Anthony Day, MD; James D. Hoehns, PharmD; Adam Roise, MD, MPH NE IA Family Medicine Residency...

Panel Discussion: Top Papers of the Past Year

Anthony Day, MD; James D. Hoehns, PharmD; Adam Roise, MD, MPHNE IA Family Medicine Residency Program, Waterloo IAJauch Memorial SymposiumMay 15, 2015

Evidence Rating

Strength of recommendation (SOR)A. Good-quality patient-oriented evidence▪ Meta-analyses, multiple RCTs

B. Inconsistent or limited-quality patient-oriented evidence

▪ Single RCT, multiple prospective cohort

C. Consensus, usual practice, opinion, disease-oriented evidence, case series

Adolescent Medicine

A 17 yo three-sport female athlete comes in for a sports physical. Her BMI is 18 and she admits to only 2 periods in the last year. Last year she had a stress fracture in her R foot.

What should you recommend?

1.OCPs to regulate cycles2.Disqualify her for athletics for three

months3.Increase dietary intake with modest

activity reduction10

Adolescent Medicine

29%35% 36%

PRACTICE CHANGER

Adolescent Medicine

Increase dietary intake with modest activity reductionLevel of Evidence: C – AMSSM literature-based consensus

statement. Restoring appropriate energy intake balance is best initial treatment.

Evidence Citation: Curr Sports Med Rep. 2014 Jul-Aug;13(4):219-32Source: Choosing Wisely AMSSM Recommendation #3

Pulmonology

A 62 y.o. with COPD is receiving inhaled salmeterol, tiotropium, and fluticasone. FEV is 30% of predicted. Which of the following may be discontinued with no significant increase in the risk of a COPD exacerbation?

1. Salmeterol2. Tiotropium3. Fluticasone

31% 31%38%

10

Pulmonology

N= 2,485

N Engl J Med 2014;371:1285-94

PRACTICE CHANGER

STRENGTH OF RECOMMENDATION

B: Based on a large, randomized controlled trial.

Discontinuation of ICS should beconsidered in COPD patients whoare stable and are receiving LABA and LAMA

Allergy

A 46 year old male presents with LE cellulitis and is admitted to the hospital. He reports a pencillin allergy. Which of the following is true?

1. He is more likely to get C difficle

2. He is more likely to receive a quinolone

3. His hospital stay is likely to be longer

4. All of the above

26%24%22%28%

10

PRACTICE CHANGER

Allergy

STRENGTH OF RECOMMENDATION

B: Based on a large, cross-sectional cohort study of adults. Most patients can receive beta lactams safely but do not and have longer stays and more complications.

Evidence Citation: J Allergy Clin Immunol. 2014 Mar;133(3):790-6Source: Choosing Wisely AAAAI March 3, 2014.

All of the above

Immunology

Parents of a 6 mo old with eczema are excited to start introducing foods. They are worried about food allergies; specifically peanut allergies as this is the leading cause of anaphylaxis. What is your advice?

1.Peanut products? At 6 months is fine!

2.Wait until age 1 to introduce.

3.Wait until they can eat peanuts and not choke.

31% 30%39%

10

PRACTICE CHANGER

Immunology

Early introduction of peanuts decreases the likelihood of

developing peanut allergies in kids at high risk.STRENGTH OF RECOMMENDATION

B: Based on a large, randomized controlled trial.

Source: Du Toit G, et al. NEJM. 2015. 372 (9): 803-813.

Hematology

Genotype-guided dosing of warfarin is associated with which of the following outcomes?

1. Less major bleeding2. Less

thromboembolic events

3. Greater time in therapeutic range

4. None of the above

22%27%

32%

19%

10

Hematology

Genotype guided vs. clinical dosing of warfarin

No benefit in: INR time therapeutic INR >4 Major bleeding VTE events

No current advantage to using genotype to guide warfarin dosing

PRACTICE CHANGER

JAMA Intern Med 2014;174:1330-8.

STRENGTH OF RECOMMENDATION

A: Based on meta-analysis of 9 RCTs.

Major bleeding

Cardiac risk factors

A 62 yo woman with well-controlled hypertension and hyperlipidemia presents for routine follow-up. Her vitals today are BP 124/84, P 68, BMI 28.5. Her last LDL was 78.

How do you address her risk?

1.Encourage daily walking and dietary changes for weight loss

2.Continue current effective medication regimen

3.Refer her for intensive behavioral counseling for diet and exercise

10

Cardiac risk factors

27%

40%33%

PRACTICE CHANGER

Refer for intensive

behavioral counseling

STRENGTH OF RECOMMENDATION

A: Review of multiple studies: US Preventive task force “B” recommendation – moderate certainty of moderate benefit for patients with cardiac risk factors.

Cardiac risk factors

Evidence Citation: LeFevre, Michael, Annals of Internal Medicine Online-First, 26 August 2014.

Cardiology/Preventive CareA 55 yo man with diabetes presents for routine follow-up. He is not fasting and due for an A1c, lipids, microalbumin, and PPV.

How do you handle ordering labs?1.Draw all labs today despite him not fasting.

2.Draw all except lipids, which you have him come back fasting for

3.Have him come back fasting for all labs

33%33%

34%

10

PRACTICE CHANGER

Stop checking fasting lipids.

Cardiology/Preventive Care

STRENGTH OF RECOMMENDATION

B: Based on a large, cross-sectional cohort study of adults followed for a mean of 14 years with patient centered outcomes.

Evidence Citation: Doran B, et al. Circulation. 2014; 130: 546-553 Source: Wootten M, et al. The Journal of Family Practice. 2015; 64 (2): 113-114.

Cardiology

Which of the following is observed with the use of niacin in patients with atherosclerotic cardiovascular disease?

1. Lower HDL2. Higher

triglycerides3. No improvement in

clinical outcomes

38%28%

34%

10

Niacin increased serious adverse events Diabetes: 3.7% GI: 1.3% Musculoskeletal: 0.7% Infection: 1.4% Bleeding: 0.7%

Niacin should not be routinely prescribed as an adjunct to statins

CardiologyPRACTICE CHANGER

N Engl J Med 2014;371:203-12.

STRENGTH OF RECOMMENDATION

A: Based on multiple high-quality RCTs.

Cardiology

A 70 yo women with well controlled hypertension has a screening A1C of 7.2. She has no history of hyperlipidemia or CAD.

Which medicine do you add?

1.Spironolactone2.Statin3.Clopidogrel4.Thiazolidinedione

10

32%

24% 25%19%

CONSIDERATION

Cardiology

Statin

STRENGTH OF RECOMMENDATION

A: Meta-analysis of 8 studies: > 65 yo with no history of CAD and at least one risk factor had absolute reduction of 1.5% of MI and CVA over 3.5 years. No change in all-cause or CV death.Evidence Citation: Savarese et al, JACC, Vol 62, No. 22, 2013, December 3, 2013:2090-9

Cardiology

Which of the following has demonstrated a decrease in hospitalizations for heart failure in patients with preserved ejection fraction (HFpEF)?

1. Hydralazine/isosorbide dinitrat

2. Spironolactone3. Prazosin

Hydralazine/isosorbide dinitrat

Spironolactone Prazosin

32%

40%

28%

10

Cardiology

Nonsignificant reduction in primary outcome CV death, HF hospitalization,

or aborted cardiac arrest S.D. in primary outcome if

enrolled with elevated natriuretic peptide

Regional differences in outcomes

Spironolactone decreased HF hospitalizations in patients with HFpEF; results difficult to interpret

PRACTICE CHANGER

N Engl J Med 2014;370:1383-92.

STRENGTH OF RECOMMENDATION

B: Based on one RCT

Cardiology

What new class of LDL-lowering medications has “early” data showing a reduction in cardiovascular events when added to statins?

1. Interleukin-1B blockers

2. CETP inhibitors3. PCSK9

inhibitors

35%34%

31%

10

Cardiology

Evolocumab (PCSK9 inhibitor) LDL decreased 61% CV events at 1

year:▪ Evolocumab: 0.95%▪ Standard therapy:

2.18% Evolocumab

lowers LDL; definitive effects on CV events is pending

PRACTICE CHANGER

N Engl J Med 2015;372:1500-9.

STRENGTH OF RECOMMENDATION

B: Based on two open-label RCTs

Wound care

An 78 yo man has significant venous stasis edema, and despite compression hose continues to develop ulcers.

Which of the following might speed wound healing?

1. Clopidogrel2. Simvastatin3. Metoprolol4. Lisinopril

Clopi

dogr

el

Sim

vast

atin

Met

opro

lol

Lisin

opril

19% 21%

35%

25%

10

PRACTICE CHANGER

Wound Care

Simvastatin 40 mg/d can help venous ulcer healing (NNT 2 at

10 weeks). STRENGTH OF RECOMMENDATION

B: Based on a high-quality randomized controlled trial.

Evidence Citation: Evangelista M, et al. Br J Dermatology. 2014; 170: 1151-7. Source: Crenshaw B, et al. The Journal of Family Practice. 2015; 64 (3): 182-184.

DVT Care

An 53 yo woman develops an acute DVT; she is worried about post-thrombotic syndrome after reading about it online.

True or false: Using graduated compression stockings prevents post-thrombotic syndrome?

1. True2. False

True False

49%

51%

10

PRACTICE CHANGER

DVT Care

Graduated compression stockings do not reduce post-thrombotic syndrome compared to placebo stockings.

STRENGTH OF RECOMMENDATION

B: Based on a large, randomized controlled trial. Evidence Citation: Kahn S, et al. Lancet. 2014; 383: 880-8..

Source: Bergeson K, et al. The Journal of Family Practice. 2014; 64 (7): 388-390.

Obstetrics

A 28 yo G2P1 presents for her new OB visit at 12 2/7 wks gestation. Her first pregnancy was complicated by mild preeclampsia with delivery at 38 weeks.

How do you address her risk?

1. Start a baby aspirin daily until delivery2. Refer to an obstetrician immediately3. See her every two weeks throughout

the pregnancy4. Start her on methyldopa to keep her BP

under 130/80 10

Obstetrics

24%

30%

26%

20%

PRACTICE CHANGER

Obstetrics

Start a baby aspirin daily

after 12 weeksSTRENGTH OF RECOMMENDATION

A: Review of multiple RCTs including meta-analysis : US Preventive task force “B” recommendation – substantial net benefit in women at high-risk for preeclampsiaEvidence Citation: LeFevre, Michael, Annals of Internal Med, Vol. 161, No. 11, 819-826.

Preeclampsia risk factors

No good evidence of ‘high risk’ status

RCTs used: Prior history of preeclampia Multifetal gestation Chronic hypertension Prior IUGR DM, kidney disease, advanced age

Substance Use Disorders

A 42 yo woman returns to your clinic after admission for detox and entering outpatient treatment for alcohol abuse. She does not meet criteria for depression.

Which of the following regimens might prevent relapse or heavy use?

1. Acomprosate2. Disulfuram3. Naltrexon4. Wellbutrin

Acom-prosate

Disulfuram Naltrexon Wellbutrin

25% 23%

14%

38%

10

PRACTICE CHANGER

Substance Use Disorders

Naltrexone may help reduce alcohol relapse (NNT 20) or return to heavy drinking (NNT 12).

STRENGTH OF RECOMMENDATION

A: Based on meta-analysis of 95 randomized control trials.Evidence Citation: Jonas DE, et al. JAMA. 2014; 311:1889-1900.

Source: HendryS, et al. The Journal of Family Practice. 2015; 64 (4): 238-240.

Male infertility

A 26 yo married man has been evaluated by you for infertility issues. His sperm count was normal but the report shows reduced motility. He would like to take a pill rather than have any invasive treatments.

What do you recommend?1. Vitamin E – the wonder drug and all-

natural2. An combination antioxidant supplement3. A month of Bactrim DS4. Clomid for 1 week prior to ‘timed’

intercourse10

Male infertility

21%

26%

32%

21%

PRACTICE CHANGER

Male infertility

An antioxidant supplementSTRENGTH OF RECOMMENDATION

B: Cochrane Review of 4 RCTs: Weak evidence of increase from 5% to 10-31% live birth rate.

Evidence Citation: Antioxidants for male subfertility (Review), Showell MG et al., The Cochrane Library 2014, Issue 12.

Geriatrics

Among geriatric patients which of the following adverse effects have been associated with the use of atypical antipsychotics?

1. Pulmonary fibrosis2. Hypercalcemia3. Acute kidney

injury

Pulmonary fibrosis

Hypercalcemia Acute kidney injury

45%

32%

23%

10

GeriatricsPRACTICE CHANGER

Ann Intern Med 2014;161:242-8.

STRENGTH OF RECOMMENDATION

C: Based on one population based cohort study

AKI-associated hospitalization more common with atypicals. Study highlights mortality risk with atypicals.

Managed Care

ACOs have been around now for only a couple of years. A few studies of cost have been published.

Initial data has shown which of the following?

1. Savings can only be achieved within large integrated medical systems2. Savings can only be achieved in high cost regions3. Savings are possible across settings even in year one

10

Managed Care

1. Savings can only be achieved within large

integrated medical systems

2. Savings can only be achieved in high cost

regions

3. Savings are possible across settings even in

year one

36%

33%

31%

KEY INFORMATION

Managed Care

Savings possible across different settings even in year one

STRENGTH OF RECOMMENDATION

B: Cohort study Medicare Pioneer ACO – in year one there were small cost savings related to decreased hospitalizations and increased office-based careEvidence Citation: McWilliams, J Michael et al., NEJM, April 15, 2015 (online)

Patient Satisfaction

Your clinic administrator is on your back as your patient satisfaction scores aren’t as high as they want them. Which of the following visit-concluding statements has been shown to decrease patients’ reporting having “unmet concerns?”

1. “Is there anything else you want to address in the visit today?”

2. “Is there something else you want to address in the visit today?”

3. “I look forward to seeing you at your next appointment.”

4. “Stay out of trouble now, ya hear?”10

Patient Satisfaction

19%

23%25%

33%

PRACTICE CHANGER

Patient Satisfaction

Using the word “something” instead of “anything” reduces patients perceptions of unmet

needs.STRENGTH OF RECOMMENDATION

B: Based on a large, randomized controlled trial.

Evidence Citation: Heritage J, et al. J Gen Int Med. 2007; 22 (10): 1429-33.

Primary Care

A 34 year old male comes in complaining of knee popping. He admits that he can ‘crack’ many of his joints and wonders if that is a problem.

How do you answer his question?

1. We have no idea why joints crack but it is considered harmless.

2. We don’t think it is harmful, but some people are studying it.

3. You will develop arthritis in your joints if you do that.

10

Primary Care

We have no idea why joints crack but it is considered

harmless.

We don’t think it is harmful, but some people are studying

it.

You will develop arthritis in your joints if you do that.

29%32%

39%

Joint cracking

JUST FOR FUN

Primary Care

Tribonucleation: fluid resists separation until critical point then separates rapidly forming a gas cavity

Evidence Citation: Doran B, et al. Circulation. 2014; 130: 546-553 Source: Wootten M, et al. The Journal of Family Practice. 2015; 64 (2): 113-114.