Conflict of Interest. The Tools for Practice 22/11/2012. Family Doctor x 15 years Academic x 10 years

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1 G Michael Allan, Associate Professor Conflict of Interest Family Doctor x 15 years Academic x 10 years Pay from U of A and Alberta Health Research and Speaking Fees Non Profit Sources (Alberta College of Family Physicians, CIHR, IHE, CFPC, ENPCN, etc) No funding from Industry The Tools for Practice Michael R Kolber, Christina Korownyk, and myself 1

2 The Tools for Practice Michael R Kolber, Christina Korownyk, and myself What are Tools for Practice Evidence based summaries to clinical questions. Question, Evidence, Context and Bottom line. Words: 300 target (max 350) Produced every 2 weeks (3 4 over summer) ed: Alberta College of Family Physician Members Also anyone signing up for distribution Sponsored by Full details on our Website ToolsforPractice.aspx About Tools Authors & Topic selection Evidence Selection Searching & writing Peer Review How & who 2

3 So how we are doing, So how we are doing, Are they successful? Total of > 75 articles 26 in Canadian Family Physician With Implementation Also on EBM websites like TRIP database Regularly added TEC Podcast We look at Website Use Signing Up for Distribution 3

4 Visits to the TFP Site. 25% of all ACFP visits are for TFP (#1 reason overall) Where are they from: Edmonton, Calgary, Ottawa, Vancouver, Toronto, Mississuaga, Halifax, Montreal, Medicine Hat, Saskatoon, Victoria, Regina, Lethbridge, Red Deer, Grande Prairie, Winnipeg, Sudbury, Auckland, St Alberta, (England, Arizona, Greece, South Korea, Scotland, Portugal, Minnesoate, Australia) etc Sign Up Requests In 11 months >700 people have registered for TFP International (percent) USA (10%): 19 states Other (6%): 10 countries US Alaska Arizona California Georgia Illinois Indiana Kentucky Maine Massachusetts Michigan Minnesota New Hampshire New Mexico Ohio Pennsylvania Rhode Island Tennessee Others Afghanistan Australia Croatia Ireland New Zealand Poland Portugal Spain Saudi Arabia United Kingdom Virginia Wisconsin Remaining 84% are from Canada Sign up requests in Canada 4

5 Let s look at some First, we ll look at whole TFP Then rapid fire through many more. Let s look at some First, we ll look at whole TFP Then rapid fire through many more. Motivating patients to activity: A light at the end of the couch? Clinical question: How can we motivate our patients to participate in regular physical activity? Evidence: 2007 systematic review (26 studies, 2767 patients): Pedometers to increase physical activity levels: 1 Pedometers increased the mean steps/day by 2491 in RCTs (P <.001) and 2183 in observational studies (P <.0001). Step goal (generally steps a day) improved activity (P =.001). Mean intervention duration was 18 weeks. Heterogeneity in study design was present (P <.001) lower quality systematic review (32 studies) pedometers: 2 Increase of approximately 2000 steps per day; Benefit of having a step goal (P <.001); and Similar benefits in studies longer and shorter than 15 weeks. 5

6 Motivating patients to activity: A light at the end of the couch? Newer randomized controlled trials show that using pedometers increases daily steps by approximately 2000 or more, 3,4 including sustained results for up to 1 year. 4 Context: In many studies, increased activity reduces mortality: Prospective cohort study (252,925 patients): moderate activity (brisk walking 30 min most days) associated with 27% (CI 22% to 32%) relative decrease in overall mortality vs no activity. 5 Regular vigorous activity reduced mortality by 50% (CI 46% to 54%). Prospective cohort study (9777 men) found the mortality rate of active men was 33% lower than inactive men (40 vs 122 deaths per patient years). 6 Motivating patients to activity: A light at the end of the couch? Other benefits of pedometers include the following: Weight reduction of 1.3 kg in 16 weeks 7 ; Reductions in systolic blood pressure of 3.8 mm Hg over 18 weeks 1 ; Improved blood glucose (BG) levels in patients with impaired glucose tolerance up to 12 months later (ie, fasting BG reduced by 0.31 (95% CI 0.03 to 0.59) mmol/l; 2 hour BG reduced by 1.3 (95% CI 0.4 to 2.2) mmol/l) 4 ; Can cost less than $30. Bottom Line: Pedometers, used with specific exercise goals, provide an inexpensive, tangible measure of a patient s physical activity, and have been demonstrated to increase physical activity levels. Motivating patients to activity: A light at the end of the couch? Implementation Written goal oriented exercise programs increase patients physical activity levels. 8 When recommending a pedometer, prescribing a step goal will help increase activity. A sample prescription might look like this: 1. Wear your pedometer every day for 1 week. 2. Calculate your daily steps 3. Add 500 steps per day to your daily average. Walk that each day for the next week. 4. Repeat step 3, adding 500 steps to last week s daily goal, and walk that each day for the next week. 5. Continue until you reach steps per day. Can Fam Physician. 2010;56(9):887. 6

7 Clarifying the Rules Guidelines Evidence Clinical question: Once we have initiated bisphosphonate therapy, how often should we check bone mineral density (BMD)? Canadian 2010 guidelines: repeat BMD 1 to 3 years BMD imprecision is 2.4 5% (2 4 weeks between tests) On Treatment, BMD increases 1 6% over 3 yrs 3 year RCT shows no benefit testing before 3 years (? Longer) Bottom line: Repeating BMD testing within 3 years of starting treatment with bisphosphonates is unnecessary and potentially confusing. By far most patients taking bisphosphonates will have adequate increases in BMD after 3 years and will have a reduced fracture risk regardless of BMD changes Can Fam Physician.2010;56(12):1299. Guidelines Evidence Clinical question: What are the pros and cons of routine self monitoring of blood glucose (SMBG) for patients with type 2 diabetes (T2D) who do not use insulin? Bottom line: Routine SMBG in patients with T2D who do not use insulin has no clinical benefits, is not cost effective, and reduces the quality of life. Clinical Question: Does Ezetimibe (Ezetrol) modify clinical outcomes? Trials: Enhance, Arbiter Halts, SEA, SHARP, Improve IT* Bottom line: 10 years after being licensed by the FDA, still no evidence that ezetimibe reduces cardiovascular outcomes. Possibly worse than Niacin and cancer concern. Can Fam Physician.2010;56(12):

8 Did you know? Nortriptyline works for smoking cessation. Atenolol decreases BP but nothing else. Ibuprofen>codiene/tylenol in kids MSK pain Myths Clinical Question: Do omega 3 fatty acid supplements reduce the risk of recurrent cardiovascular events in patients with existing cardiovascular disease (CVD)? Evidence: Meta analysis & RCT (>33,000 pts); no effect Bottom line: Although guidelines recommend increased dietary omega 3 consumption, evidence does not support using omega 3 fatty acid supplements to prevent recurrent CVD events in patients with cardiovascular disease. Emerging Information Clinical question: Will taking one or more antihypertensive drugs at night improve cardiovascular disease (CVD) outcomes and reduce drug side effects? Bottom line: Taking one or more BP meds before bed may potentially help reduce cardiovascular risk (17% vs 6%) but due to limitations of the evidence, strong recommendations are difficult. 8

9 Did you know Adding Niacin to statins has no effect Ibuprofen >Acetaminophen in pediatric fever. Medicine improves passing 25% renal stones. Some things are controversial Clinical Question: How does venous thromboembolism (VT) risk compare across varying hormonal contraceptions? Bottom line: Due to limits in the evidence, there is real uncertainty whether the risks of VT vary with different hormonal contraceptives. If they do, the increased risk appears to be about 1 extra VT per year for 2000 women. Controversies Clinical Question: Does calcium (Ca+) supplementation increase the risk of myocardial infarction and other cardiovascular disease? Bottom line: The present evidence suggests that calcium supplementation, particularly 1000mg/day, may lead to an increase risk of MI. This evidence is poor and the risk, if present, is likely <1%

10 Trends and Fashion Clinical Question: Is bioidentical micronized progesterone (MP) instead of synthetic medroxyprogesterone acetate (MPA) safer and better for menopausal symptom control? Evidence: Cohort & survey studies, surrogate marker outcomes, Tiny RCTs (<25 pts). Bottom line: The theoretical advantages of MP are not supported by the evidence. We risk repeating errors of the past by concluding MP is more or less safe or efficacious than other hormone replacement therapy (HRT) without results of large RCTs. Compounding of bioidentical hormones only serves to compound the uncertainty. Can Fam Physician. 2012;58(7):755. Did you know? Bisphosphonates can be stopped after 3 5 yrs. J BoneMinerRes2012;27: Best evidence BP target is 150/90 in the elderly. CFP. 2010;56(11):1141 Oral B12 is as effective as IM B12. PEG (17gm/d) is #1 in BM (adds 1 3 BM/week) Does the message make sense 10

11 New Products Clinical Question: For patients with non valvular atrial fibrillation (AF), do the NOACs (dabigatran, rivaroxaban, apixaban) have advantages over warfarin? Bottom line: Compared to warfarin, NOACs offer some benefits for patients with atrial fibrillation. The decision based on patient s previous INR stability, kidney function and discussion, direct and indirect costs with the patient. Vs Warfarin/yr Stroke (& SE) Major Bleed Mortality Dabi 110mg No diff NNT 143 No diff Dabi 150mg NNT 167 No diff? NNT 205 Riva No diff No diff No diff Apix NNT 303 NNT 104 NNT Did you know? Chlorthalidone is likely >hydrochlorthiazide. Topical NSAIDs are as effective as oral Anti depressants give ⅓ benefit in first week. Zoster Vaccine Zoster Vaccine reduces shingles up to 70% Study Placebo Zoster Vac Benefit NNT (3 yrs) Age (3 yrs) 2.03% 0.62% 1.41% 71 Age 60 (3 yrs) 3.42% 1.67% 1.75% 58 Bottom-Line: Over 3 years, one in patients will avoid shingles due to the vaccine - One in 350 for post-herpetic neuralgia. Tools for Practice Nov 12,

12 What else do we do? Practical Evidence for Informed Practice EBM Conference in the Fall CPD Road show 6 mini conferences/yr around Alberta ( 20 topics) Research Therapeutics Education Collaboration (TEC) Podcast Questions 12