Category Archives: Medicine

Updated prostate cancer screening guidelines from Canada

Bell N, Gorber SC, Shane A, et al. Recommendations on screening for prostate cancer with the prostate-specific antigen test.CMAJ. 2014 Nov 4;186(16):1225-1234. Epub 2014 Oct 27. (Review) PMID: 25349003

Abstract

Prostate cancer is the most commonly diagnosed non–skin cancer in men and the third leading cause of cancer-related death among men in Canada. The current estimated lifetime risk of diagnosis is 14.3%, whereas the lifetime risk of death from prostate cancer is 3.6%. The prevalence of undiagnosed prostate cancer at autopsy is high and increases with age (> 40% among men aged 40–49 yr to > 70% among men aged 70–79 yr). Most cases of diagnosed prostate cancer have a good prognosis; the 10-year estimated relative survival ratio is now 95%, the highest among all cancers in men. In Canada, the age-standardized rate of death from prostate cancer rose from 1969 to 1991, followed by a decline of 37.5% from 1992 to 2009, at an average rate of 2.6% per year. In 1990, the estimated age-standardized mortality was 30 cases per 100 000, and in 2010 it was just below 20 per 100 000. However, over the same period, the number of cases and the age-standardized incidence of prostate cancer both increased. Subsequent to the introduction and adoption of prostate-specific antigen (PSA) testing, the incidence of prostate cancer increased rapidly from 1990 to a peak in 1993 and a second, less-pronounced peak in 2001. Much of the excess incidence represents overdiagnosis, that is, the detection of cancers that would not progress to cause symptoms or death. There is no conclusive evidence to determine what proportion of the decline in prostate cancer mortality is due to screening versus improved treatment, or other factors; it is likely that both screening and treatment have contributed. If PSA screening were the primary reason for the decrease in mortality, the steep increase in incidence due to early case detection associated with screening should have been followed by a sharp reduction in mortality. Instead, the reduction in prostate cancer mortality over time has been relatively steady and began too soon after the test’s introduction to be attributed mainly to PSA screening. This guideline provides recommendations on screening for prostate cancer using the PSA test with or without digital rectal examination in men in the general population. The guideline updates a prior guideline by the task force that was last published in 1994.11

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Walking your dog helps you both lose weight

Owners and Pets Exercising Together: Canine Response to Veterinarian-Prescribed Physical Activity

Authors: Byers, Christopher G.; Wilson, Cindy C.; Stephens, Mark B.; Goodie, Jeffrey L.; Netting, F. Ellen; Olsen, Cara H.

Abstract:

Using a prospective, randomized, single-blinded clinical design, we enrolled dog owners (DOs) and their dogs presenting to a veterinary referral hospital in a two-phase trial to determine whether veterinarian-initiated counseling increases physical activity and leads to secondary health benefits for DOs and their dogs. In Phase I, self-reported health measures, height, and weight were assessed for DOs. Body condition scores (BCS) for their dogs were also determined. Owners of overweight and obese dogs (BCS > 6) were recruited for Phase II in which a baseline serum biochemical profile was obtained for DOs and dogs. Participants were randomly assigned to either a physical activity (PA) or standard care (SC) group. All DOs were provided a pedometer to determine their baseline daily step count. The PA group was counseled by a veterinarian using a standard scripted handout to encourage increased physical activity with their dogs. The veterinarian also reviewed common barriers to activity, encouraged increased levels of physical activity, and delivered a specific exercise prescription for the dog. The stated goal was for the DO to spend at least 30 minutes a day engaged in physical activity with their dog. All owners and dogs returned in three months, and biochemical and anthropometric measurements were taken again. Seventy-five DOs completed Phase I. At the completion of Phase I, 46 DOs enrolled in Phase II. Of these, 32 completed all required elements. For all participants with complete Phase I and Phase II data, there was a significant reduction in mean BCS (6.7 to 6.4; t (31) = 2.88, p = 0.007). BCS and weight decreased similarly in both groups. Glucose increased over time in the SC group but not in the PA group, yielding a significant mean group difference at followup (113 mg/dL vs. 103 mg/dL; p = 0.01). Based on our findings, both groups increased physical activity and BCS decreased significantly, and veterinarian-based counseling may have impacted these changes. No other significant biochemical changes were noted.

Hospitalist discontinuity associated with higher cost

Does hospitalist discontinuity during an inpatient stay affect cost, readmissions, or patient satisfaction?

Bottom Line:

Hospitalist discontinuity may lead to an increase in total hospital costs. The authors of this study postulate that this could be due to additional testing or treatments or new clinical issues identified by hospitalist physicians when they take over care from their colleagues. (LOE = 2b-)

Reference

Turner J, Hansen L, Hinami K, et al. The impact of hospitalist discontinuity on hospital cost, readmissions, and patient satisfaction. J Gen Intern Med 2014;29(7):1004-1008.

Study Design: Cohort (retrospective) Funding: Other
Setting: Inpatient (any location) with outpatient follow-up Allocation: Uncertain

Synopsis

To assess for physician discontinuity during a hospitalization, these authors used 2 measures: (1) the Number of Physicians Index (NPI), which accounts for the total number of unique hospitalist physicians caring for a patient, and (2) the Usual Provider of Continuity Index (UPC), which calculates the largest number of patient encounters by a single hospitalist physician divided by the total number of encounters. A higher NPI and a lower UPC suggest greater discontinuity. All patients admitted to the hospitalist service during a 3.5-year period, except for those transferred from other services such as the intensive care unit, were included in the study. A physician was defined as caring for a patient if he or she wrote an admission note or progress note during the hospitalization. Nocturnists were not included in this calculation. Outcomes assessed in this study were total costs of hospitalization (excluding physician charges), 30-day readmissions, and patient satisfaction with physician communication using patients’ responses to three questions from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. A positive outcome for patient satisfaction was defined as top box responses to all three questions. The baseline cohort consisted of approximately 18,000 hospitalizations with a mean NPI of 1.9 and a mean UPC of 0.75. Median hospital cost was $6300 per hospitalization and the 30-day readmission rate was 22%. Only 8.5% of patients answered all 3 of the patient satisfaction questions and of these, 63% had top box responses for all 3 questions. After adjusting for covariates, including demographic variables, case mix, Diagnosis Related Group (DRG) weight, and length of stay, a 1-unit increase in NPI was associated with a 0.9% higher median cost (P < .001). Alternative models categorizing DRG weight and length of stay into quartiles also showed higher costs with a 1-unit increase in NPI (8% cost increase; P < .001) and with a 0.1-unit decrease in UPC (12.6% cost increase; P < .001). For the readmissions outcome, although a 0.1-unit decrease in UPC was associated with a small decrease in 30-day readmissions (odds ratio = 0.97; 95% CI, 0.95-0.99), the other 3 models did not corroborate this finding. No statistically significant correlation was found between hospitalist discontinuity and patient satisfaction; however, the study may have been underpowered to detect this given the low number of respondents to the patient satisfaction survey.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

Increase in hospitalist workload associated with higher LOS and cost

Does increased hospitalist workload affect efficiency and quality of care?

Bottom Line

Increased hospitalist workload is associated with increased cost and length of stay (LOS). Quality metrics such as 30-day readmission rate, in-hospital mortality, and patient satisfaction were not affected by changes in workload.(LOE = 2b)

Reference

Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med 2014;174(5):786-793. Deveraux PJ, Mrkobrada M, Sessler DI et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014;370:1504-1513.

Study Design: Cohort (retrospective)
Funding: Other
Setting: Inpatient (any location)
Allocation: Uncertain

Synopsis

Using data abstracted from the central data warehouse of an academic community health system, these authors examined the association between hospitalist workload and the efficiency and quality of care provided. A private hospitalist group that provided 24-hour care to patients at 2 hospitals within the system was selected for the study. Patients included were those who either had an attending of record or had admission and discharge bills submitted by a physician in this hospitalist group. Physician daily workload was measured using the total number of relative value units (RVUs) generated and the physician’s census as determined by the number of billable encounters submitted. Efficiency was measured by LOS and cost. Quality was measured by in-hospital mortality, rapid response team activation, 30-day readmission rate, and patient satisfaction. Models were adjusted for patient characteristics, including demographics; severity of illness; visit characteristics, including admission day of the week; and hospital-level characteristics, including hospital occupancy. Approximately 20,000 hospitalizations were included in the study. Hospitalists had a mean of 15.5 patient encounters and 28.6 RVUs per day. Results for LOS were stratified by hospital occupancy. For less than 75% occupancy, LOS increased linearly from 5.5 days to 7.5 days as workload increased. For greater than 85% occupancy, the change in LOS was J-shaped with a significant increase around an RVU of 30 or a census of 17. Cost also increased with higher workloads. For every unit increase in RVU, cost increased by $111; for every unit increase in census, cost increased by $205 (after adjustment for LOS). There were no significant associations with change in workload and patient satisfaction, in-hospital mortality, rapid response team activation, or 30-day readmission rate.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

Greater continuity of care associated with fewer preventable hospitalizations

Clinical Question

In the elderly Medicare population, does greater continuity of care lower the risk of preventable hospitalizations?

Bottom Line

Elderly patients who are treated by a smaller set of providers or by a single provider (ie, have greater continuity of care) may be less likely to have preventable hospitalizations. (LOE = 2b)

Reference

Nyweide DJ, Anthony DL, Bynum JP, et al. Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med 2013;173(20):1879-1885.

Study Design:  Cohort (retrospective)  Setting:  Outpatient

Funding: Government  Allocation: Concealed

Synopsis

Using Medicare data, these investigators identified preventable hospitalizations for Medicare fee-for-service beneficiaries older than 65 years using definitions previously provided by the Agency for Healthcare Research and Quality.Preventable hospitalizations were conditions that can potentially be treated with good outpatient care, such as asthma, chronic obstructive pulmonary disease, congestive heart failure, and bacterial pneumonia. Continuity of care was defined by 2 metrics: the continuity of care score and the usual provider continuity score. The continuity of care score measures physicians’ shares of a patient’s visits, with higher scores indicating a greater number of visits with fewer providers, whereas the usual provider continuity score measures the percentage of a patient’s total visits to a single provider. Both are scored on a scale from 0 to 1, with higher scores indicating greater continuity of care. Only data from patients with 4 or more visits during a course of a year were analyzed.Of approximately 3.2 million patients, 13% of this cohort had a preventable hospitalization over a 24-month observation period. These patients were more likely to have a higher illness burden at baseline and were more likely to have Medicaid dual eligibility. The top 2 reasons for preventable hospitalizations were congestive heart failure and bacterial pneumonia. As compared with those without preventable hospitalizations, patients with preventable hospitalizations had lower scores on both continuity metrics. After adjusting for patient characteristics, illness burden, and regional market-related and practice-related characteristics, a 0.1-unit increase in either continuity metric was associated with a 2% decrease in preventable hospitalizations.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

Secondary prevention of VTE: Are oral anticoagulant or antiplatelet drugs better?

Abstract
OBJECTIVE: To summarise and compare the efficacy and safety of various oral anticoagulants (dabigatran, rivaroxaban, apixaban, and vitamin K antagonists) and antiplatelet agents (acetylsalicylic acid) for the secondary prevention of venous thromboembolism.
DESIGN: Systematic review and network meta-analysis.
DATA SOURCES: Literature search using Medline (1950 to present), Embase (1980 to present), and the Cochrane Register of Controlled Trials using the OVID interface. Publications from potentially relevant journals were also searched by hand. REVIEW
METHODS: Randomised controlled trials of patients receiving anticoagulants, antiplatelet drugs, or placebo or observation for secondary prevention of venous thromboembolism. Selected outcomes were rates of recurrent venous thromboembolism and major bleeding. Two reviewers independently extracted data onto standardised forms.
RESULTS: 12 articles met our inclusion criteria, with 11 999 patients evaluated for efficacy and 12 167 for safety. All treatments reduced the risk of recurrent venous thromboembolism. Compared with placebo or observation, vitamin K antagonists at a standard adjusted dose (target international normalised ratio 2.0-3.0) showed the highest risk difference (odds ratio 0.07; 95% credible interval 0.03 to 0.15) and acetylsalicylic acid showed the lowest risk difference (0.65; 0.39 to 1.03). Risk of major bleeding was higher with a standard adjusted dose of vitamin K antagonists (5.24; 1.78 to 18.25) than with placebo or observation. Fatal recurrent venous thromboembolism and fatal bleeding were rare. Detailed subgroup and individual patient level data were not available.
CONCLUSIONS: All oral anticoagulants and antiplatelet agents investigated in this analysis were associated with a reduced recurrence of venous thromboembolism compared with placebo or observation, although acetylsalicylic acid was associated with the lowest risk reduction. Vitamin K antagonists given at a standard adjusted dose was associated with the greatest risk reduction in recurrent venous thromboembolism, but also the greatest risk of major bleeding.
Comments:
  • Most general practitioners know that newer drugs have lesser bleeding, but they do not know the smaller effect size of new anticoagulant drugs.
  • This review emphasizes something well know in clinical practice. It is important to have this meta-analysis but nothing new is learned.
Reference:
Castellucci LA, Cameron C, Le Gal G, et al. Efficacy and safety outcomes of oral anticoagulants and antiplatelet drugs in the secondary prevention of venous thromboembolism: systematic review and network meta-analysis. BMJ. 2013 Aug 30;347:f5133. doi: 10.1136/bmj.f5133. (Review) PMID: 23996149

Does adenotonsillectomy improve outcomes in children with obstructive sleep apnea?

Bottom Line

Early adenotonsillectomy and watchful waiting both options for children with sleep apnea.  Early surgery provides some symptomatic benefit and greater normalization of polysomnographic findings (a disease-oriented outcome) than watchful waiting for children with obstructive sleep apnea (OSA). However, many of the children in the watchful-waiting group improved during the study period, and there were no cognitive or behavioral consequences to watchful waiting. Thus, either approach is a reasonable option. (LOE = 1b)

Reference

Marcus CL, Moore RH, Rosen CL, et al, for the Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 2013;368(25):2366-2376.

  • Study Design: Randomized controlled trial (single-blinded)
  • Funding: Government
  • Setting: Outpatient (specialty)
  • Allocation: Concealed

Synopsis

More than half a million children in the United States still get their tonsils and adenoids removed each year, with the most common indication being OSA. This multicenter trial included children, aged 5 years to 9 years, with an apnea-hypopnea index (AHI) score of 2 or more events per hour or an obstructive apnea index (OAI) score of at least 1 event per hour. The authors excluded children who had severe OSA, characterized by an AHI score greater than 30 per hour, an OAI score greater than 20 per hour, or an O2 saturation of less than 90% for 2% or more of sleep time. Children with significant obesity (the top 0.13% of body mass index for age), those taking medications for attention-deficit/hyperactivity disorder (ADHD), and those with recurrent tonsillitis were also excluded. The authors recruited a total of 464 children — who were randomized to receive adenotonsillectomy within 4 weeks (early surgery group) or watchful waiting — and followed them up for 7 months. Sixteen children in each group did not receive the assigned treatment. There were 30 patients lost to follow-up or who withdrew from the early surgery group; 23 in the watchful waiting group. Groups were similar at the beginning of the study: approximately half the children were girls, slightly less than half were obese or overweight, and slightly more than half were black. The outcomes were mixed. The primary outcome of measures of attention and executive function by masked outcome assessors showed no significant difference between groups. Unmasked assessment of behavior by parents using the Connors’ scale for ADHD found greater improvement in the early surgery group, as did the parental assessment of executive function and behavior. Unmasked assessment of symptoms and quality of life showed slightly greater improvement in the early surgery group. Polysomnographic abnormalities improved more in the early surgery group (from 4.8 to 1.3 per hour in the early surgery group and from 4.5 to 2.9 in the watchful-waiting group). However, it’s important to note that these differences were small and did not meet the usual cutoff for a clinically important difference. In general, a “clinically important difference” requires a change of at least 10% to 15% on a rating scale, and the above improvements were closer to a 5% difference between groups on the scale.