Panel Discussion Top Papers of the Past Year

Panel Discussion: Top Papers of the Past Year Anthony Day, MD; James D. Hoehns, Pharm. D; Adam Roise, MD, MPH NE IA Family Medicine Residency Program, Waterloo IA Jauch Memorial Symposium May 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 cycles 2. Disqualify her for athletics for three months 3. Increase dietary intake with modest activity reduction 10

Adolescent Medicine 35% 36% Disqualify her for athletics for three months Increase dietary intake with modest activity reduction 29% OCPs to regulate cycles

Adolescent Medicine PRACTICE CHANGER Increase dietary intake with modest activity reduction Level 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 -32 Source: 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. 2. 3. Salmeterol Tiotropium Fluticasone 31% Salmeterol Tiotropium 38% Fluticasone 10

Pulmonology PRACTICE CHANGER N= 2, 485 Discontinuation of ICS should be considered in COPD patients who are stable and are receiving LABA and LAMA STRENGTH OF RECOMMENDATION B: Based on a large, randomized controlled trial. N Engl J Med 2014; 371: 1285 -94

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? 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 1. 26% 24% 22% 28% He is more His hospital All of the likely to get likely to stay is likely above C difficle receive a to be longer quinolone 10

Allergy PRACTICE CHANGER All of the above 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 -6 Source: Choosing Wisely AAAAI March 3, 2014.

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. 39% 31% 30% Peanut products? At 6 months is fine! Wait until age 1 to introduce. Wait until they can eat peanuts and not choke. 10

Immunology PRACTICE CHANGER 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? 32% 22% No ne of th th er ap e ea t Gr ro th ss Le er t m im ei bo n aj sm Le s ea bo ve . ut i. . e. . . bo or b lic le ed ev in g 1. 2. 19% em Less major bleeding Less thromboembolic events 3. Greater time in therapeutic range 4. None of the above 27% 10

Hematology PRACTICE CHANGER � Genotype guided vs. Major bleeding 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 STRENGTH OF RECOMMENDATION A: Based on meta-analysis of 9 RCTs. JAMA Intern Med 2014; 174: 1330 -8.

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 40% 33% 27% Encourage daily walking and dietary changes for weight loss Continue current effective medication regimen Refer her for intensive behavioral counseling for diet and exercise

Cardiac risk factors 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. Evidence Citation: Le. Fevre, Michael, Annals of Internal Medicine Online-First, 26 August 2014.

Cardiology/Preventive Care A 55 yo man with diabetes presents for routine follow-up. He is not fasting and due for an A 1 c, 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 34% 33% Draw all labs today Draw all except Have him come despite him not lipids, which you back fasting for all fasting. have him come labs back fasting for 10

Cardiology/Preventive Care PRACTICE CHANGER Stop checking fasting lipids. 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? 38% 1. 2. 3. Lower HDL Higher triglycerides No improvement in clinical outcomes 34% 28% Lower HDL Higher triglycerides No improvement in clinical outcomes 10

Cardiology PRACTICE CHANGER � 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 STRENGTH OF RECOMMENDATION A: Based on multiple high-quality RCTs. N Engl J Med 2014; 371: 203 -12.

Cardiology A 70 yo women with well controlled hypertension has a screening A 1 C of 7. 2. She has no history of hyperlipidemia or CAD. Which medicine do you add? 32% 25% 24% 1. Spironolactone 19% 2. Statin ne el io ed in lid zo ia at St do gr Cl op i Th Sp iro no la ct on e 4. Thiazolidinedione in 3. Clopidogrel 10

Cardiology CONSIDERATION 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 (HFp. EF)? os in az la no iro Sp zin e/ iso so rb id ct o ed i. . ne . Spironolactone Prazosin 28% Pr Hydralazine/isosorbide dinitrat al a 2. 3. 32% Hy dr 1. 40% 10

Cardiology PRACTICE CHANGER � 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 STRENGTH OF RECOMMENDATION B: Based on one RCT HF hospitalizations in patients with HFp. EF; results difficult to interpret N Engl J Med 2014; 370: 1383 -92.

Cardiology What new class of LDL-lowering medications has “early” data showing a reduction in cardiovascular events when added to statins? Interleukin-1 B blockers 2. CETP inhibitors 3. PCSK 9 inhibitors 35% 34% 1. 31% Interleukin-1 B blockers CETP inhibitors PCSK 9 inhibitors 10

Cardiology PRACTICE CHANGER � Evolocumab (PCSK 9 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 STRENGTH OF RECOMMENDATION B: Based on two open-label RCTs N Engl J Med 2015; 372: 1500 -9.

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? 35% 1. Clopidogrel 2. Simvastatin 19% 25% 21% 3. Metoprolol 4. Lisinopril Clopidogrel Simvastatin Metoprolol Lisinopril 10

Wound Care PRACTICE CHANGER 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? 51% 1. 2. True False 49% True False 10

DVT Care PRACTICE CHANGER 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 G 2 P 1 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 delivery 2. Refer to an obstetrician immediately 3. See her every two weeks throughout the pregnancy 4. Start her on methyldopa to keep her BP under 130/80 10

Obstetrics 30% 24% 26% 20% Start a baby aspirin daily Refer to an obstetrician See her every two weeks Start her on methyldopa until delivery immediately throughout the to keep her BP under pregnancy 130/80

Obstetrics PRACTICE CHANGER Start a baby aspirin daily after 12 weeks STRENGTH OF RECOMMENDATION A: Review of multiple RCTs including metaanalysis : US Preventive task force “B” recommendation – substantial net benefit in women at high-risk for preeclampsia Evidence Citation: Le. Fevre, 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? 38% 1. Acomprosate 2. Disulfuram 25% 23% 14% 3. Naltrexon 4. Wellbutrin Acomprosate Disulfuram Naltrexon Wellbutrin 10

Substance Use Disorders PRACTICE CHANGER 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: Hendry. S, 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- natural 2. An combination antioxidant supplement 3. A month of Bactrim DS 4. Clomid for 1 week prior to ‘timed’ intercourse 10

Male infertility 32% 26% 21% Vitamin E – the wonder drug An combination antioxidant and all-natural supplement 21% A month of Bactrim DS Clomid for 1 week prior to ‘timed’ intercourse

Male infertility PRACTICE CHANGER An antioxidant supplement STRENGTH 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? 45% 1. 2. 3. Pulmonary fibrosis Hypercalcemia Acute kidney injury 32% 23% Pulmonary fibrosis Hypercalcemia Acute kidney injury 10

Geriatrics PRACTICE CHANGER AKI-associated hospitalization more common with atypicals. Study highlights mortality risk with atypicals. STRENGTH OF RECOMMENDATION C: Based on one population based cohort study Ann Intern Med 2014; 161: 242 -8.

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 systems 2. Savings can only be achieved in high cost regions 3. Savings are possible across settings even in year one 10

Managed Care 36% 33% 31% 1. Savings can only be 2. Savings can only be 3. Savings are possible across achieved within large achieved in high cost regions settings even in year one integrated medical systems

Managed Care KEY INFORMATION 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 care Evidence Citation: Mc. Williams, 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 33% 25% 19% “Is there anything else “Is there something “I look forward to “Stay out of trouble you want to address in else you want to seeing you at your next now, ya hear? ” the visit today? ” address in the visit appointment. ” today? ”

Patient Satisfaction PRACTICE CHANGER 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? 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. 1. 10

Primary Care 39% 29% 32% We have no idea why joints crack but it We don’t think it is harmful, but some You will develop arthritis in your joints is considered harmless. people are studying it. if you do that.

Joint cracking

Primary Care JUST FOR FUN 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.