Transcript STRENGTH OF RECOMMENDATION A

Anthony Day, MD; James D. Hoehns, PharmD; Adam Roise, MD, MPH
NE IA Family Medicine Residency Program, Waterloo IA
Jauch Memorial Symposium
May 15, 2015

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
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
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
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%
31%
Salmeterol
Tiotropium
38%
Fluticasone
10
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
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%
28%
22%
He is more He is more His hospital All of the
likely to get likely to
stay is
above
C difficle receive a likely to be
quinolone longer
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.
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.
Genotype-guided dosing of warfarin is
associated with which of the following
outcomes?
32%
27%
Less major bleeding
Less thromboembolic
events
3. Greater time in
therapeutic range
4. None of the above
1.
2.
22%
Less major
bleeding
19%
Less
Greater time in
thromboembolic therapeutic range
events
None of the
above
10
PRACTICE CHANGER
Genotype guided vs.
clinical dosing of warfarin
 No benefit in:
Major bleeding

 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.
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
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: LeFevre, Michael, Annals of Internal Medicine Online-First, 26 August 2014.
A 55 yo man with diabetes presents for routine follow-up.
He is not fasting and due for an A1c, lipids, microalbumin,
and PPV.
How do you handle ordering labs?
34%
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
33%
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.
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
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.
A 70 yo women with well controlled hypertension has a
screening A1C of 7.2. She has no history of
hyperlipidemia or CAD.
Which medicine do you add?
32%
1.Spironolactone
24%
25%
19%
2.Statin
3.Clopidogrel
4.Thiazolidinedione
Spironolactone
Statin
Clopidogrel
Thiazolidinedione
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
Which of the following has demonstrated a
decrease in hospitalizations for heart failure in
patients with preserved ejection fraction (HFpEF)?
1.
2.
3.
Hydralazine/isosorbide
dinitrat
40%
32%
28%
Spironolactone
Prazosin
Hydralazine/isosorbide
dinitrat
Spironolactone
Prazosin
10
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

STRENGTH OF RECOMMENDATION
B: Based on one RCT
Spironolactone decreased
HF hospitalizations in
patients with HFpEF;
results difficult to
interpret
N Engl J Med 2014;370:1383-92.
What new class of LDL-lowering medications has
“early” data showing a reduction in cardiovascular
events when added to statins?
1.
2.
3.
Interleukin-1B
blockers
CETP inhibitors
PCSK9 inhibitors
35%
34%
31%
Interleukin-1B
blockers
CETP inhibitors
PCSK9 inhibitors
10
PRACTICE CHANGER

Evolocumab (PCSK9
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.
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%
25%
1. Clopidogrel
2. Simvastatin
19%
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.
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.
A 28 yo G2P1 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
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: LeFevre, Michael, Annals of Internal Med, Vol. 161, No. 11, 819-826.


No good evidence of ‘high risk’ status
RCTs used:
 Prior history of preeclampia
 Multifetal gestation
 Chronic hypertension
 Prior IUGR
 DM, kidney disease, advanced age
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: HendryS, et al. The Journal of Family Practice. 2015; 64 (4): 238-240.
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?
Vitamin E – the wonder drug and allnatural
2. An combination antioxidant supplement
3. A month of Bactrim DS
4. Clomid for 1 week prior to ‘timed’
intercourse
1.
10
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.
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
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.
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
36%
33%
31%
1. Savings can only be achieved 2. Savings can only be achieved 3. Savings are possible across
within large integrated medical
in high cost regions
settings even in year one
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: McWilliams, J Michael et al., NEJM, April 15, 2015 (online)
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?”
“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?”
1.
10
33%
23%
25%
19%
“Is there anything else “Is there something else “I look forward to seeing
you want to address in you want to address in
you at your next
the visit today?”
the visit today?”
appointment.”
“Stay out of trouble
now, ya hear?”
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.
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
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
people are studying it.
is considered harmless.
if you do that.
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.