The Articles of 2011*

Transcription

1 The Articles of 2011* W H A T W A S I M P O R T A N T A T L E A S T T O S O M E O F U S

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3 Sources Essential Evidence Journal Watch Our faculty Other presentations (i.e. Frank Domino) Prioritized: key areas of FM practice might directly change clinical practice might be leading to paradigm changes

4 NSAIDS

5 Selective/Non-selective NSAIDS #1 Danish observational study 84,000 pts with 1 st MI between NSAID use associated with increased risk for recurrent MI or death, hazard ratio Some variability by NSAID Naproxen maybe better? Risks became apparent shortly after initiation of NSAID Circulation May 24; 123:2226

6 Selective/Non-selective NSAIDS #2 meta-analysis of evidence on cardiovascular safety of NSAIDS 31 trials, 116k patients, all kinds of NSAIDS. Conclusion: All NSAIDS seem to be associated with some CV harms BMJ 2011; 342:r7086

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8 Selective/Non-selective NSAIDS #3 Northern Denmark Population based case-control study 32k pts with a first dx of afib/flutter, People with new afib/flutter were more likely to be NSAID users, especially new users (start within 60d) Current users OR 1.17 for NSAIDS, 1.27 for Cox-2 OR for new users: 1.46 for NSAIDS, 1.71 Cox-2 Schmidt et al. BMJ 2011 Jul 4;343:d3450. doi: /bmj.d3450.

9 Blood Pressure Issues

10 Changes to how we measure/treat hypertension? How many BP measurements should be made to diagnose hypertension? Maybe averaging 5-6 JW Gen Med Aug 1, p. 124, and Ann Intern Med Jun 21; 154:781 Accuracy of manual BP measurements? Automated BP measurements in clinic may be more accurate than manual (mitigate white coat effect? Specific devices?) JW Gen Med Mar 1, p.37, and BMJ Feb 7; 342:d286 Ambulatory BP measurement a cost-effective way to diagnose hypertension? Maybe but not covered by Medicare unless diagnosed with white coat hypertension Lancet Oct 1; 378:1219 BP goals in DM2 may not need to be <130 systolic systolic seems to be as good as <130 (Systematic review) Bangalore S. Circulation 2011 Jun 21; 123(24):

11 Outpatient Misc

12 Inhaled steroids, COPD and pneumonia Context: inhaled steroids increase pneumonia risk in pts with COPD. What s the significance? Retrospective cohort study, VA database Pts with COPD, hospital dc dx of pneumonia Prior use of inhaled steroids: 30-d mortality 0.80 ( ) 90-d mortality 0.78 ( ) Mechanical ventilation 0.83 ( ) Vasopressors 0.88 ( ) Chen D, Observational study of inhaled corticosteroids on outcomes for COPD patients with pneumonia. Am J Respir Crit Care Med, 2011 Aug 1:184(3):312-6

13 What is this intervention?

14 CBT for secondary prevention? 362 Swedish pts with CAD related hospitalization (75 or younger) in the previous year Intervention: traditional care vs traditional care plus CBT program focused on stress management (20 2hr sessions in a year). Outcomes: all-cause mortality, hospital admission for related conditions, AMI Results: intervention group: 41% lower rate of fatal/nonfatal recurrent CVD related events 45% fewer MIs 28% lower mortality (not quite sig) Gulliksson M Arch Intern Med. 2011;171(2): doi: /archinternmed

15 AIM-HIGH NHLBI stopped clinical trial 18 months early Intervention: adding high dose, extended release niacin to statins in people with heart and vascular disease Pts with target LDL values, but low HDL and high TG Outcome: no change to CV events. HDL/TG numbers looked better, outcomes didn t NEJM Dec 15; 365:2255

16 Maternal/Child Health

17 Can you use combined OCPs with Lactating moms? RCT, 197 pts, UNM Randomized breast-feeding moms starting at 2 weeks postpartum to combined/prog only OCPs. Telephone questionnaires about continuation, pt satisfaction. Infant growth parameters measured Outcomes: Breastfeeding continuation rates at 8 weeks: 63.5% (progest only) and 64.1% (combined). No differences in contraception continuation rate No differences in measured infant growth parameters Espey, Ogburn, Leeman, et al. Obstet Gynecol Jan;119(1):5-13.

18 Public Health

19 PSA Testing What happened? Draft Recommendation 10/31 by USPSTF- to make PSA screening D grade rec Multiple editorials, see NEJM 365 from Nov 24 Who is the USPSTF? Why now? Why does this matter/what is the controversy? Good editorial: Brett AS, et al. Prostate-Cancer Screening What the U.S. Preventive Services Task Force Left Out. NEJM ; 21:

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21 Unnecessary Tests Question: what is the financial impact of the typical practices of little benefit used in primary care? Answer: a lot Data from 2 US surveys of practice, from pre-existing top 5 common but low yield practices

22 Copyright restrictions may apply. Kale, M. S. et al. Arch Intern Med 2011;171:

23 Is having Medicaid better than having nothing? Real question: what would happen if more people had insurance? (controversy does exist) 2008 Oregon lottery for Medicaid eligibility researchers caught wind... Followed so far only 1 year. Don t we know the answer to this? Finkelstein A et al. The Oregon health insurance experiment: Evidence from the first year. National Bureau of Economic Research 2011 Jul; [working paper] :1 NY Times Article:

24 Initial (1 year) findings A long list of differences, highlighted by 25% increased utilization. Some examples: 35 % more likely to go to a clinic or see a doctor, 15 percent more likely to use prescription drugs 30 percent more likely to be admitted to a hospital (8.8% vs 6.7%). unable to detect a change in emergency room use Women with insurance: 60 percent more likely to have mammograms (49% vs 30%) more likely to have their cholesterol checked More likely to go to the same clinic/provider Reported feeling better

25 Increase in Fatal OD from Prescription Opiates CDC report which reviewed national databases Key points: Death from opioid pain relievers (OPR) is an epidemic Sales of OPR quadrupled between 1999 and 2010, fatal overdoses increased by about the same National death rates highest in whites In 2008, drug OD in the United States: 36,450 deaths (37,261 deaths due to motor vehicle accidents) 20,044 prescription drug OD, 74% opiates Death rates varied by state Center for Disease Control and Prevention (CDC). Vital signs: Overdoses of prescription opioid pain relievers United States, MMWR Morb Mortal Wkly Rep 2011 Nov 4; 60:1487

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28 In the Hospital

29 Are Hospitalists Cost Effective? 58k Medicare admissions reviewed , 456 US hospitals Mean LOS.64 days shorts, mean costs $282 lower But mean Medicare costs in 30 days after dc $332 higher for these patients. Cost shifting? Various controversies and opinions KuoY-F, Association of hospitalist care with medical utilization after discharge: Evidence of cost shift from a cohort study. Ann Int Med 2011 Aug 2; 155:152.

30 Unintentional Medication Discontinuation After Hospital DC Population-based cohort study, data All hospitalizations, then outpatient Rx s in Ontario 396k patients aged 66 or older, who had 1 of 5 EBM indications for specific meds. Outcome: failure to renew the Rx within 90 days of hospital dc The 190k patients who were admitted were more likely to not fill meds at 90 days, especially if they went to the ICU. Bell C et al. JAMA, August 24/31, , No. 8.

31 Pediatrics

32 Intermittent Budesonide in preschool children with recurrent wheezing 300 preschool kids with recurrent wheezing, ages 1-4. Followed for 1 year. daily low-dose nebulized budesonide (.5mg qhs neb) vs intermittent high dose budesonide (1mg) BID-7 days at onset of illness primary endpoint: exacerbations requiring oral steroids. Results: no difference NEJM Nov 24; 365:1990

33 Some other things

34 Quick tidbits About 1/3 of pts with resistant htn seem to have white coat hypertension De la Sierra A et al. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension 2011 May; Adverse Drug Events Cause Many Hospitalization in Elders. 1.5% of all hospitalizations in the elderly, and almost half of these were in pts >80. Budnitz DS et al. Emergency hospitalizations for adverse drug events in older Americans. NEJM 2011 Nov 24; 365:2002. B-Blockers in COPD Patients: lowers 4 year mortality (probably because a lot of them have CAD). No adverse effects on lung function. Use cardioselective. Short PM et al. Effect of B-Blockers in treatment of chronic obstructive pulmonary disease: A retrospective cohort stufy. BMJ 2011 May 10; 342:d2549

35 More tidbits PPI use associated with increased risk of SBP in cirrhotic adults (add it to the list) Trikudanathan G, Int J Clin Pract Jun;65(6): doi: /j People on 3x weekly dialysis have higher mortality on the day following the 2 day dialysis hiatus. Foley RN et al. NEJM 2011 Sep 22;365(12): Something good? U.S. HF outcomes improved Hospitalization rates decreased 30%, mortality slightly decreased. Varies by state. NM has decreased hospitalization rates, but increased mortality. Chen J et al. JAMA 2011 Oct 19;306(15):

36 More tidbits Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix. Hassan SS et al. Ultrasound Obstet Gynecol Jul;38(1): doi: /uog Epub 2011 Jun 15. Introduction of solid foods before the age of 4 months is associated with an increased risk of obesity at age 3, in formula-fed infants and infants weaned before 4 months. (OR 6.3) Huh S. Pediatrics Vol 127 No 3. March 1, Bisposphonates are associated with increased risk of atypical femur fractures. Gen Med Mar 15, p. 45

37 How can you stay current?