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.