Essential Practice
Guidelines in Primary Care
CU R R E N T 䉫 C L I N I C A L 䉫 P R A C T I C E
NEIL S. SKOLNIK,MD • SERIES EDITOR
Essential Practice Guidelines in Primary Care, edited by NEIL S.
SKOLNIK, 2007
Sleep Medicine in Primary Care: A Practical Guide, edited by J. F.
PAGEL AND S. R. PANDI-PERUMAL, 2008
Sexually Transmitted Diseases: A Practical Guide for Primary Care, edited by ANITA NELSON AND JOANN WOODWARD, 2007
Allergic Diseases: Diagnosis and Treatment, Third Edition, edited by PHIL LIEBERMAN AND JOHN A. ANDERSON, 2007
Headache and Chronic Pain Syndromes: The Case-Based Guide to Targeted Assessment and Treatment, DAWN A. MARCUS, 2007 Bone Densitometry in Growing Patients: Guidelines for Clinical
Practice, edited by AENOR J. SAWYER, LAURA K. BACHRACH,AND
ELLEN B. FUNG, 2007
The Handbook of Contraception: A Guide for Practical Management, edited by DONNA SHOUPE AND SIRI L. KJOS, 2006
Obstetrics in Family Medicine: A Practical Guide, PAUL LYONS, 2006 Psychiatric Disorders in Pregnancy and the Postpartum: Principles
and Treatment, edited by VICTORIA HENDRICK, 2006
Disorders of the Respiratory Tract: Common Challenges in Primary Care, edited by MATTHEW L. MINTZ, 2006
Cardiology in Family Practice: A Practical Guide, STEVEN M.
HOLLENBERG AND TRACY WALKER, 2006
Bronchial Asthma: A Guide for Practical Understanding and Treatment, Fifth Edition, edited by M. ERIC GERSHWIN
AND TIMOTHY E. ALBERTSON, 2006
Dermatology Skills for Primary Care: An Illustrated Guide, DANIEL J.
TROZAK, DAN J. TENNENHOUSE,AND JOHN J. RUSSELL, 2006
Thyroid Disease: A Case-Based and Practical Guide for Primary Care, EMANUEL O. BRAMS, 2005
Essential Practice Guidelines
in Primary Care
Edited by
Neil S. Skolnik, MD
Abington Memorial Hospital, Abington, PA
and Temple University School of Medicine, Philadelphia, PA
Associate Editors
Doron Schneider, MD
Abington Memorial Hospital, Abington, PA
Richard Neill, MD
University of Pennsylvania, Philadelphia, PA
Lou Kuritzky, MD University of Florida, Gainesville, FL
© 2007 Humana Press Inc.
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Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regu- lations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recom- mended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication.
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Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1 eISBN: 1-59745-313-7
Library of Congress Cataloging-in-Publication Data
Essential practice guidelines in primary care / edited by Neil S. Skolnik ; associate editors, Doron Schneider, Richard Neill, Lou Kuritzky.
p. ; cm. -- (Current clinical practice) Includes bibliographical references and index.
ISBN-13: 978-1-58829-508-8 ISBN-10: 1-58829-508-7 (alk. paper)
1. Evidence-based medicine--Handbooks, manuals, etc. 2. Primary care (Medicine)--Handbooks, manuals, etc. 3. Family medicine--Handbooks, manuals, etc. I. Skolnik, Neil S. II. Series.
[DNLM: 1. Evidence-Based Medicine--Handbooks. 2. Evidence-Based Medicine--Practice Guideline.
3. Primary Health Care--Handbooks. 4. Primary Health Care--Practice Guideline. WB 39 H2359 2007]
R729.G4H36 2007 616--dc22
2006022682
Introduction
v
Wisdom is the principal thing; therefore get wisdom and with all thy getting get understanding.
—Proverbs 4:7
In addition to wisdom, physicians need information—in many different settings—when learning new and reviewing previously learned material, during case conferences, and at the point-of-care while taking care of patients. Numer- ous studies have shown that physicians regularly encounter questions that need an answer while they are seeing patients (1). Unfortunately, only about one-third of those questions are eventually pursued to find an answer, likely because of the difficulty of finding answers and the time constraints under which physicians find themselves (2–4). It is important to understand that when information is readily available, physicians utilize that information, and that information impacts on patient care and can alter the clinical decisions that occur (5–7).
National clinical guidelines have been increasingly recognized as a potential way of improving the quality of medical care by giving physicians clear, evidence- based guidance on how to treat complex diseases where an abundance of litera- ture may exist.
The evolution of medical knowledge proceeds along a predictable route. It starts with careful observation. Next comes the generation of hypotheses. The hypotheses are then tested through studies. These studies are eventually synthe- sized into evidence-based guidelines developed through a rigorous process that includes a comprehensive review of the literature combined with expert opinion.
Guidelines should be constructed with the clinician in mind so that they are understandable and easy to implement. In order for guidelines to be useful, they must then be disseminated so that physicians are familiar with their content, and tools and resources must be made available to clinicians so the guidelines can be implemented at the point-of-care and referred to wherever and whenever infor- mation is needed (8). Essential Practice Guidelines in Primary Care puts the most important evidence-based, nationally recognized, clinical guidelines together in one place so that busy clinicians can go to one source when, in the care of a patient, a question arises that is best answered by an existing clinical guideline.
The increasing amount and complexity of medical information has led to new strategies being developed to allow physicians to access current information from the medical literature in order to continue to provide excellent, up-to-date medical care. Electronic handheld references, which have emerged over the last few years, provide an opportunity for physicians to answer important clinical questions during the time those questions are most meaningful, that is, when patients are being taken care of and decisions are being made. Currently, about half of all primary care physicians are using handheld computers. In March 2004, the Institute of Medicine issued a report that stated, “Personal digital assistants [PDAs] are increasingly being used to support safety and quality in point-of-care applications. These tech- nologies have the potential for widespread adoption because of their greater flex- ibility, convenience, and mobility relative to wired network communication systems. Many physicians and other health care providers are already incorporating handheld devices into their day-to-day functioning to better manage the care of their patients while at the same time reduce medical errors” (9).
With the busy clinician in mind, Essential Practice Guidelines in Primary Care has been constructed from its origin to have a companion PDA resource, with summaries of the guidelines in this book, and additional summaries of guidelines not included in the book. In fact, the PDA version of Essential Prac- tice Guidelines in Primary Care was developed first. Shortly after being pub- lished, an Annals of Internal Medicine book review stated that the PDA-based Clinical Guidelines Handbook was “an important tool for bringing evidence- based medicine to the point-of-care.” That review was an important impetus to develop the print edition. In our opinion, the print edition is best used as a single resource where a clinician can read through a large selection of guidelines to gain an overview and understanding of any given guideline and the PDA version is best used to look up information that is needed quickly either at the point-of-care or during a conference. Together, these complimentary textbooks, in print and electronic, should facilitate the implementation of nationally recognized clinical guidelines by primary care physicians. (To order the PDA version of this title [ISBN 1-934115- 47-9], please contact the publisher, Humana Press, at www.humanapress.com.) A book, like a plant, grows best in the right environment. The development of a book works best when it occurs with the cooperation of many people, both personal and professional. That cooperation merits thanks. First of all I would like to thank the three associate editors of this book—Lou Kuritzky, Richard Neill, and Doron Schneider. Their contributions were integral to the evolution of the book.
Richard Lansing deserves praise and thanks as both a friend and as the editor at Humana Press with whom I first discussed the concept of this book and who recognized the value of practice guidelines to primary care physicians. Many thanks to Robin Weisberg for her insightful editing as this book was coming together.
vi Introduction
I would like to thank my fellow faculty in the Family Medicine Residency Program at Abington Memorial Hospital. I feel lucky to be a part of such an outstanding and caring faculty—Mathew Clark, Amy Clouse, Pam Fenstemacher, Trip Hansen, and John Russell—where we all challenge each other daily and share an excitement and joy in teaching and learning. I also owe thanks to our superb residents who stand shoulder to shoulder with us in provid- ing excellent evidence-based, compassionate care to our patients and who regu- larly, and at times respectfully, ask the tough questions that keep us attending physicians going back to the literature and keep us on our toes. I am also filled with appreciation for being a part of Abington Memorial Hospital where the administration strongly supports excellence in patient care and residency educa- tion, and where the excellent relationships between departments lead to the collaboration between the departments of Internal Medicine and Family Medi- cine that helped to make this book. Specifically within the hospital I would like to mention Dick Jones, Meg McGoldrick, Gary Candia, Jack Kelly, and Warren Matthews, all of whom provide our academic Family Medicine Residency Pro- gram with the resources and guidance we need to carry out our mission.
Finally, and of highest importance, no person, no plant, and no book grows to its fullest without the love and support of family. My eternal gratitude and love belong to my wife, Alison, who puts up with my foibles and shares my joys and dreams and is my partner in this journey that is our life; my ongoing wonder and love goes to my son, Aaron, whose intelligence, sharp observational skills, and appreciation of nature have taken us on fishing trips on lakes throughout north- eastern United States and Canada; and my ongoing wonder and love goes to my daughter Ava, whose singing and wonderful dancing I tremendously enjoy and who constantly amazes me with her beauty, intelligence, and humor.
Neil S. Skolnik, MD
REFERENCES
1. Schilling, LM, Anderson RJ. Answering patient-specific questions using information resources available in an outpatient clinic. Semin Med Prac 2000;3(4):11–21.
2. Ely JW, Osheroff JA, Ebell MH, et al. Analysis of questions asked by family doctors regard- ing patients’ care. BMJ 1999;319:358–361.
3. Gorman PN. Information needs of physicians. J Am Soc Inform Sci 1995;46:729–736.
4. Green ML, Ciampi MA, Ellis PJ. Residents’ medical information needs in clinic: are they being met? Am J Med 2000;109:218–223.
5. Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med 1985;103:596–599.
6. Sacket DL, Straus SE. Finding and applying evidence during clinical rounds: the “evidence cart.” JAMA 1998;280:1336–1338.
7. Gundersen L. The effect of clinical practice guidelines on variations in care. Ann Intern Med 2000;133:317.
Introduction vii
8. Weingarten S. Using practice guideline compendiums to provide better preventive care. Ann Intern Med 1999;130:454–458.
9. Aspeden P, Corrigan JM, Wolcott J, Erickson SM (eds.). Patient Safety: Achieving a New Standard for Care (Institute of Medicine report). Washington, DC: National Academies Press, 2004, p. 70.
viii Introduction
Contents
ix
Introduction ... v Contributors ... xiii
I: CARDIOLOGY
1. Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure ... 3 Benjamin J. Epstein
2. Hyperlipidemia ... 27 Andrew Cohen and Neil S. Skolnik
3. Management of Newly Diagnosed Atrial Fibrillation:
A Clinical Practice Guideline From the American Academy of Family Physicians and the American College
of Physicians ... 41 Jaya Udayasankar and Doron Schneider
4. Antithrombotic Therapy for Venous Thromboembolic
Disease ... 51 George P. N. Samraj
5. Antithrombotic Therapy for Atrial Fibrillation, Valvular Heart Disease, Management of Elevated INRs
and Perioperative Management ... 59 Ann Peff and Doron Schneider
6. Prevention of Bacterial Endocarditis ... 71 Margot Boigon and Doron Schneider
II: RESPIRATORY
7. Clinical Guidelines for the Diagnosis and Treatment
of Asthma ... 81 Michael Gagnon and Neil S. Skolnik
III: INFECTIOUS DISEASE
8. Community Acquired Pneumonia and Health Care-
Associated Pneumonia Clinical Guidelines ... 103 John Russell
x Contents 9. Diagnosis and Management of Otitis Media:
Joint Guidelines From the American Academy of Pediatrics
and American Academy of Family Physicians ... 119 Richard Neill
10. Appropriate Antibiotic Use for Treatment of Nonspecific Upper Respiratory Infections, Rhinosinusitis, and Acute
Bronchitis in Adults ... 125 Tina H. Degnan and Neil S. Skolnik
11. Group A Streptococcal Pharyngitis:
The Infectious Disease Society of America ... 131 Mario Napoletano
12. Prevention of Perinatal Group B Streptococcal Disease ... 137 Ross Albert, Neil S. Skolnik, and Richard Neill
13. Adult Immunizations ... 145 Brett Fissell and Neil S. Skolnik
14. Rabies Prevention ... 175 Doron Schneider
15. Practice Guidelines for the Management
of Infectious Diarrhea ... 183 Pam Fenstemacher
16. Tuberculosis Testing and Treatment of Latent Infection ... 211 Pam Fenstemacher
17. Sexually Transmitted Diseases Treatment Guidelines, 2006 ... 227 Neil S. Skolnik
18. Updated US Public Health Service Guidelines for the Management of Occupational Exposure to HBV, HCV, and HIV and Recommendations
for Postexposure Prophylaxis ... 269 David Gary Smith
IV: ENDOCRINOLOGY
19. Screening for Osteoporosis in Postmenopausal Women ... 277 Richard Neill
V: GYNECOLOGY
20. Managing Abnormal Cervical Cytology and Cervical
Intraepithelial Neoplasia: 2001 Consensus Guidelines ... 283 Amy Clouse
VI: NEUROLOGY
21. Dementia ... 295 William McCarberg
22. Diagnosis and Treatment of Migraine Headaches ... 303 Richard Neill
23. Concussion Guidelines in Athletes ... 311 David Webner
24. Restless Legs Syndrome ... 317 Mathew Clark
VII: PSYCHIATRY
25. Depression: Pharmacological Treatment ... 325 John E. Sutherland
26. Diagnosis, Evaluation, and Treatment of the School-Aged
Child With Attention Deficit Hyperactivity Disorder ... 331 Richard Neill
27. Practice Guidelines for the Treatment of Patients
With Delirium ... 341 Mary Hofmann and Doron Schneider
28. Panic Disorder ... 351 Diane Dietzen and Doron Schneider
Index ... 361
Contents xi
Contributors
xiii
ROSS ALBERT,MD,PhD • Family Medicine Residency Program, Abington Memorial Hospital, Abington, PA
MARGOT BOIGON,MD • Associate Program Director, Internal Medicine Residency Program, Abington Memorial Hospital, Abington, PA AMY CLOUSE,MD • Associate Director, Family Medicine Residency, Abington
Memorial Hospital, Abington, PA
MATHEW CLARK,MD • Associate Director, Family Medicine Residency, Abington Memorial Hospital, Abington, PA
ANDREW COHEN,MD • Family Medicine Residency, Abington Memorial Hospital, Abington, PA
TINA H. DEGNAN,MD • Family Medicine Residency, Abington Memorial Hospital, Abington, PA
DIANE DIETZEN,MD,FACP • Director, Palliative Care; Associate Program Director, Internal Medicine Residency Program, Abington Memorial Hospital, Abington, PA
BENJAMIN J. EPSTEIN,PharmD,BCPS • Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Florida, Gainesville, FL
PAM FENSTEMACHER,MD • Associate Director, Family Medicine Residency, Abington Memorial Hospital, Abington, PA
BRETT FISSELL,MD • Gwynedd Family Practice, North Wales, PA
MICHAEL GAGNON,MD • Family Medicine Residency, Abington Memorial Hospital, Abington, PA
MARY HOFMANN,MD,FACP • Chief, Section of Geriatric Medicine, Abington Memorial Hospital, Abington, PA
LOU KURITZKY,MD • Clinical Assistant Professor, Department of Community Health and Family Medicine, University of Florida, Gainesville, FL WILLIAM MCCARBERG,MD • Founder, Pain Management Program, Kaiser
Permanente San Diego, and Assistant Clinical Professor, University of California San Diego, San Diego, CA
MARIO NAPOLETANO,MD • Gwynedd Family Practice, North Wales, PA RICHARD NEILL,MD • Assistant Professor of Family Medicine and Community
Health; Residency Director, Family Medicine Residency, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA
ANN PEFF,MD • Director, Medical Student Program, Abington Memorial Hospital, Abington, PA
JOHN RUSSELL,MD • Associate Director, Family Medicine Residency, Abington Memorial Hospital, Abington, PA
GEORGE P. N. SAMRAJ,MD • Associate Professor, Department of Family Medicine, University of Florida, Gainesville, FL
DORON SCHNEIDER,MD • Associate Program Director, Internal Medicine Residency Program; and Associate Patient Safety Officer, Abington Memorial Hospital, Abington, PA
NEIL S. SKOLNIK,MD • Associate Director, Family Medicine Residency Program, Abington Memorial Hospital, Abington, PA and Professor of Family and Community Medicine, Temple University School of Medicine, Philadelphia, PA
DAVID GARY SMITH,MD,FACP • Program Director, Internal Medicine Residency Program, Abington Memorial Hospital, Abington, PA and Associate Professor of Medicine, Temple University School of Medicine, Philadelphia, PA
JOHN E. SUTHERLAND,MD • Executive/Program Director, NE Iowa Medical Education Foundation/FM Residency, Waterloo, IA
JAYA UDAYASANKAR,MD • Diabetes and Endocrine Fellow, Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, WA
DAVID WEBNER,MD • Assistant Professor, Departments of Family Medicine and Orthopaedic Surgery, Sports Medicine, Team Physician, University of Pennsylvania, Philadelphia, PA
xiv Contributors
