New ACIP adult immunization schedule recommends changes to several vaccines

1. New ACIP Adult Immunization Schedule recommends changes to several vaccines
ACIP now recommends shared decision-making for HPV, PCV13, and Meningitis B vaccines

Abstract: http://annals.org/aim/article/doi/10.7326/M20-0046
URL goes live when the embargo lifts

The Advisory Committee on Immunization Practices (ACIP) released its 2020 Recommended Immunization Schedule for adults with changes to the administration of the influenza, human papillomavirus (HPV), hepatitis A, hepatitis B, meningococcal B, and pneumococcal conjugate vaccines. The schedule, which can be complex and challenging to implement, features revised content, format, and graphics to make it easier to follow. The complete schedule, including changes in the vaccine notes section, is being simultaneously published in Annals of Internal Medicine and on the Centers for Disease Control and Prevention (CDC) web site.

The schedule is streamlined for ease of reference. Physicians should pay careful attention to the details found in the vaccine notes section, as they clarify who needs what vaccine, when, and at what dose.

In addition to changes in the administration of some vaccines, the 2020 schedule includes new instructions for shared clinical decision-making for several vaccines. First, the HPV vaccine is recommended for some patients aged 27 through 45 who are not adequately vaccinated. Clinicians should consider discussing HPV vaccination with those who are most likely to benefit from it based on a detailed list of considerations. Second, the pneumococcal 13-valent conjugate vaccine (PCV13) should be discussed with adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, and who have not previously received PCV13. And third, clinicians should consider discussing the meningitis B vaccine with adolescents and young adults age 16 through 23 who are not at increased risk for meningococcal disease.

The ACIP is comprised of 15 voting members, ex officio members who represent other federal agencies, and non-voting representatives of liaison organizations, including the American College of Physicians, that bring related immunization expertise. Each year, ACIP reviews the CDC's Recommended Adult Immunization Schedule to ensure it reflects current clinical recommendations for licensed vaccines. The recommendations are intended to guide physicians and other clinicians about the appropriate vaccines for their adult patients.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Mark Freedman, DVM, MPH, please contact him directly at fll0@cdc.gov.

2. Primary care visits on significant decline among commercially insured adults

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1834
Editorial: http://annals.org/aim/article/doi/10.7326/M19-4000
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Primary care use among commercially insured adults is on a significant decline. Findings from a national population-based study are published in Annals of Internal Medicine.

Studies suggest that primary care is key to improving health and fixing the health care system. However, Americans are seeing their PCPs less often, and it has been unclear why.

Researchers from Brigham and Women's Hospital studied claims data to describe trends in PCP visits among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits. They found that rates of PCP visits decreased by 24 percent from 2008 to 2016, and the proportion of adults with no PCP visit in a year increased from 38 percent to almost half. Specialist visit rates remained essentially unchanged, whereas visits to alternative settings, predominantly urgent care centers, sharply increased. All subgroups had a double-digit decline in PCP visits, with the largest declines among young adults, persons without chronic conditions, and those living in low-income areas. The authors note that these changes seem to be associated with decreased (real or perceived) need for primary care, rising financial barriers, and increased use of alternative venues of care.

The author of an accompanying editorial from Emory University and Alliant health Group suggests that declines in PCP visits may be an unintended consequence of money-saving efforts of large insurers that push patients to curb unnecessary health care use in an uncoordinated health care system.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Dr. Ishani Ganguli MD, MPH, please contact Haley Bridger at hbridger@bwh.harvard.edu.

3. Bedside "sitters" have limited or no effect on reducing in-hospital falls

Abstract: http://annals.org/aim/article/doi/10.7326/M19-2628
Editorial: http://annals.org/aim/article/doi/10.7326/M19-4005
URLs go live when the embargo lifts

There is scant evidence that bedside "sitters," nurses or other personnel who monitor patients and remain nearby at all times, reduce falls in hospitalized adult patients. Findings from a systematic review are published in Annals of Internal Medicine.

Falls are very common in acute care settings and may result in serious injury. Up to one million hospitalized patients fall each year, and as many as one-third of those falls are considered preventable. Preventing in-hospital falls has been a Joint Commission National Patient Safety Goal. The use of bedside sitters to provide patients with constant supervision and protection is a practice rooted in tradition, but their use is expensive. Determining how effective they are for preventing falls is important for patients and providers.

Researchers from the West Los Angeles Veterans Affairs Medical Center reviewed published evidence about the effect of sitters and alternatives to sitters on patient falls in adults in acute care hospitals. Of 20 studies meeting inclusion criteria, only two added sitters to usual care and had conflicting results. 18 studies compared alternatives to sitters. From those, the investigators found moderate-certainty evidence that interventions that included video monitoring decreased sitter use without adversely affecting fall rates when compared with use of sitters. They found little convincing evidence that close observation units or nurse assessment tools were effective alternatives. While there is a lack of evidence to support the use of 1-to-1 sitters, the rationale for their use to prevent falls is sufficiently compelling that it is premature to conclude that their use should be abandoned. The evidence is most consistent that, at best, any effect of sitters on fall risk is modest, and equally or more effective interventions may exist.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the lead author, Adela Greeley, MD, please contact the VA public affairs office at vhaglapublicaffairs@va.gov.

4. Experts in transgender medicine discuss appropriate care for a transgender patient
Annals 'Beyond the Guidelines' discussions are based on real Beth Israel Deaconess Medical Center Grand Rounds

Abstract: http://annals.org/aim/article/doi/10.7326/M19-3813
URLs go live when the embargo lifts

Two experts in transgender medicine discuss appropriate care for a transgender woman with anxiety and hypertension. The experts and the patient agree that her case should be managed in primary care and that the topic of caring for transgender patients should be included in general medical training. This is an important point, as transgender patients face discrimination in the health care setting and may not have access to medical professionals who can provide competent care.

In addition to primary medical and preventive health care, transgender patients need access to gender-affirming interventions, including hormone therapy and surgeries. Two specialists in transgender medicine discuss a patient's care in Annals of Internal Medicine.

Joshua D. Safer, MD, Director of the Center for Transgender Medicine at Mount Sinai Health System, recommends continued work with a mental health provider to treat the patient's anxiety and gender-affirming hormone therapy. He also recommends that the patient be monitored for hypertension. Her care can be managed in the primary care clinic with support from an endocrinologist. Jennifer Siegel, MD, Medical Director of the Center for Transgender Medicine and Surgery at Boston Medical Center, largely agrees with Dr. Safer and recommends that the patient's care team determine the desired elements of medical, social, and legal gender affirmation in the content of addressing all of her primary care needs.

All 'Beyond the Guidelines' papers are based on the Department of Medicine Grand Rounds at BIDMC in Boston and include print, video, and educational components. A list of topics is available at http://www.annals.org/grandrounds.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Howard Libman, MD, please contact Jennifer Kritz at jkritz@bidmc.harvard.edu.

Also new in this issue:

In The Clinic: Urinary Incontinence in Women
Camille P. Vaughan,MD,MS; Alayne D. Markland, DO,MSc
In The Clinic

Abstract: http://annals.org/aim/article/doi/10.7326/AITC202002040

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