Primary Care Medical Abstracts

Martinez, K.A., et al, Am J Prev Med 53(4):533, October 2017

The authors, from the Cleveland Clinic, explore the reasons for divergent responses to recent guideline recommendations against screening for breast cancer and prostate cancer. Both cancers are common (lifetime incidence of 12% and 16%, respectively), with indolent forms that are more prevalent with age. Screening with mammography and prostate-specific antigen (PSA) testing achieves earlier detection and relative risk reductions in cancer-specific mortality of 15% to 20%, but negligible effects on overall mortality and a risk of overtreatment that is estimated to be 30% to 80%. Benefits of screening and risks of overtreatment are unclear because of study limitations and evolution in diagnostic criteria, screening and management. Beginning in 2008, the US Preventive Services Task Force downgraded its recommendations for routine mammography (e.g., a rating of C for average-risk women aged 40-49) and for routine PSA testing (rating of D regardless of age). [EDITOR’S NOTE: USPSTF PSA screening recommendations have changed. See “USPSTF advises against widespread prostate cancer screening.”] While objections to the PSA rating were minimal, the public and professional backlash about mammography was profound. Reasons may include unique characteristics of breast (versus prostate) cancer, including mortality at a younger age, financial conflicts of interest (with mammography generating $8 billion per year in the US), bureaucratic incentives (e.g., quality measures, insurance reimbursement), and the influence of profit-generating advocacy groups. Many physicians do not understand the risks and harms of overtreatment or the inability of early detection to prevent metastasis, and patients want to be “better safe than sorry.” Rates of screening mammography may not decrease until truly informed decisions are possible, which will necessitate better algorithms to predict those cancers that are likely to spread.  20 references (martink12@ccf.org – no reprints)

Martinez, K.A., et al, Am J Prev Med 53(4):533, October 2017

The authors, from the Cleveland Clinic, explore the reasons for divergent responses to recent guideline recommendations against screening for breast cancer and prostate cancer. Both cancers are common (lifetime incidence of 12% and 16%, respectively), with indolent forms that are more prevalent with age. Screening with mammography and prostate-specific antigen (PSA) testing achieves earlier detection and relative risk reductions in cancer-specific mortality of 15% to 20%, but negligible effects on overall mortality and a risk of overtreatment that is estimated to be 30% to 80%. Benefits of screening and risks of overtreatment are unclear because of study limitations and evolution in diagnostic criteria, screening and management. Beginning in 2008, the US Preventive Services Task Force downgraded its recommendations for routine mammography (e.g., a rating of C for average-risk women aged 40-49) and for routine PSA testing (rating of D regardless of age). [EDITOR’S NOTE: USPSTF PSA screening recommendations have changed. See “USPSTF advises against widespread prostate cancer screening.”] While objections to the PSA rating were minimal, the public and professional backlash about mammography was profound. Reasons may include unique characteristics of breast (versus prostate) cancer, including mortality at a younger age, financial conflicts of interest (with mammography generating $8 billion per year in the US), bureaucratic incentives (e.g., quality measures, insurance reimbursement), and the influence of profit-generating advocacy groups. Many physicians do not understand the risks and harms of overtreatment or the inability of early detection to prevent metastasis, and patients want to be “better safe than sorry.” Rates of screening mammography may not decrease until truly informed decisions are possible, which will necessitate better algorithms to predict those cancers that are likely to spread.  20 references (martink12@ccf.org – no reprints)

Martinez, K.A., et al, Am J Prev Med 53(4):533, October 2017

The authors, from the Cleveland Clinic, explore the reasons for divergent responses to recent guideline recommendations against screening for breast cancer and prostate cancer. Both cancers are common (lifetime incidence of 12% and 16%, respectively), with indolent forms that are more prevalent with age. Screening with mammography and prostate-specific antigen (PSA) testing achieves earlier detection and relative risk reductions in cancer-specific mortality of 15% to 20%, but negligible effects on overall mortality and a risk of overtreatment that is estimated to be 30% to 80%. Benefits of screening and risks of overtreatment are unclear because of study limitations and evolution in diagnostic criteria, screening and management. Beginning in 2008, the US Preventive Services Task Force downgraded its recommendations for routine mammography (e.g., a rating of C for average-risk women aged 40-49) and for routine PSA testing (rating of D regardless of age). [EDITOR’S NOTE: USPSTF PSA screening recommendations have changed. See “USPSTF advises against widespread prostate cancer screening.”] While objections to the PSA rating were minimal, the public and professional backlash about mammography was profound. Reasons may include unique characteristics of breast (versus prostate) cancer, including mortality at a younger age, financial conflicts of interest (with mammography generating $8 billion per year in the US), bureaucratic incentives (e.g., quality measures, insurance reimbursement), and the influence of profit-generating advocacy groups. Many physicians do not understand the risks and harms of overtreatment or the inability of early detection to prevent metastasis, and patients want to be “better safe than sorry.” Rates of screening mammography may not decrease until truly informed decisions are possible, which will necessitate better algorithms to predict those cancers that are likely to spread.  20 references (martink12@ccf.org – no reprints)

Poole, R., et al, BMJ 359:J5024, November 22, 2017

BACKGROUND: Studies examining the benefits versus harms of coffee consumption have yielded conflicting results.

METHODS: The authors, from the United Kingdom, present an umbrella review of meta-analyses published up to 2017 to determine the associations between coffee consumption and any health outcome in adults.

RESULTS: This review includes 201 meta-analyses of observational studies with 67 health outcomes and 17 meta-analyses of randomized trials with 9 health outcomes according to coffee consumption defined as high versus low, any versus none, or per each extra cup per day. Coffee was associated with statistically significant protective effects against several diseases including type 2 diabetes, renal stones, Parkinson’s disease, Alzheimer’s disease, depression, leukemia, gout, colorectal cancer, liver cancer, chronic liver disease, cirrhosis, and endometrial cancer (odds ratios of 0.35-0.94). For some outcomes including all-cause mortality, cardiovascular mortality and cardiovascular disease, a nonlinear association was found whereby 3-4 cups per day (versus 0) conferred the greatest risk reduction (by 17%, 19% and 15%, respectively). High versus low consumption reduced the risk of incident cancers by 18%. Significant harms included lung cancer, urinary tract cancer, pregnancy loss, low birth weight, preterm birth, acute leukemia in childhood, and fracture risk in women (odds ratios of 1.03-1.57). Many of the harms were mitigated after adjustment for smoking, except the risks during pregnancy. This analysis of observational trials cannot prove causality.

CONCLUSIONS: Moderate levels of coffee consumption appear to be safe or even beneficial, except during pregnancy and in women at high fracture risk.  132 references (r.poole@soton.ac.uk – no reprints)

Poole, R., et al, BMJ 359:J5024, November 22, 2017

BACKGROUND: Studies examining the benefits versus harms of coffee consumption have yielded conflicting results.

METHODS: The authors, from the United Kingdom, present an umbrella review of meta-analyses published up to 2017 to determine the associations between coffee consumption and any health outcome in adults.

RESULTS: This review includes 201 meta-analyses of observational studies with 67 health outcomes and 17 meta-analyses of randomized trials with 9 health outcomes according to coffee consumption defined as high versus low, any versus none, or per each extra cup per day. Coffee was associated with statistically significant protective effects against several diseases including type 2 diabetes, renal stones, Parkinson’s disease, Alzheimer’s disease, depression, leukemia, gout, colorectal cancer, liver cancer, chronic liver disease, cirrhosis, and endometrial cancer (odds ratios of 0.35-0.94). For some outcomes including all-cause mortality, cardiovascular mortality and cardiovascular disease, a nonlinear association was found whereby 3-4 cups per day (versus 0) conferred the greatest risk reduction (by 17%, 19% and 15%, respectively). High versus low consumption reduced the risk of incident cancers by 18%. Significant harms included lung cancer, urinary tract cancer, pregnancy loss, low birth weight, preterm birth, acute leukemia in childhood, and fracture risk in women (odds ratios of 1.03-1.57). Many of the harms were mitigated after adjustment for smoking, except the risks during pregnancy. This analysis of observational trials cannot prove causality.

CONCLUSIONS: Moderate levels of coffee consumption appear to be safe or even beneficial, except during pregnancy and in women at high fracture risk.  132 references (r.poole@soton.ac.uk – no reprints)

Poole, R., et al, BMJ 359:J5024, November 22, 2017

BACKGROUND: Studies examining the benefits versus harms of coffee consumption have yielded conflicting results.

METHODS: The authors, from the United Kingdom, present an umbrella review of meta-analyses published up to 2017 to determine the associations between coffee consumption and any health outcome in adults.

RESULTS: This review includes 201 meta-analyses of observational studies with 67 health outcomes and 17 meta-analyses of randomized trials with 9 health outcomes according to coffee consumption defined as high versus low, any versus none, or per each extra cup per day. Coffee was associated with statistically significant protective effects against several diseases including type 2 diabetes, renal stones, Parkinson’s disease, Alzheimer’s disease, depression, leukemia, gout, colorectal cancer, liver cancer, chronic liver disease, cirrhosis, and endometrial cancer (odds ratios of 0.35-0.94). For some outcomes including all-cause mortality, cardiovascular mortality and cardiovascular disease, a nonlinear association was found whereby 3-4 cups per day (versus 0) conferred the greatest risk reduction (by 17%, 19% and 15%, respectively). High versus low consumption reduced the risk of incident cancers by 18%. Significant harms included lung cancer, urinary tract cancer, pregnancy loss, low birth weight, preterm birth, acute leukemia in childhood, and fracture risk in women (odds ratios of 1.03-1.57). Many of the harms were mitigated after adjustment for smoking, except the risks during pregnancy. This analysis of observational trials cannot prove causality.

CONCLUSIONS: Moderate levels of coffee consumption appear to be safe or even beneficial, except during pregnancy and in women at high fracture risk.  132 references (r.poole@soton.ac.uk – no reprints)

Murthy, S.K., et al, Endoscopy 49(12):1228, December 2017

BACKGROUND: Repeat colonoscopy is recommended ten years after a negative screening for colorectal cancer (CRC) in low-risk persons, but the real-world benefit of this recommendation is uncertain.

METHODS: These Canadian authors, coordinated at the University of Ottawa, performed a retrospective cohort study to determine the utility of ten-year repeat screening colonoscopy using population-level data from Ontario adults aged 50-74 years with a low to moderate risk of CRC (no relevant gastrointestinal disorders) who had a negative colonoscopy in 1996-2001 and a repeat negative screening within eight to twelve years, excluding those with intervening events (CRC detection, colectomy, or lower endoscopy). The primary outcome was early incident CRC in the group having repeat screening within twelve years compared with an unexposed control group matched by age, sex and year of baseline colonoscopy. 

RESULTS: A total of 13,350 matched pairs (median age 68 years; 56% female) were analyzed for CRC incidence over a median follow-up of 4.5 years.  The cumulative probability of CRC over three, five and eight years following a negative baseline colonoscopy was 0.16%, 0.30%, and 0.54%, respectively. Among patients having repeat colonoscopy, 46 developed CRC, compared with 52 in unexposed controls, for cumulative probabilities of 0.70% and 0.77%, respectively, and a hazard ratio of 0.91 (95% CI 0.68-1.22) after adjusting for competing risks and comorbidity burden. CRC-related mortality was also similar between groups (8 and 9 patients). Short follow-up was a study limitation. 

CONCLUSIONS: Repeat colonoscopy within eight to twelve years of a negative screen was not associated with subsequent CRC incidence, which raises questions about the utility of ten-year repeat screening.  21 references (smurthy@toh.on.ca – no reprints)
 

Murthy, S.K., et al, Endoscopy 49(12):1228, December 2017

BACKGROUND: Repeat colonoscopy is recommended ten years after a negative screening for colorectal cancer (CRC) in low-risk persons, but the real-world benefit of this recommendation is uncertain.

METHODS: These Canadian authors, coordinated at the University of Ottawa, performed a retrospective cohort study to determine the utility of ten-year repeat screening colonoscopy using population-level data from Ontario adults aged 50-74 years with a low to moderate risk of CRC (no relevant gastrointestinal disorders) who had a negative colonoscopy in 1996-2001 and a repeat negative screening within eight to twelve years, excluding those with intervening events (CRC detection, colectomy, or lower endoscopy). The primary outcome was early incident CRC in the group having repeat screening within twelve years compared with an unexposed control group matched by age, sex and year of baseline colonoscopy. 

RESULTS: A total of 13,350 matched pairs (median age 68 years; 56% female) were analyzed for CRC incidence over a median follow-up of 4.5 years.  The cumulative probability of CRC over three, five and eight years following a negative baseline colonoscopy was 0.16%, 0.30%, and 0.54%, respectively. Among patients having repeat colonoscopy, 46 developed CRC, compared with 52 in unexposed controls, for cumulative probabilities of 0.70% and 0.77%, respectively, and a hazard ratio of 0.91 (95% CI 0.68-1.22) after adjusting for competing risks and comorbidity burden. CRC-related mortality was also similar between groups (8 and 9 patients). Short follow-up was a study limitation. 

CONCLUSIONS: Repeat colonoscopy within eight to twelve years of a negative screen was not associated with subsequent CRC incidence, which raises questions about the utility of ten-year repeat screening.  21 references (smurthy@toh.on.ca – no reprints)
 

Murthy, S.K., et al, Endoscopy 49(12):1228, December 2017

BACKGROUND: Repeat colonoscopy is recommended ten years after a negative screening for colorectal cancer (CRC) in low-risk persons, but the real-world benefit of this recommendation is uncertain.

METHODS: These Canadian authors, coordinated at the University of Ottawa, performed a retrospective cohort study to determine the utility of ten-year repeat screening colonoscopy using population-level data from Ontario adults aged 50-74 years with a low to moderate risk of CRC (no relevant gastrointestinal disorders) who had a negative colonoscopy in 1996-2001 and a repeat negative screening within eight to twelve years, excluding those with intervening events (CRC detection, colectomy, or lower endoscopy). The primary outcome was early incident CRC in the group having repeat screening within twelve years compared with an unexposed control group matched by age, sex and year of baseline colonoscopy. 

RESULTS: A total of 13,350 matched pairs (median age 68 years; 56% female) were analyzed for CRC incidence over a median follow-up of 4.5 years.  The cumulative probability of CRC over three, five and eight years following a negative baseline colonoscopy was 0.16%, 0.30%, and 0.54%, respectively. Among patients having repeat colonoscopy, 46 developed CRC, compared with 52 in unexposed controls, for cumulative probabilities of 0.70% and 0.77%, respectively, and a hazard ratio of 0.91 (95% CI 0.68-1.22) after adjusting for competing risks and comorbidity burden. CRC-related mortality was also similar between groups (8 and 9 patients). Short follow-up was a study limitation. 

CONCLUSIONS: Repeat colonoscopy within eight to twelve years of a negative screen was not associated with subsequent CRC incidence, which raises questions about the utility of ten-year repeat screening.  21 references (smurthy@toh.on.ca – no reprints)
 

Hay, A.D., et al, JAMA 318(8):721, August 22, 2017

BACKGROUND: Although symptoms and underlying bronchial hyperresponsiveness are similar in asthma and acute lower respiratory tract infection, guidelines do not include recommendations, and evidence is scarce, regarding the use of corticosteroids for acute lower respiratory infections.

METHODS: In this multinational trial, 401 patients (mean age, 47.4 years) without a history of asthma who presented to primary care with suspected acute lower respiratory tract infection were randomized to a five-day course of oral prednisolone (40mg daily) or placebo. Study participants were followed for 28 days for the primary outcomes of the duration of moderately bad or worse cough, and mean symptom severity score on days two to four (score range 0 to 6, for the main symptoms of cough, phlegm production, shortness of breath, sleep disturbance, feeling unwell and activity disturbance).

RESULTS: In both groups, the median duration of moderately bad or worse cough was five days (hazard ratio 1.11, p=NS). On days two to four, the mean symptom severity score was 1.99 points in the prednisolone group vs. 2.16 points in placebo-treated controls (adjusted difference 0.20 point, p=0.05). Absence of a statistically significant difference between the groups persisted in sensitivity and subgroup analyses. Both groups were similar in terms of symptom duration, antibiotic use, patient satisfaction and the nature of adverse events (no serious adverse events occurred).

CONCLUSIONS: This study does not support the use of oral corticosteroids in primary care patients without asthma who present with acute lower respiratory tract infection. 35 references (alastair.hay@bristol.ac.uk – no reprints)

Hay, A.D., et al, JAMA 318(8):721, August 22, 2017

BACKGROUND: Although symptoms and underlying bronchial hyperresponsiveness are similar in asthma and acute lower respiratory tract infection, guidelines do not include recommendations, and evidence is scarce, regarding the use of corticosteroids for acute lower respiratory infections.

METHODS: In this multinational trial, 401 patients (mean age, 47.4 years) without a history of asthma who presented to primary care with suspected acute lower respiratory tract infection were randomized to a five-day course of oral prednisolone (40mg daily) or placebo. Study participants were followed for 28 days for the primary outcomes of the duration of moderately bad or worse cough, and mean symptom severity score on days two to four (score range 0 to 6, for the main symptoms of cough, phlegm production, shortness of breath, sleep disturbance, feeling unwell and activity disturbance).

RESULTS: In both groups, the median duration of moderately bad or worse cough was five days (hazard ratio 1.11, p=NS). On days two to four, the mean symptom severity score was 1.99 points in the prednisolone group vs. 2.16 points in placebo-treated controls (adjusted difference 0.20 point, p=0.05). Absence of a statistically significant difference between the groups persisted in sensitivity and subgroup analyses. Both groups were similar in terms of symptom duration, antibiotic use, patient satisfaction and the nature of adverse events (no serious adverse events occurred).

CONCLUSIONS: This study does not support the use of oral corticosteroids in primary care patients without asthma who present with acute lower respiratory tract infection. 35 references (alastair.hay@bristol.ac.uk – no reprints)

Hay, A.D., et al, JAMA 318(8):721, August 22, 2017

BACKGROUND: Although symptoms and underlying bronchial hyperresponsiveness are similar in asthma and acute lower respiratory tract infection, guidelines do not include recommendations, and evidence is scarce, regarding the use of corticosteroids for acute lower respiratory infections.

METHODS: In this multinational trial, 401 patients (mean age, 47.4 years) without a history of asthma who presented to primary care with suspected acute lower respiratory tract infection were randomized to a five-day course of oral prednisolone (40mg daily) or placebo. Study participants were followed for 28 days for the primary outcomes of the duration of moderately bad or worse cough, and mean symptom severity score on days two to four (score range 0 to 6, for the main symptoms of cough, phlegm production, shortness of breath, sleep disturbance, feeling unwell and activity disturbance).

RESULTS: In both groups, the median duration of moderately bad or worse cough was five days (hazard ratio 1.11, p=NS). On days two to four, the mean symptom severity score was 1.99 points in the prednisolone group vs. 2.16 points in placebo-treated controls (adjusted difference 0.20 point, p=0.05). Absence of a statistically significant difference between the groups persisted in sensitivity and subgroup analyses. Both groups were similar in terms of symptom duration, antibiotic use, patient satisfaction and the nature of adverse events (no serious adverse events occurred).

CONCLUSIONS: This study does not support the use of oral corticosteroids in primary care patients without asthma who present with acute lower respiratory tract infection. 35 references (alastair.hay@bristol.ac.uk – no reprints)

Berlowitz, D.R., et al, N Engl J Med 377(8):733, August 24, 2017

BACKGROUND: The Systolic Blood Pressure Intervention Trial (SPRINT) showed that a systolic blood pressure (SBP) target lower than 120 mm Hg (intensive treatment) led to lower rates of cardiovascular morbidity and mortality than a 140 mm Hg target (standard treatment). The impact of intensive treatment on patient-reported outcomes is unknown.

METHODS: This study coordinated at the Bedford (MA) Veterans Affairs Hospital assessed patient perceptions using data from SPRINT, a multicenter (n=102) trial of adults aged 50 or older with hypertension at baseline (SBP 130-180 mm Hg) and increased cardiovascular risk but without a history of diabetes or stroke who were randomized to intensive treatment (n=4678) or standard treatment (n=4683). Study endpoints were the Veterans RAND 12-Item Health Survey (Physical Component Summary score [PCS] and Mental Component Summary score [MCS] of 0-100, with higher scores indicating better health), Patient Health Questionnaire 9-item depression scale (PHQ-9, scored 0-27 with higher scores indicating worse depression), 5-point scale for patient satisfaction (from very satisfied to very dissatisfied), and 8-item scale for treatment adherence (with higher scores indicating better adherence).

RESULTS: SBP was 139.7 mm Hg at baseline, 121.4 mm Hg after intensive treatment, and 136.2 mm Hg after standard treatment. Baseline PCS was 44.6 and 44.8, respectively; MCS was 53.2 and 53.1; and PHQ-9 was 3.1 in both groups. Scores were stable and similar between groups throughout three years of follow-up, regardless of age and physical and cognitive function. Both groups were satisfied or very satisfied with their care (88% each), and adherence was similar (score of 8 in 44% each).

CONCLUSIONS: Patient-reported outcomes were similar with intensive versus standard SBP treatment among patients participating in SPRINT. 34 references (dan.berlowitz@va.gov for reprints)

Berlowitz, D.R., et al, N Engl J Med 377(8):733, August 24, 2017

BACKGROUND: The Systolic Blood Pressure Intervention Trial (SPRINT) showed that a systolic blood pressure (SBP) target lower than 120 mm Hg (intensive treatment) led to lower rates of cardiovascular morbidity and mortality than a 140 mm Hg target (standard treatment). The impact of intensive treatment on patient-reported outcomes is unknown.

METHODS: This study coordinated at the Bedford (MA) Veterans Affairs Hospital assessed patient perceptions using data from SPRINT, a multicenter (n=102) trial of adults aged 50 or older with hypertension at baseline (SBP 130-180 mm Hg) and increased cardiovascular risk but without a history of diabetes or stroke who were randomized to intensive treatment (n=4678) or standard treatment (n=4683). Study endpoints were the Veterans RAND 12-Item Health Survey (Physical Component Summary score [PCS] and Mental Component Summary score [MCS] of 0-100, with higher scores indicating better health), Patient Health Questionnaire 9-item depression scale (PHQ-9, scored 0-27 with higher scores indicating worse depression), 5-point scale for patient satisfaction (from very satisfied to very dissatisfied), and 8-item scale for treatment adherence (with higher scores indicating better adherence).

RESULTS: SBP was 139.7 mm Hg at baseline, 121.4 mm Hg after intensive treatment, and 136.2 mm Hg after standard treatment. Baseline PCS was 44.6 and 44.8, respectively; MCS was 53.2 and 53.1; and PHQ-9 was 3.1 in both groups. Scores were stable and similar between groups throughout three years of follow-up, regardless of age and physical and cognitive function. Both groups were satisfied or very satisfied with their care (88% each), and adherence was similar (score of 8 in 44% each).

CONCLUSIONS: Patient-reported outcomes were similar with intensive versus standard SBP treatment among patients participating in SPRINT. 34 references (dan.berlowitz@va.gov for reprints)

Berlowitz, D.R., et al, N Engl J Med 377(8):733, August 24, 2017

BACKGROUND: The Systolic Blood Pressure Intervention Trial (SPRINT) showed that a systolic blood pressure (SBP) target lower than 120 mm Hg (intensive treatment) led to lower rates of cardiovascular morbidity and mortality than a 140 mm Hg target (standard treatment). The impact of intensive treatment on patient-reported outcomes is unknown.

METHODS: This study coordinated at the Bedford (MA) Veterans Affairs Hospital assessed patient perceptions using data from SPRINT, a multicenter (n=102) trial of adults aged 50 or older with hypertension at baseline (SBP 130-180 mm Hg) and increased cardiovascular risk but without a history of diabetes or stroke who were randomized to intensive treatment (n=4678) or standard treatment (n=4683). Study endpoints were the Veterans RAND 12-Item Health Survey (Physical Component Summary score [PCS] and Mental Component Summary score [MCS] of 0-100, with higher scores indicating better health), Patient Health Questionnaire 9-item depression scale (PHQ-9, scored 0-27 with higher scores indicating worse depression), 5-point scale for patient satisfaction (from very satisfied to very dissatisfied), and 8-item scale for treatment adherence (with higher scores indicating better adherence).

RESULTS: SBP was 139.7 mm Hg at baseline, 121.4 mm Hg after intensive treatment, and 136.2 mm Hg after standard treatment. Baseline PCS was 44.6 and 44.8, respectively; MCS was 53.2 and 53.1; and PHQ-9 was 3.1 in both groups. Scores were stable and similar between groups throughout three years of follow-up, regardless of age and physical and cognitive function. Both groups were satisfied or very satisfied with their care (88% each), and adherence was similar (score of 8 in 44% each).

CONCLUSIONS: Patient-reported outcomes were similar with intensive versus standard SBP treatment among patients participating in SPRINT. 34 references (dan.berlowitz@va.gov for reprints)

Foy, A.J., et al, JAMA Intern Med 177(11):1623, November 1, 2017

BACKGROUND: Coronary computed tomography angiography (CCTA) is more accurate than functional stress testing for the diagnosis of coronary artery disease, but it is unclear whether this superiority leads to better clinical outcomes.

METHODS: The authors performed a systematic review and meta-analysis of 13 randomized, controlled trials that included 20,092 patients (mean age 58) and compared CCTA (n=10,315) with functional stress testing (n=9,777) in patients being evaluated for coronary artery disease. The primary endpoints included clinical outcomes and changes in therapy.

RESULTS: There was no difference between the groups in the overall mortality rate or the rate of cardiac hospitalization (2.7% in both groups). The CCTA group had a lower incidence of myocardial infarction (0.7% vs. 1.1% in the stress test group), and a higher incidence of revascularization (7.2 vs. 4.5), invasive coronary angiography (11.7% vs. 9.1%), and a new CAD diagnosis (18.3% vs. 8.3%). The CCTA group also had a higher rate of use of aspirin (21.6% vs. 8.2%) and statins (20.0% vs. 7.3%).

CONCLUSIONS: When compared with functional stress testing, CCTA appears to be associated with a decreased incidence of myocardial infarction in patients with chest pain, but an increased probability of revascularization, invasive angiography and medication change. However, rates of cardiac hospitalization and overall mortality were similar in patients evaluated with CCTA vs. functional stress testing. 23 references (afoy@pennstatehealth.psu.edu – no reprints)

Foy, A.J., et al, JAMA Intern Med 177(11):1623, November 1, 2017

BACKGROUND: Coronary computed tomography angiography (CCTA) is more accurate than functional stress testing for the diagnosis of coronary artery disease, but it is unclear whether this superiority leads to better clinical outcomes.

METHODS: The authors performed a systematic review and meta-analysis of 13 randomized, controlled trials that included 20,092 patients (mean age 58) and compared CCTA (n=10,315) with functional stress testing (n=9,777) in patients being evaluated for coronary artery disease. The primary endpoints included clinical outcomes and changes in therapy.

RESULTS: There was no difference between the groups in the overall mortality rate or the rate of cardiac hospitalization (2.7% in both groups). The CCTA group had a lower incidence of myocardial infarction (0.7% vs. 1.1% in the stress test group), and a higher incidence of revascularization (7.2 vs. 4.5), invasive coronary angiography (11.7% vs. 9.1%), and a new CAD diagnosis (18.3% vs. 8.3%). The CCTA group also had a higher rate of use of aspirin (21.6% vs. 8.2%) and statins (20.0% vs. 7.3%).

CONCLUSIONS: When compared with functional stress testing, CCTA appears to be associated with a decreased incidence of myocardial infarction in patients with chest pain, but an increased probability of revascularization, invasive angiography and medication change. However, rates of cardiac hospitalization and overall mortality were similar in patients evaluated with CCTA vs. functional stress testing. 23 references (afoy@pennstatehealth.psu.edu – no reprints)

Foy, A.J., et al, JAMA Intern Med 177(11):1623, November 1, 2017

BACKGROUND: Coronary computed tomography angiography (CCTA) is more accurate than functional stress testing for the diagnosis of coronary artery disease, but it is unclear whether this superiority leads to better clinical outcomes.

METHODS: The authors performed a systematic review and meta-analysis of 13 randomized, controlled trials that included 20,092 patients (mean age 58) and compared CCTA (n=10,315) with functional stress testing (n=9,777) in patients being evaluated for coronary artery disease. The primary endpoints included clinical outcomes and changes in therapy.

RESULTS: There was no difference between the groups in the overall mortality rate or the rate of cardiac hospitalization (2.7% in both groups). The CCTA group had a lower incidence of myocardial infarction (0.7% vs. 1.1% in the stress test group), and a higher incidence of revascularization (7.2 vs. 4.5), invasive coronary angiography (11.7% vs. 9.1%), and a new CAD diagnosis (18.3% vs. 8.3%). The CCTA group also had a higher rate of use of aspirin (21.6% vs. 8.2%) and statins (20.0% vs. 7.3%).

CONCLUSIONS: When compared with functional stress testing, CCTA appears to be associated with a decreased incidence of myocardial infarction in patients with chest pain, but an increased probability of revascularization, invasive angiography and medication change. However, rates of cardiac hospitalization and overall mortality were similar in patients evaluated with CCTA vs. functional stress testing. 23 references (afoy@pennstatehealth.psu.edu – no reprints)

Watkins, K.E., et al, JAMA Intern Med 177(10):1480, October 1, 2017

BACKGROUND: Collaborative care has been reported to be an effective strategy for the delivery of evidence-based treatments and improving patient outcomes, but its utility for substance abuse treatment in primary care has not been evaluated.

METHODS: The Substance Use Motivation and Medication Integrated Treatment (SUMMIT) study, coordinated at RAND Corporation, included 377 adults (mean age 42 years; 80% male) attending two community health clinics for opioid and alcohol use disorders. The study excluded patients with bipolar disorder, schizophrenia, or current substance abuse treatment. Study participants were randomized to collaborative care (n=187) or usual care (n=190). Patients were assessed for their use of evidence-based treatments (brief six-session psychotherapy treatment and treatment with buprenorphine/naloxone or naltrexone) and self-reported abstinence from opioids and alcohol at six months.

RESULTS: Only 13% of the patients had received any substance abuse treatment in the previous year. After six months, more patients in the collaborative care group than controls had received psychotherapy or medications (39.0% versus 16.8%; adjusted odds ratio [OR] 3.97, 95% CI 2.32-6.79; p<0.001); the difference was explained by a higher rate of psychotherapy (35.8% versus 10.5%; OR 6.22, 95% CI 3.4-11.5; p<0.001), while rates of medication use in the two groups were similar (13.4% versus 12.6%). Self-reported abstinence at six months was also more frequent with collaborative care (32.8% versus 22.3%; adjusted effect estimate, beta = 0.12; 95% CI 0.01-0.23; p=0.03). Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement increased significantly with collaborative care (both, p<0.001).

CONCLUSIONS: A collaborative care intervention increased treatment uptake and six-month abstinence in these primary care patients with opioid and alcohol abuse disorders. 69 references (kwatkins@rand.org – no reprints)

Watkins, K.E., et al, JAMA Intern Med 177(10):1480, October 1, 2017

BACKGROUND: Collaborative care has been reported to be an effective strategy for the delivery of evidence-based treatments and improving patient outcomes, but its utility for substance abuse treatment in primary care has not been evaluated.

METHODS: The Substance Use Motivation and Medication Integrated Treatment (SUMMIT) study, coordinated at RAND Corporation, included 377 adults (mean age 42 years; 80% male) attending two community health clinics for opioid and alcohol use disorders. The study excluded patients with bipolar disorder, schizophrenia, or current substance abuse treatment. Study participants were randomized to collaborative care (n=187) or usual care (n=190). Patients were assessed for their use of evidence-based treatments (brief six-session psychotherapy treatment and treatment with buprenorphine/naloxone or naltrexone) and self-reported abstinence from opioids and alcohol at six months.

RESULTS: Only 13% of the patients had received any substance abuse treatment in the previous year. After six months, more patients in the collaborative care group than controls had received psychotherapy or medications (39.0% versus 16.8%; adjusted odds ratio [OR] 3.97, 95% CI 2.32-6.79; p<0.001); the difference was explained by a higher rate of psychotherapy (35.8% versus 10.5%; OR 6.22, 95% CI 3.4-11.5; p<0.001), while rates of medication use in the two groups were similar (13.4% versus 12.6%). Self-reported abstinence at six months was also more frequent with collaborative care (32.8% versus 22.3%; adjusted effect estimate, beta = 0.12; 95% CI 0.01-0.23; p=0.03). Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement increased significantly with collaborative care (both, p<0.001).

CONCLUSIONS: A collaborative care intervention increased treatment uptake and six-month abstinence in these primary care patients with opioid and alcohol abuse disorders. 69 references (kwatkins@rand.org – no reprints)

Watkins, K.E., et al, JAMA Intern Med 177(10):1480, October 1, 2017

BACKGROUND: Collaborative care has been reported to be an effective strategy for the delivery of evidence-based treatments and improving patient outcomes, but its utility for substance abuse treatment in primary care has not been evaluated.

METHODS: The Substance Use Motivation and Medication Integrated Treatment (SUMMIT) study, coordinated at RAND Corporation, included 377 adults (mean age 42 years; 80% male) attending two community health clinics for opioid and alcohol use disorders. The study excluded patients with bipolar disorder, schizophrenia, or current substance abuse treatment. Study participants were randomized to collaborative care (n=187) or usual care (n=190). Patients were assessed for their use of evidence-based treatments (brief six-session psychotherapy treatment and treatment with buprenorphine/naloxone or naltrexone) and self-reported abstinence from opioids and alcohol at six months.

RESULTS: Only 13% of the patients had received any substance abuse treatment in the previous year. After six months, more patients in the collaborative care group than controls had received psychotherapy or medications (39.0% versus 16.8%; adjusted odds ratio [OR] 3.97, 95% CI 2.32-6.79; p<0.001); the difference was explained by a higher rate of psychotherapy (35.8% versus 10.5%; OR 6.22, 95% CI 3.4-11.5; p<0.001), while rates of medication use in the two groups were similar (13.4% versus 12.6%). Self-reported abstinence at six months was also more frequent with collaborative care (32.8% versus 22.3%; adjusted effect estimate, beta = 0.12; 95% CI 0.01-0.23; p=0.03). Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement increased significantly with collaborative care (both, p<0.001).

CONCLUSIONS: A collaborative care intervention increased treatment uptake and six-month abstinence in these primary care patients with opioid and alcohol abuse disorders. 69 references (kwatkins@rand.org – no reprints)

Roehr, B., BMJ 359:j4727, October 19, 2017

The author, a biomedical journalist from Washington, DC, explains how a zero-tolerance policy to opioid prescribing will impede the delivery of care for patients with severe pain. He notes that he has used hydrocodone daily for nearly ten years for nerve damage due to knee replacement and spinal surgeries, and suggests that reports of the opioid epidemic “crisis” represent overblown rhetoric from persons with an interest in promoting a “war on drugs” agenda. In fact, research shows that while 38% of the US population used a prescription opioid in 2015, few of whom were being treated for cancer, only 0.8% were classified as drug abusers. The author considers himself dependent on hydrocodone in the same way that he is dependent on his blood pressure medication, and states that hydrocodone allows him to remain relatively pain-free and productive but without adverse effects. The dramatic rise in opioid-related deaths is fueled in part by fentanyl and other illicit street drugs. In fact, he contends that CDC mortality data are methodologically flawed because deaths due to street drugs including heroin are combined with deaths due to prescription opioids, while in fact prescription drug deaths have been decreasing over the past few years. Efforts to control the opioid supply with prescribing limits, prosecution of “pill mills,” and tamper-resistant formulations were all in place before the recent increases in opioid-related deaths. The author disputes the concept of opioids as gateway drugs, stating that the gateway theory has long been disproven, yet he acknowledges that patients who lose access to prescription opioids may turn to more accessible, black-market options such as street drugs containing fentanyl. He concludes that denial of opioids to everyone because some are abusers will mean that many patients with legitimate need will suffer unnecessarily. 4 references (bobroehr@aol.com – no reprints)

Roehr, B., BMJ 359:j4727, October 19, 2017

The author, a biomedical journalist from Washington, DC, explains how a zero-tolerance policy to opioid prescribing will impede the delivery of care for patients with severe pain. He notes that he has used hydrocodone daily for nearly ten years for nerve damage due to knee replacement and spinal surgeries, and suggests that reports of the opioid epidemic “crisis” represent overblown rhetoric from persons with an interest in promoting a “war on drugs” agenda. In fact, research shows that while 38% of the US population used a prescription opioid in 2015, few of whom were being treated for cancer, only 0.8% were classified as drug abusers. The author considers himself dependent on hydrocodone in the same way that he is dependent on his blood pressure medication, and states that hydrocodone allows him to remain relatively pain-free and productive but without adverse effects. The dramatic rise in opioid-related deaths is fueled in part by fentanyl and other illicit street drugs. In fact, he contends that CDC mortality data are methodologically flawed because deaths due to street drugs including heroin are combined with deaths due to prescription opioids, while in fact prescription drug deaths have been decreasing over the past few years. Efforts to control the opioid supply with prescribing limits, prosecution of “pill mills,” and tamper-resistant formulations were all in place before the recent increases in opioid-related deaths. The author disputes the concept of opioids as gateway drugs, stating that the gateway theory has long been disproven, yet he acknowledges that patients who lose access to prescription opioids may turn to more accessible, black-market options such as street drugs containing fentanyl. He concludes that denial of opioids to everyone because some are abusers will mean that many patients with legitimate need will suffer unnecessarily. 4 references (bobroehr@aol.com – no reprints)

Roehr, B., BMJ 359:j4727, October 19, 2017

The author, a biomedical journalist from Washington, DC, explains how a zero-tolerance policy to opioid prescribing will impede the delivery of care for patients with severe pain. He notes that he has used hydrocodone daily for nearly ten years for nerve damage due to knee replacement and spinal surgeries, and suggests that reports of the opioid epidemic “crisis” represent overblown rhetoric from persons with an interest in promoting a “war on drugs” agenda. In fact, research shows that while 38% of the US population used a prescription opioid in 2015, few of whom were being treated for cancer, only 0.8% were classified as drug abusers. The author considers himself dependent on hydrocodone in the same way that he is dependent on his blood pressure medication, and states that hydrocodone allows him to remain relatively pain-free and productive but without adverse effects. The dramatic rise in opioid-related deaths is fueled in part by fentanyl and other illicit street drugs. In fact, he contends that CDC mortality data are methodologically flawed because deaths due to street drugs including heroin are combined with deaths due to prescription opioids, while in fact prescription drug deaths have been decreasing over the past few years. Efforts to control the opioid supply with prescribing limits, prosecution of “pill mills,” and tamper-resistant formulations were all in place before the recent increases in opioid-related deaths. The author disputes the concept of opioids as gateway drugs, stating that the gateway theory has long been disproven, yet he acknowledges that patients who lose access to prescription opioids may turn to more accessible, black-market options such as street drugs containing fentanyl. He concludes that denial of opioids to everyone because some are abusers will mean that many patients with legitimate need will suffer unnecessarily. 4 references (bobroehr@aol.com – no reprints)

Rothstein, M.A., Am J Publ Health 107(8):1253, August 2017

The author, from the University of Louisville School of Medicine, comments on the unintended consequences of restricting opioid prescribing. Causes and outcomes of the opioid addiction epidemic are well documented, including aggressive marketing by pharmaceutical companies without full disclosure of risk and a four-fold increase in US opioid-related deaths between 1999 and 2014 alone. Countermeasures include prescription drug monitoring programs to restrict use, legal limits on pill numbers per prescription, opioid patient “contracts,” and drug testing to ensure compliance. For fear of medicolegal risk, many physicians have decided to stop prescribing opioids for patients with chronic pain, limiting use to postoperative pain, cancer pain and terminal illness. In some cases, patients with severe pain turn to illicit drugs as the only alternative, leading to diseases such as HIV and hepatitis, as well as more overdose deaths. Eliminating opioids entirely as an option for chronic pain shows a lack of compassion and violates both standards of care and medical ethics. Many patients with severe pain due to chronic conditions legitimately need potent analgesics such as opioids, especially during acute episodes, because over-the-counter analgesics are completely ineffective. Patients who became addicted after using a lawful prescription also cannot be abandoned but need proper management. Stakeholders at all levels must address the undertreatment of pain with research, education and policy changes to acknowledge both the problem of opioid abuse and the needs of patients with chronic pain. After all, policies “should not presume that all physicians are reckless prescribers or that all patients are deceitful drug seekers.” 7 references (mark.rothstein@louisville.edu – no reprints)

Rothstein, M.A., Am J Publ Health 107(8):1253, August 2017

The author, from the University of Louisville School of Medicine, comments on the unintended consequences of restricting opioid prescribing. Causes and outcomes of the opioid addiction epidemic are well documented, including aggressive marketing by pharmaceutical companies without full disclosure of risk and a four-fold increase in US opioid-related deaths between 1999 and 2014 alone. Countermeasures include prescription drug monitoring programs to restrict use, legal limits on pill numbers per prescription, opioid patient “contracts,” and drug testing to ensure compliance. For fear of medicolegal risk, many physicians have decided to stop prescribing opioids for patients with chronic pain, limiting use to postoperative pain, cancer pain and terminal illness. In some cases, patients with severe pain turn to illicit drugs as the only alternative, leading to diseases such as HIV and hepatitis, as well as more overdose deaths. Eliminating opioids entirely as an option for chronic pain shows a lack of compassion and violates both standards of care and medical ethics. Many patients with severe pain due to chronic conditions legitimately need potent analgesics such as opioids, especially during acute episodes, because over-the-counter analgesics are completely ineffective. Patients who became addicted after using a lawful prescription also cannot be abandoned but need proper management. Stakeholders at all levels must address the undertreatment of pain with research, education and policy changes to acknowledge both the problem of opioid abuse and the needs of patients with chronic pain. After all, policies “should not presume that all physicians are reckless prescribers or that all patients are deceitful drug seekers.” 7 references (mark.rothstein@louisville.edu – no reprints)

Rothstein, M.A., Am J Publ Health 107(8):1253, August 2017

The author, from the University of Louisville School of Medicine, comments on the unintended consequences of restricting opioid prescribing. Causes and outcomes of the opioid addiction epidemic are well documented, including aggressive marketing by pharmaceutical companies without full disclosure of risk and a four-fold increase in US opioid-related deaths between 1999 and 2014 alone. Countermeasures include prescription drug monitoring programs to restrict use, legal limits on pill numbers per prescription, opioid patient “contracts,” and drug testing to ensure compliance. For fear of medicolegal risk, many physicians have decided to stop prescribing opioids for patients with chronic pain, limiting use to postoperative pain, cancer pain and terminal illness. In some cases, patients with severe pain turn to illicit drugs as the only alternative, leading to diseases such as HIV and hepatitis, as well as more overdose deaths. Eliminating opioids entirely as an option for chronic pain shows a lack of compassion and violates both standards of care and medical ethics. Many patients with severe pain due to chronic conditions legitimately need potent analgesics such as opioids, especially during acute episodes, because over-the-counter analgesics are completely ineffective. Patients who became addicted after using a lawful prescription also cannot be abandoned but need proper management. Stakeholders at all levels must address the undertreatment of pain with research, education and policy changes to acknowledge both the problem of opioid abuse and the needs of patients with chronic pain. After all, policies “should not presume that all physicians are reckless prescribers or that all patients are deceitful drug seekers.” 7 references (mark.rothstein@louisville.edu – no reprints)

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references (sacha.bhatia@wchospital.ca – no reprints)

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references (sacha.bhatia@wchospital.ca – no reprints)

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references (sacha.bhatia@wchospital.ca – no reprints)