NAPCRG Pearls: What Is New? The top nine research studies that will impact clinical practice for...

NAPCRG Pearls: What Is New? The top nine research studies that will impact clinical prac=ce for family physicians

Dr. David M. Kaplan MD MSc CCFP Associate Professor

Department of Family & Community Medicine Primary Care Lead, Central Local Health IntegraCon Network

Dr. David G. White MD CCFP FCFP Professor & Deputy Chair

Department of Family & Community Medicine

Tweet the talk! @davidkaplanmd @davidgordonwhite #FMF2014 #FMFpearls2014

Disclosure – Dr. David Kaplan

•  Dr. Kaplan is a member of the NAPCRG Clinician Advisory Group

•  Dr. Kaplan has salary support from the Central Local Health IntegraCon Network, one of the regional health authoriCes in Ontario

Disclosure – Dr. David White

•  Dr. White has nothing to disclose.

The 2013 NAPCRG Pearl Process

NAPCRG 2014 – Pearl 1

SystemaCc review of the diagnosCc accuracy of capillary refill Cme for serious illness in children S Fleming, P Gill, C Jones, A Van den Bruel, J Taylor, C Heneghan, M Thompson

The Research Ques=on

•  Is capillary refill Cme (CRT) as a good diagnosCc indicator of serious illness in children?

•  Why this is important? – simple and quick test requiring no equipment – easily performed on every child – widely recommended, but no exisCng systemaCc review

What the Researchers Did

•  SystemaCc review of diagnosCc accuracy –  aged ≥18 years –  consulCng with an illness where an acute or worsened cough was the main or dominant symptom or had a suggested lower respiratory tract infecCon present for ≥28 days

•  Search strategy idenCfied 23 relevant papers –  9 papers on mortality –  6 papers on dehydraCon –  10 papers on other serious outcomes

What the Researchers Found •  Mortality

– CRT è highly specific, but low sensiCvity – specificity 92.3% – data predominantly from low income sebngs

•  DehydraCon and other serious outcomes – é CRT increases post-‐test probability of serious outcomes

– Normal CRT does not noCceably reduce probability of adverse outcomes

What This Means for Clinical Prac=ce

•  CRT has value as a “red flag” for a wide variety of serious illnesses in children

•  In low-‐income sebngs, there is evidence for CRT as a “red-‐flag” for risk of mortality

•  Clinicians trea=ng children with prolonged (≥3s) CRT should consider the possibility of serious illness


The potenCal role of NT-‐proBNP in screening for heart failure and in predicCng prognosis Taylor CJ, Roalfe AK, Iles R, Hobbs FDR. The potenCal role of NT-‐proBNP in screening for and predicCng prognosis in heart failure: a survival analysis. BMJ Open 2014; 4:4 e004675 doi:10.1136/bmjopen-‐2013-‐004675

The Research Ques=on What is the role of N-‐terminal B type natriureCc pepCde (NT-‐proBNP) in screening for and predicCng prognosis in heart failure? Why is this important?

–  HF is common, very costly (to paCents and healthcare systems), and has a large evidence base for management

–  HF omen diagnosed in late stage or misdiagnosed and omen under-‐managed

What the Researchers Did •  594 subjects with a baseline NT-‐proBNP result •  4 randomly sampled cohorts: general populaCon, those with exisCng HF, those at high risk of HF, those on diureCcs)

•  ProspecCve sub-‐study of parCcipants with an NT-‐proBNP level at baseline from all four cohorts and with validated diagnoses and long term follow up for mortality.

What the Researchers Found

•  Risk of heart failure increased almost 18-‐fold –  for NT-‐proBNP ≥ 150pg/ml

•  10y survival in the general populaCon cohort: – 61% for those with NT-‐proBNP ≥ 150pg/ml – 89% for those below the cut-‐off at baseline

•  NT-‐proBNP level ≥ 150pg/ml was associated with a 58% increase in the risk of death within 10 years


•  Raised NT-‐proBNP levels are predicCve of a diagnosis of heart failure

•  lower threshold than guidelines currently advocate for diagnosing symptomaCc presenCng paCents is needed for screening

•  baseline NT-‐proBNP levels also predicted reduced survival at 10 years


Does Cardiovascular Risk Predict Sta=n Use? Michael Johansen MD MS, Ohio State University, Lee Green MD MPH, Ananda Sen PhD, Sheetal Kircher MD MS, Caroline Richardson MD MS. Cardiovascular Risk and StaCn Use in the United States. Ann Fam Med. (In Press)


Does cardiovascular risk predict sta=n use? Why this is important?

– StaCns are highly efficacious in reducing death in individuals with high cardiovascular risk


•  Cross-‐secConal study •  determine the proporCon of individuals who were on a staCn (2 or more prescripCons in a year) – straCfy by risk profiles – determine condiCons associated with use


•  58% of individuals with reported coronary artery disease were on staCns

•  52% of individuals with diabetes over age 40 reported staCn use

•  Hyperlipidemia, not cardiovascular risk, was most strongly associated with staCn users


•  There are large numbers of individuals with coronary artery disease and/or diabetes that benefit from staCns who are not taking them

•  Gebng more high-‐risk people on staCns could save lives

•  Refocus staCn use from being a cholesterol lowering medicaCon to one that reduces cardiovascular events and mortality


Performance of a Rapid Influenza Detec=on Test (RIDT) in Ambulatory Primary Care Wisconsin: 2009-‐2013 Temte JL, Barlow S, Greene P, Haupt T, Reisdorf E, Wedig M, Shult P, Giorgi A, Fowlkes A. University of Wisconsin


What pa=ent, illness and pathogen characteris=cs affect performance of rapid influenza detec=on tests? Why this is important?

–  RIDTs are designed to provide point-‐of-‐care diagnosis in a meaningful Cmeframe

–  RIDTs have been limited by some performance measures – primarily sensiCvity

–  Package inserts suggest that paCent age can affect sensiCvity


•  Primary care paCents with acute respiratory infecCons –  N = 1,219 (age 0 to 88.1 years) –  November 2009 to April 2013 –  Four family medicine clinics in Wisconsin

•  ProspecCve respiratory virus surveillance –  PragmaCc (mulCple sites, 90 clinicians, diverse ARIs)

•  Comparison of sensiCvity of RIDT to PCR (gold standard) –  Uniform demographic, epidemiologic and symptom data on all

paCents

What the Researchers Found Factors associated with Sensi=vity

univariate analysis (Chi Square)

Sex of PaCent N.S Male > Female

Age of pa=ent P=0.001 younger > older (7 age groups)

ILI vs. ARI N.S. ILI > ARI

Days from onset P=0.001 earlier > later (5 Cme groups

Vaccinated N.S. Unvaccinated > vaccinated

Influenza strain N.S. B > AH3 > AH1

mulitvariate analysis (Binary LogisCc Regression)

Age of pa=ent –  SensiCvity drops by 20% for each

decade of life –  Odds raCo = 0.80 –  P = 0.004

Days from Onset –  SensiCvity drops by 26% for each

passing day amer onset –  Odds raCo = 0.74 –  P = 0.01


•  Rapid Influenza DiagnosCc Test performance requires appropriate paCent selecCon – PaCent Age and Time from Illness Onset are key parameters •  SensiCvity drops by 20% for each decade of life •  SensiCvity drops by 26% for each passing day amer illness onset


Helping Pa=ents Reach a Balanced Understanding of Controversial Cancer Screening Recommenda=ons: The Impossible Dream? B Saver, R Luckmann, M Hayes, K Mazor, G Bacigalupe, J Calista, N Esparza, T Gorodetsky

The Research Ques=on Why this is important? •  The USPSTF has recently issued controversial

recommendaCons about prostate cancer screening and mammography for women aged 40-‐49

•  PaCents and some providers are confused by the counterintuiCve recommendaCons and conflicCng evidence

•  InformaCon alone rarely changes behavior – can a persuasive, evidence-‐based approach be effecCve?

What the Researchers Did •  Par=cipants: 27 men aged 50-‐74 and 28 women aged

40-‐49 recruited from academic & community health center clinics

•  Design: For each topic, 2 English-‐ and 1 Spanish-‐language focus group

•  Basic Method/Interven=on: –  IniCal focus group on each topic presented informaCon about tests, benefits, harms, guidelines and how generated

–  Scripts for subsequent focus groups modified to focus more on persuading parCcipants to trust/believe USPSTF recommendaCons

–  Polled periodically during final groups for opinions about screening

What the Researchers Found •  Neither men nor women aware of USPSTF •  No tracCon from disCnguishing between processes used by USPSTF and other groups

•  No tracCon without first making harms clear – Men did not easily grasp cascade following abnormal PSA test, but readily understood and wished to avoid treatment harms

– Women had much greater difficulty appreciaCng mammography harms

•  SocializaCon to the value of mammography is very strong, but providers are generally trusted


•  A persuasive approach, starCng with making harms clear and then clarifying current knowledge about benefits, may help many men accept USPSTF recommendaCon against PSA screening

•  This approach for women and mammography may be less accepted

•  Provider recommendaCons are very important –  USPSTF recommendaCons likely to change paCent behavior only as they affect provider recommendaCons


Does the management of paCents with chronic non-‐malignant pain (CMNP) differ between those with and without co-‐exisCng mental illness?

Elder NC, White C, Regan S – University of CincinnaC Department of Family and Community Medicine


•  Why is this important? •  livle is known about the effect of these co-‐exisCng condiCons on pain management in primary care

•  Known bi-‐direcConal associaCon with CNMP and mental illness

•  paCents with CNMP 2X more likely to have mood/anxiety disorder

•  paCents with mood/anxiety disorder 2X more likely to experience pain


•  21 family physicians in CincinnaC Area •  completed modified Primary Care Network Survey on 533 consecuCve paCent visits –  Did paCent have chronic pain? –  Did paCent have mental health diagnosis (mainly depression and anxiety)?

•  Reviewed charts of chronic pain paCents for documentaCon of pain assessment and management

What the Researchers Found •  138 (26%) have chronic pain •  196 (37%) have mental illness •  73 have both (14%) •  PaCents with CNMP more likely to have a mental health diagnosis (56% vs 31%, p<.001)

•  PaCents with CNMP & mental health diagnosis are: –  Younger (54 vs. 61 years old p=.003) –  More likely to have >3 types of pain (57 vs 33% p=.005) and be on

mulCple medicaCons –  More likely to be prescribed chronic opioids (28% vs 9% p=.005)

What This Means for Clinical Prac=ce •  Opiates have the potenCal to exacerbate mood symptoms over Cme

•  The known comorbid substance abuse risk with mental illness makes this populaCon at greater risk for opioid abuse

•  Depression raises the risk of overdose and suicide avempts, and opiates have a high death rate.

•  Despite this, pa=ents with mental illness, mainly depression and mental illness, and chronic pain are prescribed opioids significantly more oden.


Using Lean Management to Improve Opioid Prescribing for Pain in Ambulatory Care Connie van Eeghen DrPH, Amanda Kennedy PharmD, Mark Pasanen MD, Benjamin Livenberg MD, Charles MacLean MD University of Vermont


The Ques=on •  Is a structured, systems-‐based QI method, such as LEAN,

effecCve in helping pracCces implement a set of best pracCce strategies?

Why this is important? •  Opportunity for increased prescripCon pain relief and

reducCon in drug diversion/addicCon •  Structured problem-‐solving approaches such as LEAN have

potenCal to improve many primary care processes

What the Researchers Did •  Engaged 9 primary pracCces & 1 orthopaedic pracCce in LEAN redesign of office work

•  Mixed methods, prospecCve, observaConal •  MulCple case studies, paired pre-‐ and post-‐intervenCon surveys from providers and staff –  155 study parCcipants; 77% response rate –  36 prescribers and 83 staff responded (n=119) –  Primary outcome: provider saCsfacCon with opioid prescripCon management

What This Means for Clinical Prac=ce •  The LEAN approach embedded key strategies into office work successfully.

•  Most common: –  Use of state-‐sponsored prescripCon data base –  Provider/staff team approach to managing Rx –  Consistent approach across enCre pracCce

•  LEAN was effecCve and well-‐received regardless of the specific strategies selected

•  A toolkit to guide the use of LEAN in primary care may have broad applicaCon


How oden do pa=ents with musculoskeletal (MSK) complaints newly treated with NSAIDs, subsequently consult their GP because of an adverse drug reac=on (ADR)?

AR Koffeman, AR van Buul, VE Valkhoff, GW ‘t Jong, PJE Bindels, J van der Lei, MCJM Sturkenboom, PAJ Luijsterburg, SMA Bierma-‐Zeinstra


Why is this important? GPs frequently treat MSK complaints with NSAIDs

The occurrence of serious NSAID-‐related ADRs has been studied extensively

Less known about the incidence of non-‐serious ADRs in primary care and resulCng health care uClizaCon in the form of GP consultaCons

What the Researchers Did •  PopulaCon/Subjects

–  16, 626 adult paCents newly treated with an NSAID by their GP because of a MSK complaint

•  Design –  Cohort study performed within a large electronic healthcare database

•  Basic Method/IntervenCon –  Manual assessment of the electronic medical record of included

paCents for the duraCon of NSAID use (with a maximum of 2 months), to determine whether the GP was reconsulted because of an adverse event

–  Causality assessment to esCmate the likelihood that the adverse events was causally related to the use of the NSAID

What the Researchers Found •  995 (6%) consulted their GP because of at least one adverse event

•  In total 1271 adverse events were presented by these 995 paCents

•  The most frequent adverse events presented were dyspepsia (31.3%), dyspnea (12%) and skin reacCons (11%)

•  Amer causality assessment, 215 adverse events were classified a likely ADR, 515 as a possible ADR

•  This means that 4% of paCents prescribed an NSAID for the treatment of a MSK complaint, subsequently consulted their GP because of a likely or possible ADR

What This Means for Clinical Prac=ce •  In primary care paCents with MSK complains treated with NSAIDs, one in

25 were found to reconsult their GP because of a possible or likely ADR

•  The true incidence of ADRs is likely to be higher, as not all paCents suffering from an ADR will consult their GP; some may choose to disconCnue NSAID treatment without further consultaCon

•  GPs should address not only the risk of serious ADRs when discussing treatment opCons for MSK complaints with their paCents, but also our finding of reconsultaCon for non-‐serious ADRs

•  Although these non-‐serious ADRs are less harmful to the paCent, they lead to an increase in primary health care uClizaCon and may outweigh the benefits of NSAID treatment for many paCents


Has this pa=ent with chest pain coronary artery disease? Diagnos=c u=lity of a clinical decision rule. J Haasenriver, S Bösner, N Donner-‐Banzhoff (Philipps University Marburg, Germany)


•  What is the diagnosCc uClity of the Marburg Heart Score (MHS) in terms of improving the accuracy of the GP‘s iniCal clinical diagnosis?

•  Why this is important? –  GPs must idenCfy paCents with CAD while avoiding unnecessary

tesCng and hospital admissions in the large majority of paCents with non-‐cardiac pain.

–  The Marburg Heart Score (MHS) is an easy to use, valid, and robust tool for ruling out CAD in chest pain paCents.

(Bösner et al. 2010, Haasenriver et al. 2012)

–  Its impact on improving the GP’s iniCal clinical diagnosis is unclear.

What the Researchers Did •  832 consecuCve paCents aged ≥ 35 years presenCng with chest pain in primary care/56 general pracCConers (GPs)

•  ComparaCve diagnosCc accuracy study •  Basic Method/IntervenCon

–  Compara=ve test: GP’s unaided clinical judgment based on history and physical examinaCon.

–  New/index tests: 1) Marburg Heart Score (MHS); 2) GP’s aided clinical judgment based on history, physical examinaCon and results of the MHS; 3) Using the MHS as a triage, only paCents with a score value of 3 were further assessed by GPs.

–  Reference diagnosis was established using a delayed-‐type reference standard in combinaCon with an independent expert panel.

Marburg Heart Score (MHS)

Item Value

Age female≥65, male≥55

1 P

Known vascular disease (CAD, stroke, PAD)

1 P

Pain worse during exercise

1 P

Pain not reproducible by palpaCon

1 P

PaCent assumes pain is of cardiac origin

1 P

Score Probability of CAD

0-‐2 points 2.3% (1) 2.1% (2)

3-‐5 points 39.6% (1) 23.3% (2)

•  Easy to use, valid and robust tool for ruling out CAD in chest pain patients

(1)  Bösner et al. CMAJ 2010;182:1295 (2)  Haasenritter et al. Br J Gen Pract. 2012;62:e415


•  Results of the current study suggest that using the MHS may improve the accuracy of the GP’s clinical diagnosis.

•  Considering also other aspects of the MHS (simplicity) and previous study results (validity, robustness) we recommend the MHS as a useful tool for ruling out CAD in chest pain paCents in primary care.

Ques=ons?

NAPCRG Pearls: What Is New? The top nine research studies that will impact clinical practice for...

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