Monday, August 18, 2014

ACC/AHA cholesterol guideline: summary and perspectives

- Kenny Lin, MD, MPH

As previewed in a previous blog post, the August 15th issue of AFP features a concise summary of the American College of Cardiology / American Heart Association updated cholesterol treatment guideline. Key points include an expansion of the role of statins in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); elimination of specific low-density lipoprotein cholesterol (LDL-C) target levels; and a new tool for assessing of 10-year and lifetime risk for ASCVD. An accompanying POEM notes that full implementation of the new guideline would increase the number of U.S. adults eligible to take statins by nearly 13 million, with the percentage of adults 60 to 75 years of age for whom statins are recommended rising from 47.8% to 77.3%.

Two editorials in the same issue further explore the implications of the new guideline. Writing for the members of the guideline panel, Dr. Patrick McBride and colleagues emphasize that the recommendations are largely based on high-quality evidence from randomized controlled trials that measured patient-oriented outcomes. They argue that "these changes should simplify the approach to clinical practice by reducing titration of medication, the addition of other medications, and the frequency of follow-up laboratory testing." In a second editorial, Dr. Rodney Hayward concurs with the panel's decision to abandon LDL-C targets, but disagrees with setting a universal 10-year ASCVD risk threshold of 7.5% for treatment with a statin:

My biggest criticism of the new guideline is that it does not acknowledge a specific gray zone—a range in which the potential benefits and harms of a statin make the “right decision” predominantly a matter of individual patient circumstances and preferences. It may be reasonable to set 7.5% as a starting point for discussion (e.g., for every 33 patients treated for 10 years, roughly one heart attack will be prevented [i.e., number needed to treat = 33]). But these risks and benefits are estimates with a nontrivial margin of error. The guideline does note that shared decision making should be used, but it provides no clear direction on when statins should be recommended rather than just discussed.

A similar debate is taking place in the United Kingdom, where its National Institute for Health and Care Excellence (NICE) recently recommended offering a statin to all persons with a 10-year cardiovascular event risk of 10% or more. An editorial in BMJ observed that doctors need better shared decision making tools to help patients understand the tradeoffs involved in taking medications that have potentially large population health benefits but are unlikely to prevent a bad outcome in an individual patient:

Doctors are unlikely to start giving patients clear numerical information simply because they are told to do so. They might do so if NICE can recommend information tools with the same force as when it recommends drugs, and if it becomes as easy to give contextual numerical advice as it is to print a prescription. ... We will need better data, from bigger trials, and better risk communication than for conventional medical treatment. ... Without such innovation in the use of medical data, we can say only that statins are—broadly speaking—likely to do more good than harm. That is not good enough.

Have you already integrated the ACC/AHA cholesterol guideline into your practice? If so, how do you decide whether to "recommend" versus "discuss" statins with patients? If not, what reservations or workflow issues have prevented you from transitioning to the new guideline?

Monday, August 11, 2014

More evidence against initiation of perioperative beta blockers in non-cardiac surgeries

- Jennifer Middleton, MD, MPH

Patients undergoing intermediate- or high-risk non-cardiac surgeries often get a perioperative beta blocker, and the American College of Cardiology Fellows (ACCF) and the American Heart Association (AHA)'s 2007 guideline advises as such. The ACCF/AHA's 2009 update, though, recommends perioperative beta blockers only in patients with a history of coronary artery disease (CAD) and/or at least 2 CAD risk factors. A 2014 meta-analysis additionally found that perioperative beta blockade in patients not chronically on beta blockers increased mortality -- even if they had CAD or at least 2 CAD risk factors.

JFP reviewed this 2014 meta-analysis recently in an online article. This article discussed serious methodological problems regarding a group of Dutch studies that heavily informed the ACCF/AHA 2007 guideline and 2009 update. These studies failed to consistently obtain written informed consent for subjects, recruited inappropriate patients, and could not produce their raw data when requested by a review panel. These flawed studies are the backbone for the ACCF/AHA's current recommendation to add a perioperative beta blocker to patients with at least 2 CAD risk factors and/or a history of CAD*.

Perioperative beta blockers were certainly controversial even prior to these studies' public disgrace; a 2012 AFP article on Perioperative Cardiac Risk Reduction cited several of the studies included in the 2014 meta-analysis and advised caution in using perioperative beta blockers in patients without known cardiac disease.

The 2014 meta-analysis examined post-operative outcomes for patients who were not taking a beta blocker prior to surgery (including patients with CAD and/or risk factors) and who were undergoing non-cardiac surgeries. The researchers included 9 high quality randomized controlled trials (RCTs) and excluded the suspect data from the Dutch trials. They found that beta blockers did decrease perioperative non-fatal myocardial infarctions (RR = 0.73 [0.61-0.88]), but they also increased the risk of stroke (RR = 1.73 [1.00-2.79]), hypotension (RR = 1.51[1.37-1.67]), and 30-day all cause mortality (RR = 1.27 [1.01-1.60]). For patients not previously on a beta blocker prior to intermediate- or high-risk surgery, adding one causes more harm than good (NNH for 30-day all cause mortality = 160).

When newer studies conflict with previously published guidelines, physicians have an important decision to make. Assuming the new study is methodologically sound, should we abandon the earlier guideline because of the updated evidence? Or, should we wait until the original recommending body assesses the new evidence?

The answer probably involves multiple variables: the amount of trust in the earlier guidelines, the degree to which our colleagues are changing their practice, and, perhaps, even our level of comfort in assessing the study's quality. Maybe it feels like the stakes are too high to change our practice based on one study, especially if larger recommending bodies have yet to weigh in.

Our specialty is fortunate to have high quality journals whose editorial experts sift through new studies and assist us with interpreting and applying them. AFP recently reviewed the ACCF/AHA guidelines for management of congestive heart failure, for example, and handily summarized the high points of this 300 page document into a brief article geared toward busy family docs. Although we should use our evidence-based medicine skills to reach our own independent conclusions about newly published studies, we can also rely on AFP and others to help confirm our assessments.

How comfortable are you changing your practice when new studies conflict with prior recommendations?

* Admittedly, most patients with CAD should be on a beta blocker chronically, but I suspect I'm not the only family doc with a couple of patients who either can't tolerate them or refuse to take one. Several of the studies included in this 2014 meta-analysis included this group of patients in their RCTs.

Monday, August 4, 2014

The most popular posts of January - June 2014

- Kenny Lin, MD, MPH

Diabetes, weight loss, the future of family medicine, antibiotic safety, and athlete's foot were the topics of the AFP Community Blog's top 5 most viewed posts from the first six months of 2014. Each of these posts has been viewed between 500 and 650 times to date.

1. Does metformin prevent recurrent events in diabetic patients with CAD? (January 20)

This study helps to reinforce that metformin (rather than a sulfonylurea) is the right choice when initiating treatment for type 2 diabetes. What to add when additional glycemic control is needed, however, remains up to each physician's clinical judgment.

2. Weight loss medications: how much of a solution are they? (March 10)

Frankly, I'd prefer to see us work to lessen biologic and environmental pressures instead of adding another pill to our patients' regimens. Our commitment as 21st century family physicians must be to our communities as well as our individual patients if we are ever to turn the tide of rising obesity rates.

3. The Future of Family Medicine - Some Sacrifices Required (June 16)

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care.

4. Azithromycin and levofloxacin safety concerns continue (March 24)

Although many physicians prefer basing practice change on a prospective study, retrospective studies are better suited than prospective studies to detect rare events.

5. What is the best topical antifungal for treating tinea pedis? (May 27)

Given that 1 week of therapy is preferable to most patients instead of 4, and the price difference is negligible (around $10-16 for 30 grams of either), I will still favor terbinafine over clotrimazole for treating tinea pedis.

Monday, July 21, 2014

Nebulizers: old habits die hard

- Jennifer Middleton, MD, MPH

Last week's JFP discussed an updated Cochrane review reasserting that nebulizers cost more, cause more side effects, and offer equivalent treatment compared with a metered dose inhaler (MDI) and a spacer (aerochamber). The Cochrane reviewers conducted a systematic review of 39 trials that included both children and adults as well as office and emergency department (ED) settings. They found no difference in hospital admission rates for adults or children who received albuterol via a MDI and spacer versus a nebulizer. Hospital length of stay was no different for adults who received albuterol via an MDI/spacer versus a nebulizer. Children's ED visit time was, on average, 33 minutes less for those who received albuterol with an MDI/spacer instead of a nebulizer. Children using an MDI/spacer had less tremor, and both children and adults using an MDI/spacer had less tachycardia.

(If you'd like to read more about asthma, check out this AFP By Topic on asthma. You can also brush up on spacer techniques here.)

This is not new information; several randomized controlled studies and the original 2003 Cochrane review demonstrated similar findings. If your office and/or hospital setting is anything like mine, though, nebulizers are everywhere, despite a decade's worth of research showing that MDIs offer equivalent therapy with fewer side effects and less cost. Why the continued love affair with nebulizers when they're not only therapeutically equivalent to MDIs with spacers but also cause more side effects, cost more per dose, and result in longer ED visits?

Well, a study from last year found that 80% of COPD patients and their families felt that using a nebulizer was better than using an MDIA small study of pediatricians found that most would benefit from "better training" regarding spacer use. These small studies may not be generalizable to an American family medicine office, but it's still possible that patients like using nebulizers and that physicians are more comfortable ordering nebulizers. And, I have to confess that it's much more efficient in my office for my nurse to give an albuterol nebulizer treatment than it is to track down a clean spacer and educate a patient on how to use it.

UItimately, the nebulizer epidemic is part of a larger problem in medicine: physicians are slow to change their practice to accommodate new evidence-based findings. Debate exists as to how long it takes for evidence-based research to percolate into widespread physician behavior changes, but estimates around 10-20 years are not hard to believe. Physician leaders have hypothesized the reasons behind this lag, including this NEJM editorial likening local physicians' practices as "where the [information] highway reaches its end and divides into a number of smaller avenues and lanes, and it is also where...concepts may get lost." One team of researchers theorize that just reading about new evidence is insufficient for physicians to place that information in the proper context when applicable patient situations arise; they advocate for more case-based learning in continuing medical education (CME).

Perhaps the first step for each of us is to just acknowledge that the lag exists; perhaps the next step is to think about how each of our "avenues and lanes" might systematically ensure that evidence-based changes become routine care faster. Perhaps we also must advocate for innovation in how CME is delivered.

How do you translate evidence-based changes into your daily practice?

Tuesday, July 15, 2014

Palliative care consists of more than pain control

- Kenny Lin, MD, MPH

In inpatient settings, family physicians frequently care for patients with progressive, incurable conditions that cause severe pain. Interventions aimed at slowing the progress of a disease often add to patients' physical distress; therefore, pharmacologic management of pain is a key component of end-of-life care, as outlined in an article in the July 1st issue of American Family Physician. However, as Drs. Timothy Daaleman and Margaret Helton discuss in an accompanying editorial, providing analgesia is only the starting point for effective palliative care:

Palliative care generally begins with diagnosis of a life-limiting disease and initiation of an ongoing conversation on the goals of care and treatment. This often begins in patient-centered medical homes, continues through acute hospitalizations, and may conclude in long-term care facilities. At each point, family physicians may be called on to provide primary palliative care and can expect to encounter nonpharmacologic challenges in managing pain.

Misconceptions about palliative care are common. For example, many believe that palliative care, like hospice care, cannot be offered to patients who are still pursuing "aggressive" treatments such as chemotherapy for cancer. On the contrary, one of the American Academy of Hospice and Palliative Medicine's Choosing Wisely recommendations states, "Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment." Palliative care does not necessarily increase patient comfort at the cost of shortening life; in a randomized trial of patients with metastatic non-small-cell lung cancer, patients assigned to early palliative care not only experienced better quality of life and fewer symptoms of depression than patients receiving standard care, they actually lived more than two months longer.

The recent announcement by a large health insurance company in the Pacific Northwest that it will prioritize palliative care by training physicians and caregivers about having appropriate end-of-life conversations; and pay for previously unreimbursed home health services and counseling about advanced directive planning suggests that policymakers are finally recognizing the value of improving the availability of palliative care to appropriate patients. What have been your experiences with connecting patients or loved ones to palliative care services?

Monday, July 7, 2014

Behavioral interventions to help motion sickness

- Jennifer Middleton, MD, MPH

When my father tells the story of his parents' second honeymoon, which was a cruise, he relates how my grandmother had a delightful time sailing the seas while my grandfather sat in the cabin feeling irritable and dizzy in between bouts of emesis. (This story inevitably seemed to come up right after my sister had vomited in the car during a family road trip; a recent study estimated the prevalence of motion sickness in cars among children aged 7-12 at 43%.)

For as prevalent as motion sickness is, the recent AFP review article on this topic, Prevention and Treatment of Motion Sickness, reminds us that there is much we can do to help our patients overcome this discomfort. The article reminds us that prevention is the mainstay of treatment, and beyond the multiple pharmacologic options (nicely summarized in Table 3) the authors also point out important behavioral strategies (Table 2).

Two of the cited studies regarding behavioral interventions looked at how music and deep breathing may help. Denise et al investigated the use of controlled breathing as participants were upside-down, rightside-up again, and tilted to the side while watching an asynchronous 180 degree video screen; in all positions, controlled breathing lowered sickness ratings and prolonged participants' tolerance to movement.

In the second study, Sang et al had healthy participants listen "to music audiotape designed to reduce motion sickness symptoms," do breathing exercises, or neither (control group) while undergoing a lab simulation to evoke motion sickness symptoms. The participants began the music or deep breathing after the onset of mild motion sickness symptoms, and both interventions prolonged the development of moderate motion sickness symptoms for about ten minutes compared with placebo. Another just published study found that "pleasant music" reduced motion sickness symptoms overall to participants exposed to symptom-inducing stimuli. While it's unclear in this latter study who decided what "pleasant music" was, it's probably reasonable to extrapolate that "pleasant" is in the ear of the beholder.

Listening to music and controlled breathing exercises are simple, zero-risk interventions that would require only brief counseling in the office to recommend to patients, and they may complement the prescription therapies described in the article.

How do you discuss motion sickness prevention with your patients?