The Best of Primary Care Research from NAPCRG 2015
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Transcript of The Best of Primary Care Research from NAPCRG 2015
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TheBestofPrimaryCareResearchfromNAPCRG2015ThetopresearchstudiesthatwillimpactclinicalpracticeforfamilyphysiciansDavidM.KaplanMDMScCCFP
AssociateProfessorDepartmentofFamily&CommunityMedicineUniversityofTorontoProvincialPrimaryCareLead,HealthQualityOntario
DavidG.WhiteMDCCFPFCFP
Professor&InterimChairDepartmentofFamily&CommunityMedicineUniversityofTorontoPresident-Elect,CollegeofFamilyPhysiciansofCanada
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Tweetthetalk!
@davidkaplanmd@davidgordwhite#FMF2016#FMFpearls2016
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Disclosure– Dr.DavidKaplan
• Dr.KaplanisaBoardMemberofNAPCRGandistheChairoftheCommunityClinicianAdvisoryGroup
• Dr.KaplanistheProvincialPrimaryCareLeadatHealthQualityOntario,theprovincialadvisoryonhealthcarequality.
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Disclosure– Dr.DavidWhite
• Dr.Whitehasnothingtodisclose.
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www.napcrg.org/pearls
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Howarethe“Pearls”Picked?
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NAPCRG2015– Pearl1
PhysicalExerciseforLateLifeDepression:TailoredTreatmentsBetweenPsychiatryandPrimaryCare
Klea Bertakis,MD,MPH;MarioAmore;Fabrizio Asioli;LuigiBagnoli;MarcoMenchetti;MartinoMurri;MicroNeri;FrancescaNeviani;MatteoSiena;Guilio Toni;FerdinandoTripi;StamatulaZanetidou;DonatoZocchi
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TheResearchQuestion
Toexaminewhichpatient- andcontext-relatedfactorsimpacttheantidepressantefficacyofexerciseintherealclinicalworld,amongelderlypatientssufferingfrommajordepression
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WhattheResearchersDid• SEEDSstudycomparedtheantidepressantefficacyofsertralineplusphysicalexercise(24weeks,3timesperweek)vs.sertralinealone.
• Setting: consultationliaisonprogramforprimary care
• post-hocanalysis:identifiedfactorspredictedhigherchancesofremissionintheexperimentalgroup;contextualfactorsandPCPsopinionswerealsoexplored
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WhattheResearchersFound• Ideal candidate toreceive sertralineplusexercise:patientwhoisolderthan75,hasretainedagoodaerobicfitness,displayspsychomotorretardationbut notsevereanxiety
• Longstandingconsultationliaisonprogramisimportantfortherecruitmentandfollowupofpatients:PCPsexpressedveryfavorableviews re: addingexercise asanantidepressant
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WhatThisMeansforClinicalPractice
• Olderpatientswithmajordepressioncanbesafelyandeffectivelytreatedwithacombinationofstructuredphysicalexerciseandantidepressantdrugs.
• ThefeasibilityofthisinterventiondependsonthelevelofcollaborationbetweenPCPsandotherspecialists.Moreover,theeffectivenessagainstdepressionisparticularlyhighamongselectedpatients.
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NAPCRG2015– Pearl2
MissedOpportunitiesforPreventionofStrokeandTransientIschaemicAttack(TIA)inPrimaryCare
GraceMoran;MelanieCalvert;MaxFeltham;TomMarshall;RonanRyan
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TheResearchQuestion1. Calculatetheproportionofstrokes/TIAs with
priormissedopportunitiesforprevention2. Determineiftheproportionofmissed
opportunitieshaschangedovertime3. Investigatetheassociationwithpatientor
demographic characteristics
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WhattheResearchersDidRetrospectiveanalysisofanonymised,electronicUKprimarycarerecords
Population• First-stroke/TIA• ≥18years• 2009-2013
OutcomesAnticoagulant,
Antihypertensive orLipidLoweringdrugsNOT prescribedwhenclinicallyindicated
Analysis• %ofpatientswith
missedpreventionopportunities
• Logisticregression
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WhattheResearchersFound%Missedopportunities:• Anypreventiondrug:54%(9,579/17,680)– Anticoagulants:52% (1,647/3,194)– Lipidloweringdrugs:49% (7,836/16,028)– Antihypertensives: 25% (1,740/7,008)
Changeovertime(2009-2013)• Onlyanticoagulantdrugprescribingimproved
Predictivepatient/demographiccharacteristics• Differentprofileforeachdrug
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WhatThisMeans forClinical PracticePrimarystrokepreventionisinadequate
•Ageingpopulation•Guidelinechanges•Legalconsiderations
Barrierstoprescribing
Patient MD Organizational
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NAPCRG2015– Pearl3
PrescriptionOpioidDoseandDurationandRiskforDepressioninThreeLargeHealthcareCenterPatientPopulations
JeffreyScherrer,PhD;JoanneSalas,MPH;LaurelCopeland;BrianAhmedani;EileenStock;ThomasBurroughs,PhD,MA,MS;F.DavidSchneider,MD,MSPH;KathleenBucholz;MarkSullivan;PatrickLustman
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TheResearchQuestion
Doeslongerdurationofprescriptionopioiduseleadtonewonsetdepressionwhencontrollingformaximumdailydose,painandotherconfounders?
Doesmaximumdailydoseofprescriptionopioiduseleadtonewonsetdepressionwhencontrollingfordurationofuse,painandotherconfounders?
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WhattheResearchersDid• Retrospectivecohortdesign from:
– VeteransAdministration(VA),n=70,997– BaylorScott&White(BSW),n=13,777– HenryFordHealthSystem(HFHS),n=22,981
• VariablescreatedfromICD-9-CMcodes,pharmacyrecords,vitalsigns,labresultsetc.
• SeparateCoxmodelscomputedtoestimateassociationbetweenopioidduration,morphineequivalentdoseandnewdiagnosisofdepression
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WhattheResearchersFound
• Riskofnewonsetdepressionincreasedwithopioiddurationineachpatientsample.>90dayusewasassociatedwith35%to105%increasedriskofnewonsetdepressioncomparedto1-30 day use.
• Dosewasnotassociatedwithnewonsetdepression
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WhatThisMeans forClinical Practice
• Baseline depression screening insufficient, consider depression screening at each opioid refill
• Add depression to risk:benefit discussion• Short term euphoria but long term depression• Opioid taper if new onset depression in
chronic pain• Consider opioid, not just pain, as source of
depression
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NAPCRG2015– Pearl4
AdjunctiveScreeningforBreastCancerinWomenwithDenseBreasts:ASystematicReview
JoyMelnikow,MD,MPH;JoshuaFenton,MD,MPH;EvelynWhitlock,MD,MPH;DianaMiglioretti,PhD;JamieThompson,MPH;MeghanWeyrich,MPH
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TheResearchQuestion
Whatistheevidenceondiagnostictestperformanceandclinicaloutcomesofsupplementalscreening ofwomenwithdensebreastswithultrasound,MRI,ordigitalbreasttomosynthesis?
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WhattheResearchersDid
• Systematic reviewofthepublished,English-languagemedicalliteratureon:– Sensitivity,specificity,PPV,cancerdetectionratesrecallrates,andlongtermoutcomesofsupplementalscreening(afteranormalmammogram)withUS,MRIorDBTforwomenwithdensebreasts(BI-RADSc/ddensity)
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WhattheResearchersFound• Nostudiesofbreastcancermorbidityormortality• Hand-heldUS
• Sensitivity80-83%;specificity86-94%;PPV3-8%• Additionalcancerdetection4.4per1,000exams;recallrates14%(onestudy)
• MRI• Sensitivity75-100%;specificity78-89%;PPV3-33%.• Additionalcancerdetection4to29per1,000exams;recallrates12%-24%per1,000exams
• DBT• Additionalcancerdetection:Increasedbyabout1cancerper1000exams(4/1000to5/1000)
• Recallrates:7-11%withDBT+mammographyvs9-17%withmammographyalone
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WhatThisMeans forClinical Practice
• Noevidenceonwhethersupplementalscreeningreducesbreastcancermortalityormorbidity• Rigorousstudieswithlongtermfollow-upareneeded
• SupplementalUSandMRIincreasedcancerdetectionbuthadhighfalsepositiverates
• DBTmayreducerecallratesbutevidenceforwomenwithdensebreastsisverypreliminary
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WhatThisMeans forClinical Practice
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NAPCRG2015– Pearl5
TheEffectivenessofMaintenanceSSRITreatmentinPrimaryCareDepressiontoPreventRecurrence:MulticentreDoubleBlindedPlaceboControlledRCT.DeeMangin;ClaireDowson;RogerMulder;ElisabethWells;LesToop;TonyDowell;BruceArroll
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TheResearchQuestion
WhatistheeffectivenessofmaintenanceSSRItreatmentinpreventingdepressionrecurrenceinprimarycarepatients?
Whythisisimportant?– IncreasingSSRIprescriptionislargelydrivenbyuseofmaintenancetherapy;ThereisnoevidencefromRCTSformaintenancetreatmentinprimarycarepatients
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WhattheResearchersDid
• Multicentre,placebocontrolled,dbl blindedRCT• Intervention:continuationofmaintenanceSSRIvsdiscontinuation(tapertoplacebo)
• Population: primarycaretreatedpatientscurrentlytakingfluoxetineformaintenancetopreventrecurrence
• Primaryoutcome:occurrenceofmoderatelyseveredepressionover18months
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WhattheResearchersFound• Maintenancetreatmentpreventedadepressionepisodein12.8%(23.3%vs10.5%)p=0.005NNT(18mo)=8• 7/8patientsexperiencednobenefitover18months• 6%ofpatientshadtorestartbecauseofintolerablediscontinuationsymptoms,despitetaperingNNH=16
• Therewasnoharmintrialingdiscontinuation:nosuggestionofpooreroutcomesat18monthsinthetaperarm• (Patientrelevantmeasuresincludingmood,qualityoflife,overall
psychologicaldistress/symptoms,socialandoccupationfunctioning)
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WhatThisMeans forClinical Practice
• TheabsolutebenefitofSSRIsinpreventingdepressionrecurrenceinprimarycareismuchsmallerthanthatpreviouslyestimated
• Itseemsreasonabletodiscussthesedatawithpatientsonmaintenancetreatmentandofferadiscontinuationtrial topatients
• Thisprovidesgoodprimarycaredataforshareddecisionmakingwhenconsideringinitiationofmaintenancetreatment
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NAPCRG2015– Pearl6
TheFitFamilyChallenge:APrimaryCare-BasedPediatricObesityProgram
BonnieJortberg,PhD,RD,CDE;RaquelRosen;SarahRoth
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TheResearchQuestion
Canachildhoodobesitybehaviormodification programbeimplementedinprimarycarepractices?
Isiteffective?
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WhattheResearchersDid
Developedachildhoodobesitybehaviormodprogram,basedon“5-2-1-0”(perday)• 5+servingsoffruitsandvegetables;• 2orfewerhoursofscreentime;• 1hourormoreofphysicalactivity;• 0servingsofsugar-sweetenedbeverages
– “Shelf-ready”programwithcurriculumfor18groupvisits(availableinSpanish)
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WhattheResearchersDid
• Enrolled20primarycarepracticesinColorado:– Offered1-daytrainingandbi-annualLearningCollaboratives;on-goingtechnicalsupport
• 290childrenages6-12years+familymembersenrolled
• Collectedmonthlydatafor12-15monthsforBMI%ile & lifestylefactorsrelatedto5-2-1-0
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WhattheResearchersFound
• Baselineto9-15monthsofparticipation:– DecreaseinBMI%-tile(p<.04);BMIz-Scores(p<.02)
• LifestyleFactors:significantimprovementsfor– Dailyfruitandvegetableintake(p<.0001);daysofphysicalactivityof1hour+(p<.0001);familyactivity/week(p<.0001);dailyscreentime(p<.05);intakeofsugarsweetenedbeverages(p<.0003);#oftimeseatingouteachweek(p<.001)
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WhattheResearchersFound
• ChildrenfromSpanishspeakingfamiliesandchildrenfromfamiliesthatreportedatleastsomefoodinsecurity(vs.neverornoresponse)hadlessfollow-up(p<.02)
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WhatThisMeansforClinicalPractice
• Itisfeasible toimplementachildhoodobesitybehaviormodificationprograminprimarycarepractices,whichcanproduceclinicallymeaningfulimprovementsinBMI%-tileandlifestylefactors
• Familiesreportingfoodinsecurityissuesmaybelesslikelytofollow-upandstayengagedintheprogram.
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NAPCRG2015– Pearl7
NotasTransientastheNameSuggests:Fatigue,PsychologicalandCognitiveImpairmentFollowingTransientIschemicAttack(TIA)
GraceMoran;MelanieCalvert;MaxFeltham;TomMarshall;RonanRyan
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TheResearchQuestion
• TIAisdefinedbyshort-lastingsymptoms• Medicalmanagementfocusesonstrokeprevention
InvestigatetheassociationbetweenTIAandconsultations forfatigue,cognitive,orpsychologicalimpairmentinprimarycare
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WhattheResearchersDidDesign:Retrospectivecohortstudy
OutcomesPatientsDatasource
Electronicmedicalrecords
TIAConsultation
forimpairment
ControlsConsultation
forimpairment
Matched 1:5AgeSexGeneral practice
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WhattheResearchersFound
TIApatientsmorelikelytoconsultforall3impairments
AdjustedHazardratiosFatigue:1.43Psychologicalimpairment:1.26Cognitiveimpairment:1.46
TIA patients Controls
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WhatThisMeans forClinical Practice
• Challengesthe‘transient’definition ofTIA
• Currentmanagement ofTIAmaynotbeadequate
• Impactonqualityof life andstrokeprevention
• Futureresearch• Mechanism• Identificationofimpairments• Treatmentofimpairments
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NAPCRG2015– Pearl8
SterileVersusNon-SterileGlovesforMinorSurgeryinGeneralPractice
ClareHealandShampavi SriHaran
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TheResearchQuestion
Arenon-sterileglovesworsethansterileglovesforminorskinexcisions?
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WhattheResearchersDid
• Prospectiverandomisedcontrollednon-inferioritytrial
• SingleAustralianGeneralPractice
• 478participants
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WhattheResearchersFound
Infectionrates:• Sterilegloves9.3% (22/237)• Nonsterilegloves8.7% (21/241)• DifferenceinInfection-0.6%(95%CI-4.0to+2.9)
Infectionactuallylowerinthenon-sterileglovegroup!
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WhatThisMeansforClinicalPractice
• Theuseofnon-sterileglovesisNOTWORSEthansterilegloves intermsofinfectionratesinminorskinproceduresinaFP/GPsetting
• Cost-saving
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