Download - Recent Papers that Shaped My Practice Alan Dow, MD, MSHA Virginia Commonwealth University
Recent Papers thatShaped My PracticeAlan Dow, MD, MSHAVirginia Commonwealth University
March 1st, 2013
Disclosures Employment
Virginia Commonwealth University and MCV Physicians
Grant funding Josiah H. Macy, Jr Foundation Donald W. Reynolds Foundation
Other compensation The Frontier Project and Critical
Communications Group
None of the above should have implications for my talk.
Question
For patients on dialysis, statin therapy decreases mortality by:
1. 0%2. 15%3. 33%4. 50%5. 75%
CKD & Statin vs control:
86 comparisons (51,099 pts)
CKD w/o dialysis: 48
comparisons (39,820 pts)
CKD w/ dialysis: 21
comparisons (7982 pts)
Renal transplant:
17 comparisons (3297 pts)
All-cause and cardiovascular mortality
Palmer SC et al. Ann Intern Med. 2012;157(4):263-275.
Palmer SC et al. Ann Intern Med. 2012;157(4):263-275.
Statin benefit:• ~20% for non-dialysis pts• No benefit for dialysis patients• Uncertain benefits for transplant patients
Statins and kidney disease Clear benefit prior to dialysis
After dialysis is initiated, the benefits no longer accrue
Unclear if the lack of benefit is due to the advanced state of existing disease or statin effects being muted by dialysis
Consider stopping statins in ESRD patients to decrease the risk of polypharmacy
Question
For pregnant women with periodontal disease, using antimicrobial mouthwash cuts the risk of preterm birth by:
1. 0%2. 10%3. 33%4. 50%5. 75%
226 pregnant women
• 6-20 weeks gestation • Periodontal disease• Refused mechanical dental care• Matched by smoking status, prior preterm birth (< 35 wks)
71 antimicrobial mouth
rinse155 control
• 5.6% preterm births
• Mean gest age = 38.4
weeks• Mean wt =
3100 g
• 21.9% preterm births• Mean gest
age = 36.8 weeks
• Mean wt = 2625 g
Jeffcoat M et al. Am J of OB and Gyn. 2011
p < 0.01 for all
comparisons
Tonetti MS et al. N Engl J Med. 2007.
Organizing Principles for a New Oral Health Initiative
1. Establish high-level accountability.2. Emphasize disease prevention and oral health promotion.3. Improve oral health literacy and cultural competence.4. Reduce oral health disparities.5. Explore new models for payment and delivery of care.6. Enhance the role of nondental health care professionals.7. Expand oral health research, and improve data collection.8. Promote collaboration among private and public stakeholders.9. Measure progress toward short-term and long-term goals andobjectives.10. Advance the goals and objectives of Healthy People 2020.
Advancing Oral Health in America. IOM. 2011
Periodontal Disease
Clear association with systemic disease; causality less certain
Antimicrobial mouth rinse may be a cheap, over-the-counter way to improve oral health and systemic disease
How do I screen for periodontal disease?
How do I treat and follow periodontal disease?
QuestionCompared to usual practice for partner
violence assessment, using a computerized program to screen and refer patients resulted in how great a decrease in partner violence?
1. No change2. 10% decrease3. 25% decrease4. 50% decrease5. 75% decrease
2708 women in primary
care settings
No resources;
no screening
Resource list; no
screening
Computerized screening
video/resource list
• 3 question Partner Violence Screen• + support video and resources
Quality of life, lost days of work and household activities, hospitalizations, ED visits, annual
incidence of partner violence
Klevens J et al. JAMA. 2012
Results at one year follow-up 9.9% of women experienced partner
violence in the preceding year 4.4% contacted a partner violence
resource No significant difference among groups for:
Partner violence incidence Partner violence resource use Quality of life Lost days of work or household activities Healthcare utilization
Klevens J et al. JAMA. 2012
Partner violence
High annual incidence
About 40% of women affected by partner violence seek help annually
The interventions in this study had little effect on outcomes related to partner violence
Question
A patient presents with recurrent C. diff. He has previously been treated with a course of PO vancomycin and is non-toxic. What is the next best step in treatment?1. Repeat course of PO vancomycin2. A course of PO fidaxomicin3. Duodenal infusion of donor feces4. PO and IV metronidazole
43 Patients with recurrent
C. Diff
• Failed 1 course of PO vancomycin or flagyl
13 pts: PO vancomycin
13 pts: PO vancomycin and bowel
lavage
17 pts: donor-feces infusion
Cure without relapse in 10 weeks
van Nood E et al. NEJM. 2013. 368:407-15.
Infusion protocol Donor stool screened for C. diff,
parasites, enteropathogenic bacteria Donor blood screened for HIV,
hepatitis, HTLV 1&2, CMV, EBV, syphilis, Strongyloides, & Entamoeba
Stool combined with saline and infused per tube into duodenum
Patients who had recurrence after infusion had a repeat infusion from a different donor
van Nood E et al. NEJM. 2013. 368:407-15.
Fidaxomicin and C. diff
629 pts withC. diff
Vancomycin 125 mg PO
every 6 hours
Fidaxomicin 200 mg PO every 12
hours
Cure and recurrence
Louie TJ et al. NEJM. 2011. 364(5):422-31.
Louie TJ et al. NEJM. 364(5):422-31.mITT: Modified Intention-to-TreatPP: Per protocol
Evolving C. diff Treatment Possible rank of C. diff therapies:Duodenal feces infusion >> fidaxomicin >
vancomycin >> metronidazole IDSA Guidelines update in progress Cost:
Fidaxomicin course: $2800 Vancomycin course: $1194.63 Metronidazole course: $25.99 Duodeneal feces infusion: ???
Evolving Appreciation of Gut Flora
Probiotics may have benefits for: C. diff prevention (Johnston BC et al. Annals Int Med.
2012) NASH (Wong VW et al. Ann Hepatol. 2013) Hepatic enchephalopathy prevention
(Agrawal A et al. Am J Gastroenterology. 2012) Candida colonization/candiduria in
critically kids (Kumar S et al. Crit Care Med. 2013) Postoperative infections (Zhang JW et al. Am J Med
Sci. 2012)
Question
In order to decrease hospitalizations in high-risk Medicare patients, care coordination programs should:1. Provide intense medication
management2. Focus on transitions of care3. Act as a communication hub for all
providers4. Educate patients about their
disease states5. Provide all of the above services or
the program will not be successful
CMS Care Coordination
Demonstration Projects: Decrease
utilization in high-risk Medicare patients
Four successful:8-33% decrease in
hospitalizations
11 unsuccessful:No change or
increasein hospitalizations
• Wash U in St. Louis (urban, academic)
• Mercy Medical Center (rural, intergated)
• Hospice of the Valley (Phoenix, hospice and home health)
• Health Quality Partners (non-profit, PCP adjunct in SE PA)Features of successful programs (3+ of 4; absent in
most or all of unsuccessful programs):• Care coordinator as communication hub• Face-to-face contact between patients and care
coordinators• Face-to-face contact between physicians and care
coordinators• Patient education• Medication management• Comprehensive transitions of care
Brown RS et al. Health Affairs. 2012. 31:1156-66.
Care Coordinat
orPatient
PCP
Hospitalist
Pharmacist
Implementing the model
What are the implications of the care coordination role for physicians?
How does the care coordinator get empowered to work across silos?
Will programs be funded by health systems or Medicare managed care programs?
Question
How many additional adults would need to be covered by Medicaid to prevent 1 death per year?
1. 142. 1763. 8984. 156,3585. Expanding Medicaid does not
reduce mortality.
Adjusted comparisons five years before and after Medicaid expansion of CDC mortality data
Sommers BD et al. NEJM. 2012;367:1025-1034
−25.4 deaths per 100,000 population (p=0.02)
A significant increase in Medicaid coverage (p=0.01)
Self-rated health significantly increased (p<0.01)
Sommers BD et al. NEJM. 2012;367:1025-1034
Puzzling findings
Deaths from both internal and external causes decreased
Non-Medicaid patients had increased insurance rates and access to care in expansion states as well
Medicaid expansion
Expanded insurance coverage is associated with decreased mortality. Causality uncertain
If a similar benefit is seen with PPACA expansion, about 170,000 lives will be saved annually.
Question
When Medicaid was expanded in Massachusetts in a fashion similar to the PPACA, which of the following was not observed?1. For the first 3 years, only administrative
positions were added to the healthcare workforce
2. The wait time for primary care almost doubled
3. Costs were as budgeted4. Patient satisfaction improved
Massachusetts Medicaid Expansion During the first three years, only
administrative positions were added to the healthcare workforce (Staiger, Auerbach, & Buerhaus. NEJM. 2011)
The wait time for new primary care visits doubled (Shorob & Bodenheimer. NEJM. 2012)
Costs were higher than budgeted (Steinbrook. NEJM. 2009)
Patient satisfaction was high (Long. Health Affairs. 2008)
Implications in Virginia
487,000 newly insured 407,000 from Medicaid expansion 80,000 from insurance exchanges
5.2% increase in state spending on Medicaid
31.4% increase in federal spending on Medicaid
How will we provide the healthcare workforce to care for these patients?
How will we adjust to cost pressures?
Holahan et al. Kaiser Family Foundation. November, 2012