TheBestofPrimaryCareResearchfromNAPCRG2015ThetopresearchstudiesthatwillimpactclinicalpracticeforfamilyphysiciansDavidM.KaplanMDMScCCFP

AssociateProfessorDepartmentofFamily&CommunityMedicineUniversityofTorontoProvincialPrimaryCareLead,HealthQualityOntario

DavidG.WhiteMDCCFPFCFP

Professor&InterimChairDepartmentofFamily&CommunityMedicineUniversityofTorontoPresident-Elect,CollegeofFamilyPhysiciansofCanada

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@davidkaplanmd@davidgordwhite#FMF2016#FMFpearls2016

Disclosure– Dr.DavidKaplan

• Dr.KaplanisaBoardMemberofNAPCRGandistheChairoftheCommunityClinicianAdvisoryGroup

• Dr.KaplanistheProvincialPrimaryCareLeadatHealthQualityOntario,theprovincialadvisoryonhealthcarequality.

Disclosure– Dr.DavidWhite

• Dr.Whitehasnothingtodisclose.

www.napcrg.org/pearls

Howarethe“Pearls”Picked?

NAPCRG2015– Pearl1

PhysicalExerciseforLateLifeDepression:TailoredTreatmentsBetweenPsychiatryandPrimaryCare

Klea Bertakis,MD,MPH;MarioAmore;Fabrizio Asioli;LuigiBagnoli;MarcoMenchetti;MartinoMurri;MicroNeri;FrancescaNeviani;MatteoSiena;Guilio Toni;FerdinandoTripi;StamatulaZanetidou;DonatoZocchi

TheResearchQuestion

Toexaminewhichpatient- andcontext-relatedfactorsimpacttheantidepressantefficacyofexerciseintherealclinicalworld,amongelderlypatientssufferingfrommajordepression

WhattheResearchersDid• SEEDSstudycomparedtheantidepressantefficacyofsertralineplusphysicalexercise(24weeks,3timesperweek)vs.sertralinealone.

• Setting: consultationliaisonprogramforprimary care

• post-hocanalysis:identifiedfactorspredictedhigherchancesofremissionintheexperimentalgroup;contextualfactorsandPCPsopinionswerealsoexplored

WhattheResearchersFound• Ideal candidate toreceive sertralineplusexercise:patientwhoisolderthan75,hasretainedagoodaerobicfitness,displayspsychomotorretardationbut notsevereanxiety

• Longstandingconsultationliaisonprogramisimportantfortherecruitmentandfollowupofpatients:PCPsexpressedveryfavorableviews re: addingexercise asanantidepressant

WhatThisMeansforClinicalPractice

• Olderpatientswithmajordepressioncanbesafelyandeffectivelytreatedwithacombinationofstructuredphysicalexerciseandantidepressantdrugs.

• ThefeasibilityofthisinterventiondependsonthelevelofcollaborationbetweenPCPsandotherspecialists.Moreover,theeffectivenessagainstdepressionisparticularlyhighamongselectedpatients.

NAPCRG2015– Pearl2

MissedOpportunitiesforPreventionofStrokeandTransientIschaemicAttack(TIA)inPrimaryCare

GraceMoran;MelanieCalvert;MaxFeltham;TomMarshall;RonanRyan

TheResearchQuestion1. Calculatetheproportionofstrokes/TIAs with

priormissedopportunitiesforprevention2. Determineiftheproportionofmissed

opportunitieshaschangedovertime3. Investigatetheassociationwithpatientor

demographic characteristics

WhattheResearchersDidRetrospectiveanalysisofanonymised,electronicUKprimarycarerecords

Population• First-stroke/TIA• ≥18years• 2009-2013

OutcomesAnticoagulant,

Antihypertensive orLipidLoweringdrugsNOT prescribedwhenclinicallyindicated

Analysis• %ofpatientswith

missedpreventionopportunities

• Logisticregression

WhattheResearchersFound%Missedopportunities:• Anypreventiondrug:54%(9,579/17,680)– Anticoagulants:52% (1,647/3,194)– Lipidloweringdrugs:49% (7,836/16,028)– Antihypertensives: 25% (1,740/7,008)

Changeovertime(2009-2013)• Onlyanticoagulantdrugprescribingimproved

Predictivepatient/demographiccharacteristics• Differentprofileforeachdrug

WhatThisMeans forClinical PracticePrimarystrokepreventionisinadequate

•Ageingpopulation•Guidelinechanges•Legalconsiderations

Barrierstoprescribing

Patient MD Organizational

NAPCRG2015– Pearl3

PrescriptionOpioidDoseandDurationandRiskforDepressioninThreeLargeHealthcareCenterPatientPopulations

JeffreyScherrer,PhD;JoanneSalas,MPH;LaurelCopeland;BrianAhmedani;EileenStock;ThomasBurroughs,PhD,MA,MS;F.DavidSchneider,MD,MSPH;KathleenBucholz;MarkSullivan;PatrickLustman

TheResearchQuestion

Doeslongerdurationofprescriptionopioiduseleadtonewonsetdepressionwhencontrollingformaximumdailydose,painandotherconfounders?

Doesmaximumdailydoseofprescriptionopioiduseleadtonewonsetdepressionwhencontrollingfordurationofuse,painandotherconfounders?

WhattheResearchersDid• Retrospectivecohortdesign from:

– VeteransAdministration(VA),n=70,997– BaylorScott&White(BSW),n=13,777– HenryFordHealthSystem(HFHS),n=22,981

• VariablescreatedfromICD-9-CMcodes,pharmacyrecords,vitalsigns,labresultsetc.

• SeparateCoxmodelscomputedtoestimateassociationbetweenopioidduration,morphineequivalentdoseandnewdiagnosisofdepression

WhattheResearchersFound

• Riskofnewonsetdepressionincreasedwithopioiddurationineachpatientsample.>90dayusewasassociatedwith35%to105%increasedriskofnewonsetdepressioncomparedto1-30 day use.

• Dosewasnotassociatedwithnewonsetdepression

WhatThisMeans forClinical Practice

• Baseline depression screening insufficient, consider depression screening at each opioid refill

• Add depression to risk:benefit discussion• Short term euphoria but long term depression• Opioid taper if new onset depression in

chronic pain• Consider opioid, not just pain, as source of

depression

NAPCRG2015– Pearl4

AdjunctiveScreeningforBreastCancerinWomenwithDenseBreasts:ASystematicReview

JoyMelnikow,MD,MPH;JoshuaFenton,MD,MPH;EvelynWhitlock,MD,MPH;DianaMiglioretti,PhD;JamieThompson,MPH;MeghanWeyrich,MPH

TheResearchQuestion

Whatistheevidenceondiagnostictestperformanceandclinicaloutcomesofsupplementalscreening ofwomenwithdensebreastswithultrasound,MRI,ordigitalbreasttomosynthesis?

WhattheResearchersDid

• Systematic reviewofthepublished,English-languagemedicalliteratureon:– Sensitivity,specificity,PPV,cancerdetectionratesrecallrates,andlongtermoutcomesofsupplementalscreening(afteranormalmammogram)withUS,MRIorDBTforwomenwithdensebreasts(BI-RADSc/ddensity)

WhattheResearchersFound• Nostudiesofbreastcancermorbidityormortality• Hand-heldUS

• Sensitivity80-83%;specificity86-94%;PPV3-8%• Additionalcancerdetection4.4per1,000exams;recallrates14%(onestudy)

• MRI• Sensitivity75-100%;specificity78-89%;PPV3-33%.• Additionalcancerdetection4to29per1,000exams;recallrates12%-24%per1,000exams

• DBT• Additionalcancerdetection:Increasedbyabout1cancerper1000exams(4/1000to5/1000)

• Recallrates:7-11%withDBT+mammographyvs9-17%withmammographyalone

WhatThisMeans forClinical Practice

• Noevidenceonwhethersupplementalscreeningreducesbreastcancermortalityormorbidity• Rigorousstudieswithlongtermfollow-upareneeded

• SupplementalUSandMRIincreasedcancerdetectionbuthadhighfalsepositiverates

• DBTmayreducerecallratesbutevidenceforwomenwithdensebreastsisverypreliminary

WhatThisMeans forClinical Practice

NAPCRG2015– Pearl5

TheEffectivenessofMaintenanceSSRITreatmentinPrimaryCareDepressiontoPreventRecurrence:MulticentreDoubleBlindedPlaceboControlledRCT.DeeMangin;ClaireDowson;RogerMulder;ElisabethWells;LesToop;TonyDowell;BruceArroll

TheResearchQuestion

WhatistheeffectivenessofmaintenanceSSRItreatmentinpreventingdepressionrecurrenceinprimarycarepatients?

Whythisisimportant?– IncreasingSSRIprescriptionislargelydrivenbyuseofmaintenancetherapy;ThereisnoevidencefromRCTSformaintenancetreatmentinprimarycarepatients

WhattheResearchersDid

• Multicentre,placebocontrolled,dbl blindedRCT• Intervention:continuationofmaintenanceSSRIvsdiscontinuation(tapertoplacebo)

• Population: primarycaretreatedpatientscurrentlytakingfluoxetineformaintenancetopreventrecurrence

• Primaryoutcome:occurrenceofmoderatelyseveredepressionover18months

WhattheResearchersFound• Maintenancetreatmentpreventedadepressionepisodein12.8%(23.3%vs10.5%)p=0.005NNT(18mo)=8• 7/8patientsexperiencednobenefitover18months• 6%ofpatientshadtorestartbecauseofintolerablediscontinuationsymptoms,despitetaperingNNH=16

• Therewasnoharmintrialingdiscontinuation:nosuggestionofpooreroutcomesat18monthsinthetaperarm• (Patientrelevantmeasuresincludingmood,qualityoflife,overall

psychologicaldistress/symptoms,socialandoccupationfunctioning)

WhatThisMeans forClinical Practice

• TheabsolutebenefitofSSRIsinpreventingdepressionrecurrenceinprimarycareismuchsmallerthanthatpreviouslyestimated

• Itseemsreasonabletodiscussthesedatawithpatientsonmaintenancetreatmentandofferadiscontinuationtrial topatients

• Thisprovidesgoodprimarycaredataforshareddecisionmakingwhenconsideringinitiationofmaintenancetreatment

NAPCRG2015– Pearl6

TheFitFamilyChallenge:APrimaryCare-BasedPediatricObesityProgram

BonnieJortberg,PhD,RD,CDE;RaquelRosen;SarahRoth

TheResearchQuestion

Canachildhoodobesitybehaviormodification programbeimplementedinprimarycarepractices?

Isiteffective?

WhattheResearchersDid

Developedachildhoodobesitybehaviormodprogram,basedon“5-2-1-0”(perday)• 5+servingsoffruitsandvegetables;• 2orfewerhoursofscreentime;• 1hourormoreofphysicalactivity;• 0servingsofsugar-sweetenedbeverages

– “Shelf-ready”programwithcurriculumfor18groupvisits(availableinSpanish)

WhattheResearchersDid

• Enrolled20primarycarepracticesinColorado:– Offered1-daytrainingandbi-annualLearningCollaboratives;on-goingtechnicalsupport

• 290childrenages6-12years+familymembersenrolled

• Collectedmonthlydatafor12-15monthsforBMI%ile & lifestylefactorsrelatedto5-2-1-0

WhattheResearchersFound

• Baselineto9-15monthsofparticipation:– DecreaseinBMI%-tile(p<.04);BMIz-Scores(p<.02)

• LifestyleFactors:significantimprovementsfor– Dailyfruitandvegetableintake(p<.0001);daysofphysicalactivityof1hour+(p<.0001);familyactivity/week(p<.0001);dailyscreentime(p<.05);intakeofsugarsweetenedbeverages(p<.0003);#oftimeseatingouteachweek(p<.001)

WhattheResearchersFound

• ChildrenfromSpanishspeakingfamiliesandchildrenfromfamiliesthatreportedatleastsomefoodinsecurity(vs.neverornoresponse)hadlessfollow-up(p<.02)

WhatThisMeansforClinicalPractice

• Itisfeasible toimplementachildhoodobesitybehaviormodificationprograminprimarycarepractices,whichcanproduceclinicallymeaningfulimprovementsinBMI%-tileandlifestylefactors

• Familiesreportingfoodinsecurityissuesmaybelesslikelytofollow-upandstayengagedintheprogram.

NAPCRG2015– Pearl7

NotasTransientastheNameSuggests:Fatigue,PsychologicalandCognitiveImpairmentFollowingTransientIschemicAttack(TIA)

GraceMoran;MelanieCalvert;MaxFeltham;TomMarshall;RonanRyan

TheResearchQuestion

• TIAisdefinedbyshort-lastingsymptoms• Medicalmanagementfocusesonstrokeprevention

InvestigatetheassociationbetweenTIAandconsultations forfatigue,cognitive,orpsychologicalimpairmentinprimarycare

WhattheResearchersDidDesign:Retrospectivecohortstudy

OutcomesPatientsDatasource

Electronicmedicalrecords

TIAConsultation

forimpairment

ControlsConsultation

forimpairment

Matched 1:5AgeSexGeneral practice

WhattheResearchersFound

TIApatientsmorelikelytoconsultforall3impairments

AdjustedHazardratiosFatigue:1.43Psychologicalimpairment:1.26Cognitiveimpairment:1.46

TIA patients Controls

WhatThisMeans forClinical Practice

• Challengesthe‘transient’definition ofTIA

• Currentmanagement ofTIAmaynotbeadequate

• Impactonqualityof life andstrokeprevention

• Futureresearch• Mechanism• Identificationofimpairments• Treatmentofimpairments

NAPCRG2015– Pearl8

SterileVersusNon-SterileGlovesforMinorSurgeryinGeneralPractice

ClareHealandShampavi SriHaran

TheResearchQuestion

Arenon-sterileglovesworsethansterileglovesforminorskinexcisions?

WhattheResearchersDid

• Prospectiverandomisedcontrollednon-inferioritytrial

• SingleAustralianGeneralPractice

• 478participants

WhattheResearchersFound

Infectionrates:• Sterilegloves9.3% (22/237)• Nonsterilegloves8.7% (21/241)• DifferenceinInfection-0.6%(95%CI-4.0to+2.9)

Infectionactuallylowerinthenon-sterileglovegroup!

WhatThisMeansforClinicalPractice

• Theuseofnon-sterileglovesisNOTWORSEthansterilegloves intermsofinfectionratesinminorskinproceduresinaFP/GPsetting

• Cost-saving