are disseminated to family physicians. Guidelines are usually passively distributed by mail and in paper form. Although there are increasing exceptions, they also tend to be long, detailed, and do not provide specific clinically useful summaries for busy doctors.⁹

Improving guidelines

Is there a way to improve CPGs and to reduce the enormous time pressures that burgeoning guidelines place on family physicians? I believe that the answer is yes, but several changes in current practice and in the way that guidelines are developed and disseminated are necessary.

Guidelines need to be "done" differently. Guideline panels typically consist of large numbers of specialist content experts with 2 or 3 family physicians included. Having sat on a guideline panel in the past,¹⁰ I can reflect that much of the discussion over 2 days was about research evidence to support the recommendations. While this discussion is critically important, very little time was spent on the equally important issue of dissemination (or knowledge translation). This is a world turned upside down. I propose that guideline panels of the future have much greater representation from family physicians working in different settings, with a small number of content experts to advise them on content. In that way, perhaps, greater attention will be paid to how family physicians can use the guidelines in their practices.

Greater emphasis needs to be placed on applying guidelines to the type of patients seen in family practice settings—the elderly and those with multiple chronic conditions. Furthermore, greater attention needs to be placed on the evidence for the effectiveness of interventions in guidelines. Family physicians are swamped with maneuvers supported only by expert opinion.

This has been said and written many times before, but more attention needs to be paid to the effective dissemination and implementation of good guidelines. Stronger input from family physicians is crucial if dissemination is to be successful.

As family physicians move toward working in family health teams or groups that incorporate and integrate other health care professionals, greater attention needs to be paid to the role of other providers in the delivery of acute, chronic, and preventive care. Clearly, if family physicians are to continue to provide high-quality care and incorporate guideline recommendations into their practices, they will need to share this work with other professionals. Many preventive care maneuvers can be performed, for example, by nurse practitioners integrated into family health teams. Similarly, nurse practitioners can effectively provide care for some chronic conditions, allowing family physicians to focus on acute care or on patients with chronic illnesses that are unstable.

Family physicians are under increasing time pressures to provide both preventive and chronic illness care. The growth in CPGs for both preventive and chronic care and the expectation that they will be closely followed by family physicians has contributed substantially to the time pressures. Improvements in the quality and in the dissemination of guidelines and the integration of other health care providers, such as nurse practitioners, into family health teams could help ease time pressures on family physicians and improve the quality of their work lives.

Footnotes

Competing interests

None declared

The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

References

1. Bodenheimer T. Primary care—will it survive? New Engl J Med 2006;355:861-4.[Free Full Text]
2. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-41.[Abstract/Free Full Text]
3. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3:209-14.[Abstract/Free Full Text]
4. Gilchrist V, McCord G, Schrop SL, King BD, McCormick KF, Oprandi AM, et al. Physician activities during time out of the examination room. Ann Fam Med 2005;3:494-9.[Abstract/Free Full Text]
5. Gottschalk A, Flocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med 2005;3:488-93.[Abstract/Free Full Text]
6. Slade S, Busing N. Weekly work hours and clinical activities of Canadian family physicians: results of the 1997–98 National Family Physician Survey of the College of Family Physicians of Canada. CMAJ 2002;166:1407-11.[Abstract/Free Full Text]
7. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999;281:1900-5.[Abstract/Free Full Text]
8. Upshur RE. The complex, the exhausted and the personal: reflections on the relationship between evidence-based medicine and casuistry. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. J Eval Clin Pract 2006;12(3):281-8.[Medline]
9. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ 2004;328:343-5.[Free Full Text]
10. Ontario Ministry of Health and Long-Term Care. Ontario guidelines for the prevention and treatment of osteoporosis. Ontario Program for Optimal Therapeutics. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2000. Available from: www.opot.org/guidelines/osteoporosis.pdf. Accessed 2007 November 27.

Fuente:

Who has time for family medicine?

Nicholas Pimlott, MD CCFP
Associate Professor in the Department of Family and Community Medicine at the University of Toronto, Research Director of the Family Practice Health Centre at Women’s College Hospital in Toronto, Ont., and Associate Editor of Canadian Family Physician

Correspondence to: Dr Nicholas Pimlott, 60 Grosvenor St, Toronto, ON M5S 1B6; telephone 416 323–6065; fax 416 323–6335; e-mail nick.pimlott@utoronto.ca

Recently a number of articles in the medical literature have discussed the many dissatisfactions of primary care physicians, including family physicians.

Bodenheimer¹ has clearly documented the growing pressures on primary care physicians in the United States. Patients are dissatisfied as they experience longer wait times and perceive the quality of care they receive to be inadequate. Physicians are dissatisfied because they feel they are paid for volume, not quality; they earn half the income of specialists and the gap is widening; and they find that the workload is becoming impossible to sustain. The situation is similar in Canadian primary care.

Time pressures

The first published evidence examining family physician workload appeared in 2003. Yarnall et al² used published and estimated times per service to determine the physician time required to provide all of the services recommended by the US Preventive Services Task Force, at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population. They found that to fully satisfy the US Preventive Services Task Force recommendations, a physician would have to spend 1773 hours per year, or 7.4 hours per working day, providing preventive services.

Recently, using similar methods, Østbye et al³ applied guideline recommendations for 10 common chronic diseases to a panel of 2500 primary care patients (with an age and sex distribution and chronic disease prevalence similar to those of the general population) and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician. They found that 823 hours per year, or 3.5 hours a day, were required to provide care for the 10 most common chronic diseases, provided the diseases were stable and in good control. They recalculated this estimate based on increased time requirements for uncontrolled disease. The estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2484 hours per year or 10.6 hours a day. The authors concluded that meeting current practice guidelines for only 10 chronic illnesses requires more time than primary care physicians have available for patient care overall.

When we combine the results of these 2 studies, the average American family physician will spend between 10.9 and 18 hours per day delivering preventive and chronic illness care. Such estimates fail to account for time spent in the delivery of acute care for common conditions, such as upper respiratory tract infections and urinary tract infections, that make up much of a typical day. They also fail to account for time spent outside the examination room answering telephone calls, filling out forms, making referrals, and so on, which takes up a substantial part of the day.^4,5

The situation begs some obvious questions. How did expectations for family physicians outstrip the number of hours in the day? Since even the most conscientious family physician is not working 24 hours a day,⁶ how do family physicians cope with such expectations and demands on their time? Finally, how can expectations of family physicians be made more realistic without compromising the quality of patient care?

Guideline explosion

Several factors have contributed to the time crunch for family physicians, but I believe one factor in particular has had an enormous effect—the explosion of clinical practice guidelines (CPGs) over the past decade. Clinical practice guidelines emerged in the 1970s in most of the industrialized world, beginning with the Canadian Task Force on the Periodic Health Examination in Canada and the US Preventive Services Task Force in the United States. The task forces had an admirable purpose and necessary goals: to evaluate the scientific evidence behind preventive care and to make evidence-based recommendations for practice. These task forces established clear evidence hierarchies and a clear process for the evaluation and the dissemination of clinical evidence. Their recommendations continue to guide primary preventive care today.

Since that time there has been an explosion of CPGs aimed at family physicians. There are more than 2000 guidelines available from the website of the National Guidelines Clearinghouse (www.guideline.gov) in the United States (although not all of them are relevant to family physicians). At last count there were 124 CPGs posted on the website (http://gacguidelines.ca) of the Ontario-based Guidelines Advisory Committee (GAC), an organization dedicated to the evaluation and dissemination of guidelines relevant to family physicians; the GAC’s mission is "to promote better health for the people of Ontario by encouraging physicians and other practitioners to use evidence-based clinical practice guidelines and clinical practices based on best available evidence. In particular, to increase awareness and use of best available evidence, [they] identify, evaluate, endorse and summarize guidelines for use in Ontario."

While the GAC evaluates and rates CPGs according to criteria for quality, there are many problems with CPGs, including many of those that the GAC has favourably evaluated. First, there is strong evidence that guidelines are not developed according to stringent criteria. Shaneyfelt has demonstrated that "Guidelines published in the peer-reviewed medical literature during the past decade do not adhere well to established methodological standards. While all areas of guideline development need improvement, greatest improvement is needed in the identification, evaluation, and synthesis of the scientific evidence."⁷ Second, guidelines follow the clinical research paradigm and are often developed with only one condition or disease in mind. Patients seen by family physicians usually present with several chronic and interacting conditions, making the application of guideline recommendations more difficult.⁸ Third, guidelines often do not take into account patient preferences for care, something that family physicians are explicitly trained to do. Fourth, even high-quality guidelines fall short in the way they are disseminated to family physicians. Guidelines are usually passively distributed by mail and in paper form. Although there are increasing exceptions, they also tend to be long, detailed, and do not provide specific clinically useful summaries for busy doctors.⁹

Improving guidelines

Is there a way to improve CPGs and to reduce the enormous time pressures that burgeoning guidelines place on family physicians? I believe that the answer is yes, but several changes in current practice and in the way that guidelines are developed and disseminated are necessary.

Guidelines need to be "done" differently. Guideline panels typically consist of large numbers of specialist content experts with 2 or 3 family physicians included. Having sat on a guideline panel in the past,¹⁰ I can reflect that much of the discussion over 2 days was about research evidence to support the recommendations. While this discussion is critically important, very little time was spent on the equally important issue of dissemination (or knowledge translation). This is a world turned upside down. I propose that guideline panels of the future have much greater representation from family physicians working in different settings, with a small number of content experts to advise them on content. In that way, perhaps, greater attention will be paid to how family physicians can use the guidelines in their practices.

Greater emphasis needs to be placed on applying guidelines to the type of patients seen in family practice settings—the elderly and those with multiple chronic conditions. Furthermore, greater attention needs to be placed on the evidence for the effectiveness of interventions in guidelines. Family physicians are swamped with maneuvers supported only by expert opinion.

This has been said and written many times before, but more attention needs to be paid to the effective dissemination and implementation of good guidelines. Stronger input from family physicians is crucial if dissemination is to be successful.

As family physicians move toward working in family health teams or groups that incorporate and integrate other health care professionals, greater attention needs to be paid to the role of other providers in the delivery of acute, chronic, and preventive care. Clearly, if family physicians are to continue to provide high-quality care and incorporate guideline recommendations into their practices, they will need to share this work with other professionals. Many preventive care maneuvers can be performed, for example, by nurse practitioners integrated into family health teams. Similarly, nurse practitioners can effectively provide care for some chronic conditions, allowing family physicians to focus on acute care or on patients with chronic illnesses that are unstable.

Family physicians are under increasing time pressures to provide both preventive and chronic illness care. The growth in CPGs for both preventive and chronic care and the expectation that they will be closely followed by family physicians has contributed substantially to the time pressures. Improvements in the quality and in the dissemination of guidelines and the integration of other health care providers, such as nurse practitioners, into family health teams could help ease time pressures on family physicians and improve the quality of their work lives.

Footnotes

Competing interests

None declared

The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

References

1. Bodenheimer T. Primary care—will it survive? New Engl J Med 2006;355:861-4.[Free Full Text]
2. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-41.[Abstract/Free Full Text]
3. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3:209-14.[Abstract/Free Full Text]
4. Gilchrist V, McCord G, Schrop SL, King BD, McCormick KF, Oprandi AM, et al. Physician activities during time out of the examination room. Ann Fam Med 2005;3:494-9.[Abstract/Free Full Text]
5. Gottschalk A, Flocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med 2005;3:488-93.[Abstract/Free Full Text]
6. Slade S, Busing N. Weekly work hours and clinical activities of Canadian family physicians: results of the 1997–98 National Family Physician Survey of the College of Family Physicians of Canada. CMAJ 2002;166:1407-11.[Abstract/Free Full Text]
7. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999;281:1900-5.[Abstract/Free Full Text]
8. Upshur RE. The complex, the exhausted and the personal: reflections on the relationship between evidence-based medicine and casuistry. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. J Eval Clin Pract 2006;12(3):281-8.[Medline]
9. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ 2004;328:343-5.[Free Full Text]
10. Ontario Ministry of Health and Long-Term Care. Ontario guidelines for the prevention and treatment of osteoporosis. Ontario Program for Optimal Therapeutics. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2000. Available from: www.opot.org/guidelines/osteoporosis.pdf. Accessed 2007 November 27.

Who has time for family medicine?

Nicholas Pimlott, MD CCFP
Associate Professor in the Department of Family and Community Medicine at the University of Toronto, Research Director of the Family Practice Health Centre at Women’s College Hospital in Toronto, Ont., and Associate Editor of Canadian Family Physician

Correspondence to: Dr Nicholas Pimlott, 60 Grosvenor St, Toronto, ON M5S 1B6; telephone 416 323–6065; fax 416 323–6335; e-mail nick.pimlott@utoronto.ca

Recently a number of articles in the medical literature have discussed the many dissatisfactions of primary care physicians, including family physicians.

Bodenheimer¹ has clearly documented the growing pressures on primary care physicians in the United States. Patients are dissatisfied as they experience longer wait times and perceive the quality of care they receive to be inadequate. Physicians are dissatisfied because they feel they are paid for volume, not quality; they earn half the income of specialists and the gap is widening; and they find that the workload is becoming impossible to sustain. The situation is similar in Canadian primary care.

Time pressures

The first published evidence examining family physician workload appeared in 2003. Yarnall et al² used published and estimated times per service to determine the physician time required to provide all of the services recommended by the US Preventive Services Task Force, at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population. They found that to fully satisfy the US Preventive Services Task Force recommendations, a physician would have to spend 1773 hours per year, or 7.4 hours per working day, providing preventive services.

Recently, using similar methods, Østbye et al³ applied guideline recommendations for 10 common chronic diseases to a panel of 2500 primary care patients (with an age and sex distribution and chronic disease prevalence similar to those of the general population) and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician. They found that 823 hours per year, or 3.5 hours a day, were required to provide care for the 10 most common chronic diseases, provided the diseases were stable and in good control. They recalculated this estimate based on increased time requirements for uncontrolled disease. The estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2484 hours per year or 10.6 hours a day. The authors concluded that meeting current practice guidelines for only 10 chronic illnesses requires more time than primary care physicians have available for patient care overall.

When we combine the results of these 2 studies, the average American family physician will spend between 10.9 and 18 hours per day delivering preventive and chronic illness care. Such estimates fail to account for time spent in the delivery of acute care for common conditions, such as upper respiratory tract infections and urinary tract infections, that make up much of a typical day. They also fail to account for time spent outside the examination room answering telephone calls, filling out forms, making referrals, and so on, which takes up a substantial part of the day.^4,5

The situation begs some obvious questions. How did expectations for family physicians outstrip the number of hours in the day? Since even the most conscientious family physician is not working 24 hours a day,⁶ how do family physicians cope with such expectations and demands on their time? Finally, how can expectations of family physicians be made more realistic without compromising the quality of patient care?

Guideline explosion

Several factors have contributed to the time crunch for family physicians, but I believe one factor in particular has had an enormous effect—the explosion of clinical practice guidelines (CPGs) over the past decade. Clinical practice guidelines emerged in the 1970s in most of the industrialized world, beginning with the Canadian Task Force on the Periodic Health Examination in Canada and the US Preventive Services Task Force in the United States. The task forces had an admirable purpose and necessary goals: to evaluate the scientific evidence behind preventive care and to make evidence-based recommendations for practice. These task forces established clear evidence hierarchies and a clear process for the evaluation and the dissemination of clinical evidence. Their recommendations continue to guide primary preventive care today.

Since that time there has been an explosion of CPGs aimed at family physicians. There are more than 2000 guidelines available from the website of the National Guidelines Clearinghouse (www.guideline.gov) in the United States (although not all of them are relevant to family physicians). At last count there were 124 CPGs posted on the website (http://gacguidelines.ca) of the Ontario-based Guidelines Advisory Committee (GAC), an organization dedicated to the evaluation and dissemination of guidelines relevant to family physicians; the GAC’s mission is "to promote better health for the people of Ontario by encouraging physicians and other practitioners to use evidence-based clinical practice guidelines and clinical practices based on best available evidence. In particular, to increase awareness and use of best available evidence, [they] identify, evaluate, endorse and summarize guidelines for use in Ontario."

While the GAC evaluates and rates CPGs according to criteria for quality, there are many problems with CPGs, including many of those that the GAC has favourably evaluated. First, there is strong evidence that guidelines are not developed according to stringent criteria. Shaneyfelt has demonstrated that "Guidelines published in the peer-reviewed medical literature during the past decade do not adhere well to established methodological standards. While all areas of guideline development need improvement, greatest improvement is needed in the identification, evaluation, and synthesis of the scientific evidence."⁷ Second, guidelines follow the clinical research paradigm and are often developed with only one condition or disease in mind. Patients seen by family physicians usually present with several chronic and interacting conditions, making the application of guideline recommendations more difficult.⁸ Third, guidelines often do not take into account patient preferences for care, something that family physicians are explicitly trained to do. Fourth, even high-quality guidelines fall short in the way they are disseminated to family physicians. Guidelines are usually passively distributed by mail and in paper form. Although there are increasing exceptions, they also tend to be long, detailed, and do not provide specific clinically useful summaries for busy doctors.⁹

Improving guidelines

Is there a way to improve CPGs and to reduce the enormous time pressures that burgeoning guidelines place on family physicians? I believe that the answer is yes, but several changes in current practice and in the way that guidelines are developed and disseminated are necessary.

Guidelines need to be "done" differently. Guideline panels typically consist of large numbers of specialist content experts with 2 or 3 family physicians included. Having sat on a guideline panel in the past,¹⁰ I can reflect that much of the discussion over 2 days was about research evidence to support the recommendations. While this discussion is critically important, very little time was spent on the equally important issue of dissemination (or knowledge translation). This is a world turned upside down. I propose that guideline panels of the future have much greater representation from family physicians working in different settings, with a small number of content experts to advise them on content. In that way, perhaps, greater attention will be paid to how family physicians can use the guidelines in their practices.

Greater emphasis needs to be placed on applying guidelines to the type of patients seen in family practice settings—the elderly and those with multiple chronic conditions. Furthermore, greater attention needs to be placed on the evidence for the effectiveness of interventions in guidelines. Family physicians are swamped with maneuvers supported only by expert opinion.

This has been said and written many times before, but more attention needs to be paid to the effective dissemination and implementation of good guidelines. Stronger input from family physicians is crucial if dissemination is to be successful.

As family physicians move toward working in family health teams or groups that incorporate and integrate other health care professionals, greater attention needs to be paid to the role of other providers in the delivery of acute, chronic, and preventive care. Clearly, if family physicians are to continue to provide high-quality care and incorporate guideline recommendations into their practices, they will need to share this work with other professionals. Many preventive care maneuvers can be performed, for example, by nurse practitioners integrated into family health teams. Similarly, nurse practitioners can effectively provide care for some chronic conditions, allowing family physicians to focus on acute care or on patients with chronic illnesses that are unstable.

Family physicians are under increasing time pressures to provide both preventive and chronic illness care. The growth in CPGs for both preventive and chronic care and the expectation that they will be closely followed by family physicians has contributed substantially to the time pressures. Improvements in the quality and in the dissemination of guidelines and the integration of other health care providers, such as nurse practitioners, into family health teams could help ease time pressures on family physicians and improve the quality of their work lives.

Footnotes

Competing interests

None declared

The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

References

1. Bodenheimer T. Primary care—will it survive? New Engl J Med 2006;355:861-4.[Free Full Text]
2. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-41.[Abstract/Free Full Text]
3. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3:209-14.[Abstract/Free Full Text]
4. Gilchrist V, McCord G, Schrop SL, King BD, McCormick KF, Oprandi AM, et al. Physician activities during time out of the examination room. Ann Fam Med 2005;3:494-9.[Abstract/Free Full Text]
5. Gottschalk A, Flocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med 2005;3:488-93.[Abstract/Free Full Text]
6. Slade S, Busing N. Weekly work hours and clinical activities of Canadian family physicians: results of the 1997–98 National Family Physician Survey of the College of Family Physicians of Canada. CMAJ 2002;166:1407-11.[Abstract/Free Full Text]
7. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999;281:1900-5.[Abstract/Free Full Text]
8. Upshur RE. The complex, the exhausted and the personal: reflections on the relationship between evidence-based medicine and casuistry. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. J Eval Clin Pract 2006;12(3):281-8.[Medline]
9. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ 2004;328:343-5.[Free Full Text]
10. Ontario Ministry of Health and Long-Term Care. Ontario guidelines for the prevention and treatment of osteoporosis. Ontario Program for Optimal Therapeutics. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2000. Available from: www.opot.org/guidelines/osteoporosis.pdf. Accessed 2007 November 27.

http://www.cfp.ca/cgi/content/full/54/1/14