Tuesday, March 31, 2015

Palliative care at the end and the beginning of life

- Kenny Lin, MD, MPH

A troubling study published earlier this year in the Annals of Internal Medicine reported that patients and their caregivers were more likely to report pain, depression, and periodic confusion during the last year of life in 2010 than in 1998. This worsening trend occurred despite increasingly frequent calls to improve end-of-life care communication and the interim publication of practice guidelines on palliative care for adults from the National Consensus Project for Quality Palliative Care and the American College of Physicians. Although the reasons for underutilization of palliative care are not entirely clear, persistent misconceptions about these services being the equivalent of "giving up" on patients or hastening their death likely play a role.

On the other end of the age spectrum, a Close-ups in the April 1st issue of American Family Physician highlighted the benefits of providing palliative care at the beginning of life: in this case, to a baby with trisomy 13 diagnosed by prenatal genetic testing. The devastated parents testified to the importance of their family physician providing support and guidance throughout the pregnancy and after their child's birth:

She helped us understand the decisions we had to make and helped us express our goals for the care of our unborn daughter. We wanted our daughter to have a comfortable life - for however long she lived - and a natural death. At the same time, we wanted as few medical interventions as possible to avoid unnecessarily prolonging her death or suffering.

Although less well-studied than palliative care in adults, critically ill neonates and infants who received palliative care consultations spent fewer days in intensive care units, received fewer blood draws and invasive interventions, and received more referrals to chaplains and social services than comparable patients with life-limiting diagnoses. Perinatal hospice programs take perinatal palliative care one step further and provide compassionate, multidisciplinary support for parents from the time of prenatal diagnosis through the remainder of pregnancy and their child's birth and death. Clinicians who provide maternity and/or newborn care and would like to learn more about perinatal hospice can consult the website perinatalhospice.org, which lists contact information for more than 200 programs across the United States and internationally.

Monday, March 23, 2015

Stop beta-blockers 30 days after acute MI?

- Jennifer Middleton, MD, MPH

Although prescribing a beta-blocker for patients with acute myocardial infarction (AMI) has been dogma for decades, a recent meta-analysis raises serious questions about the benefit - and harms - of continued use afterwards. The March 15 AFP reviews this study that found the benefits of beta-blockade may be limited to 30 days after AMI, and the harms may be greater than previously realized.

The authors of this large meta-analysis identified 60 studies that met their inclusion criteria (randomized controlled trials examining beta-blocker use in patients with AMI); they divided studies into pre-reperfusion-era ("early," before stents, thrombolytics, etc) and reperfusion-era ("modern era"). They found that, while in the early studies, beta-blockers conferred significant survival benefit (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94), in the modern era they did not (IRR 0.98; 95% CI, 0.92-1.05). In the modern era, beta-blockers did reduce angina and reinfarction rates, but only in the first 30 days, and they increased the rates of heart failure and cardiogenic shock. The authors hypothesized that reperfusion technologies are so effective nowadays that any added benefit from beta-blockers is minimal.

COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) was by far the largest study in the modern era group; published in 2005, it had 45,000+ participants and found that metoprolol did not reduce the risk of death, reinfarction, or cardiac arrest even in the first few days after AMI. The COMMIT authors did not seem to seek to change practice widely, however, stating only that "it might generally be prudent to consider starting β-blocker therapy in hospital only when the haemodynamic condition after MI has stabilised."

Beta-blocker use following AMI is a Joint Commission Core Measure, and hospitals receive performance incentives for demonstrating that patients admitted with AMI are discharged with a beta-blocker. The American College of Cardiology and the American Heart Association's (ACC/AHA) 2013 Guideline for the Management of ST-Elevation Myocardial Infarction also recommends beta-blocker use after AMI. (The AFP By Topic on Coronary Artery Disease/Coronary Heart Disease includes many additional resources if you'd like to read more.)

The COMMIT trial sought to explore appropriate beta-blocker use immediately after AMI; the Joint Commission and ACC/AHA, similarly, describe recommended practice immediately after AMI. While this new meta-analysis potentially raises questions about beta-blocker use immediately after AMI, the bigger issue is what happens 30 days after AMI, when the risk of harm and lack of benefit are clear. The greatest challenge for family physicians managing patients following up after an AMI admission may be the decision to stop a beta-blocker. Discontinuing therapies may be difficult for physicians; many physicians continue clopidogrel (Plavix) past its recommended 12 months following drug-eluting stent placement, and many patients with asthma remain on controller treatment regimens past the 3 month time when physicians and patients should investigate stepping down that regimen. Inertia can be difficult to overcome, especially when other colleagues and specialities follow other practices. 

Will this meta-analysis change how you care for patients when they follow-up after AMI?

Monday, March 16, 2015

Advise patients to steer clear of these six orthopedic procedures

- Kenny Lin, MD, MPH

After the American Academy of Orthopaedic Surgeons (AAOS) released its Choosing Wisely list, it was criticized for selecting items that are uncommonly used or have little effect on the income of its members. In an editorial in the New England Journal of Medicine, Dr. Nancy Morden and colleagues pointed out that the five services listed by this specialty group were particularly "low impact":

The American Academy of Orthopaedic Surgeons named use of an over-the-counter supplement [glucosamine and chondroitin] as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.

At the Lown Institute's recent "Road to Right Care" conference, a group of orthopedic surgeons identified five other low-value surgical procedures that, in contrast to the AAOS list, are frequently performed at great expense in the U.S. but provide little or no benefit to patients.

1) Vertebroplasty for spinal compression fractures - in two randomized controlled trials comparing vertebroplasty to a sham procedure, there were no differences in pain or quality of life between the intervention and control groups. Risks of vertebroplasty include causing compression fractures in adjacent vertebrae, dural tears, osteomyelitis, cement migration, and radiculopathies requiring subsequent surgery.

2) Rotator cuff repair for non-traumatic tears in older adults - A randomized trial comparing physical therapy, physical therapy plus acromioplasty, and physical therapy plus acromioplasty and rotator cuff repair found no differences between the control and surgery groups after one year. About 600,000 Americans undergo rotator cuff surgery every year.

3) Clavicle fracture plating in adolescents - In adolescents with clavicle fractures that were displaced and shortened, there were no differences between nonoperative management (a sling for the affected arm) and surgery in appearance, range of motion, or participation in sports activity two years after the injury. However, 1 in 4 adolescents who underwent surgery required re-operation for surgical complications.

4) Anterior cruciate ligament (ACL) reconstruction - In young, active adults with acute ACL tears, a randomized trial comparing early (within 10 weeks of the injury) ACL reconstructive surgery plus physical rehabilitation to rehabilitation plus optional delayed reconstruction up to 2 years after the injury found similar outcomes between the groups. 61 percent of the optional reconstruction group did not require surgery. More than 100,000 ACL reconstructions are performed in the U.S. each year.

5) Partial medial meniscectomy for adults with knee osteoarthritis and no mechanical symptoms - A randomized trial found no benefit of partial meniscectomy compared to sham surgery in adults with degenerative meniscal tears and no osteoarthritis. A systematic review of 7 trials came to the same conclusion. In adults with osteoarthritis, surgery plus physical therapy was not more effective than physical therapy alone. Arthroscopic partial meniscectomy is the most commonly performed orthopedic procedure in the U.S., with 700,000 operations annually.

Finally, a randomized trial just published in JAMA suggested that another procedure whose use is increasing worldwide provides no benefits.

6) Surgery for adults with displaced proximal humerus fractures - Patients who underwent fracture fixation or humeral head replacement within 3 weeks of sustaining a displaced fracture of the proximal humerus had no better outcomes than patients assigned to nonoperative management (sling immobilization) after 2 years.

What accounts for the continued popularity of ineffective orthopedic procedures? Excessive magnetic resonance imaging (MRI) plays a role; immediate MRI is rarely indicated for common musculoskeletal conditions, and may often provide deceptive or confusing results, such as identifying meniscal tears that are unlikely to be the cause of patients' chronic knee pain. Primary care clinicians' lack of comfort with the orthopedic examination may lead to unnecessary referrals. Patients who perceive surgery to be a "quick fix" may not have the patience to stick with physical therapy and rehabilitation. And there is the inescapable reality that, necessary or not, these procedures pay well.

Monday, March 9, 2015

Helping patients with neuropathic pain

- Jennifer Middleton, MD, MPH

Neuropathic pain can be difficult to treat, and a 2014 Cochrane systematic review brings the efficacy of one treatment option into question. The March 1 issue of AFP includes a "Cochrane for Clinicians" about this review that showed minimal benefit to patients with neuropathic pain from controlled-release oxycodone (Oxycontin or "oxycodone CR").

The Cochrane authors sought to include randomized controlled trials (RCTs) of oxycodone CR for any type of neuropathic pain and/or fibromyalgia. They found only three studies that met these criteria; the studies included patients with diabetic neuropathy and postherpetic neuralgia, but none investigated fibromyalgia. Each study compared oxycodone CR with a placebo (1 used benztropine as its placebo). The Cochrane authors concluded that:
No convincing, unbiased evidence suggests that oxycodone (as oxycodone CR) is of value in treating people with painful diabetic neuropathy or postherpetic neuralgia.
A meta-analysis published in The Lancet Neurology earlier this year studied this question more broadly; they sought to include all treatments for all types of neuropathic pain. The authors categorized "strong opiates" as "a weak recommendation for use and [proposed them] as third-line" treatment behind first-line options of tricyclic antidepressants (TCAs), serotonin-noradrenaline reuptake inhibitors (SNRIs), pregabalin, and gabapentin and second-line options of tramadol and topical capsaicin patches.

Although both of these reviews come to different conclusions, it is possible that both are accurate within their self-defined parameters. Perhaps other opiates are more effective for neuropathic pain than oxycodone CR, or perhaps opiates, in general, are more effective for other types of neuropathic pain besides diabetic neuropathy and postherpetic neuralgia. Both systematic reviews agree in placing the utility of opiates for neuropathic pain below that of other medication classes. Both reviews noted the high incidence of unpleasant side effects with opiate use.

I suspect that many family physicians, though, could relate stories of patients who have benefited from oxycodone CR or other opiates for intractable neuropathic pain. These two new pieces of evidence still allow for individual physician judgment and specific patient needs; "EBM [evidence-based medicine] integrates clinical experience and patient values with the best available research information." Most patients with neuropathic pain should start with one of the first- or second-line options above, but for some patients those options may not suffice. Oxycodone and other opiates for neuropathic pain remain an option for treating patients whose symptoms have inadequately responded to other modalities, but family physicians should remain cautious with their use given the risk of adverse events.

You can read more about treating neuropathy in the AFP By Topics on Pain: Chronic and Diabetes: Type 2.

How do you care for patients with neuropathic pain? Will these systematic reviews change your management?

Tuesday, March 3, 2015

ACC/AHA and Framingham calculators overestimate cardiovascular risk

- Kenny Lin, MD, MPH

After more than a decade of titrating medications to low density lipoprotein cholesterol targets, family physicians who have transitioned to the 2013 American College of Cardiology / American Heart Association cholesterol treatment guideline now base treatment decisions on a patient's estimated 10-year risk for a cardiovascular event. Although it endorsed the ACC/AHA guideline last year, the American Academy of Family Physicians expressed concern that the guideline's new risk calculator had not been validated in contemporary U.S. populations and could potentially overestimate risk compared to the venerable Framingham calculator.

An analysis published in the Annals of Internal Medicine compared predicted risk scores from the ACC/AHA calculator and four other cardiovascular risk calculators (three derived from the Framingham Heart study) to actual cardiovascular events observed in the Multi-Ethnic Study of Atherosclerosis (MESA), a diverse cohort of adults recruited from six U.S. communities in 2000 to 2002 and followed for ten years. The authors found that both the ACC/AHA and Framingham-derived risk calculators overestimated cardiovascular risk by 37 to 154 percent in men and 8 to 67 percent in women. The Reynolds Risk Score, which includes a measurement of high-sensitivity C-reactive protein, was the most accurate at predicting cardiovascular risk in the MESA cohort, underestimating events by 3 percent overall.

A previous AFP editorial criticized the ACC/AHA guideline for recommending a statin for primary prevention in patients with 7.5 percent 10-year cardiovascular risk, noting that personal estimates of potential benefits of statin therapy relied on a calculator with a "nontrivial margin of error." Nontrivial, indeed. The Annals analysis found that men in the MESA cohort with a calculated ACC/AHA risk score of 7.5 to 10 percent had an actual event rate of only 3 percent; and just over 5 percent of women with a similar risk score experienced cardiovascular events.

Although statins appear to reduce the risk of future cardiovascular events by the same relative proportions in high-risk and low-risk populations, lower-risk patients will experience lower absolute benefits that may not be outweighed by the inconvenience, expense, and potential side effects of therapy. Compounding this problem, a recent systematic review found that most patients already overestimate treatment benefits and underestimate harms. This new analysis won't lead me to abandon cardiovascular risk calculators, but going forward (or until better ones are developed) I plan to acknowledge their lack of precision in discussions with patients, especially those on the lower end of the range of risk where statins are recommended.