NAPCRG Pearls: What Is New? The top nine research studies that will impact clinical practice for family physicians as presented by Drs. David Kaplan and David White at Family Medicine Forum in Quebec City, QC Nov 2014
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NAPCRG Pearls: What Is New? The top nine research studies that will impact clinical practice for family physicians
1. 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
2. Tweet
the
talk!
@davidkaplanmd
@davidgordonwhite
#FMF2014
#FMFpearls2014
3. 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
4. Disclosure
–
Dr.
David
White
• Dr.
White
has
nothing
to
disclose.
6. 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
7. 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
8. 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
9. 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
10. 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
11. NAPCRG
2014
–
Pearl
2
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
12. 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
13. 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.
14. 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
15. What
This
Means
for
Clinical
Prac=ce
• 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
16. NAPCRG
2014
–
Pearl
3
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)
17. The
Research
Ques=on
Does
cardiovascular
risk
predict
sta=n
use?
Why
this
is
important?
– StaCns
are
highly
efficacious
in
reducing
death
in
individuals
with
high
cardiovascular
risk
18. What
the
Researchers
Did
• 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
19. What
the
Researchers
Found
• 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
20. What
This
Means
for
Clinical
Prac=ce
• 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
21. NAPCRG
2014
–
Pearl
4
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
22. The
Research
Ques=on
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
23. What
the
Researchers
Did
• 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
24. 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
25. What
This
Means
for
Clinical
Prac=ce
• 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
26. NAPCRG
2014
–
Pearl
5
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
27. 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?
28. 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
29. 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
30. What
This
Means
for
Clinical
Prac=ce
• 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
31. NAPCRG
2014
–
Pearl
6
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
32. The
Research
Ques=on
• 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
33. What
the
Researchers
Did
• 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
34. 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)
35. 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.
36. NAPCRG
2014
–
Pearl
7
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
37. The
Research
Ques=on
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
38. 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
40. 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
41. NAPCRG
2014
–
Pearl
8
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
42. The
Research
Ques=on
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
43. 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
44. 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
45. 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
46. NAPCRG
2014
–
Pearl
9
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)
47. The
Research
Ques=on
• 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.
48. 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.
49. Marburg
Heart
Score
(MHS)
• Easy to use, valid and robust tool for ruling out
CAD in chest pain patients
Item
Value
Age
1
P
female≥65,
male≥55
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)
(1) Bösner et al. CMAJ 2010;182:1295
(2) Haasenritter et al. Br J Gen Pract. 2012;62:e415
51. What
This
Means
for
Clinical
Prac=ce
• 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.