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Archive for June, 2013

Primary Care Corner with Geoffrey Modest MD: Hepatitis C and HIV screening

28 Jun, 13 | by EBM

new recommendations from cdc (and adopted by US Prev Service Task Force) for hep c screening (see link: http://www.uspreventiveservicestaskforce.org/uspstf12/hepc/hepcfinalrs.htm for USPSTF recommendations and http://www.ncbi.nlm.nih.gov/books/NBK115423/ for the Agency for Health Care Research full paper). both formally released in past month or so.  basically,

–common (anti-HCV Ab in 1.6% of noninstitutionalized adults), 3/4 of HCV cases in people born between 1945-1965 and peak prevalence of 4.3% in those aged 40-49. Hep C is most common indication for liver transplant, 30% of cases. also, about 1/2 of the 3-fold increase in hepatocellular carcinoma over the past few decades attributable to hep c.

–benefits of early detection: no direct evidence that screening helps. but good data that treatment leads to improved clinical outcomes

–risk assessment: major risk factor is injection drug use, or pts with hemophilia (significant percutaneous exposure) in 60-90% of cases. less significant percutaneous exposure in 10-30% (eg hemodialysis, tattoos). also sexual exposure in 1-10% (data are pretty consistent across many studies i’ve seen of discordant couples that with <10 years exposure, about 4-8% get HCV, after 10 years it goes up some to the 10-15% range). blood transfusions, esp if before 1992, is a risk factor. also, maternal-child transmission

–evaluation: HCV Ab test is best. a prior large study i saw found that using ALT levels to screen was inadequate, since about 50% of HCV positive people would be missed. about 80% of people with HCV Ab have current infection (as determined by HCV viral load)

–treatment: standard interferon treatments work and when achieve sustained viral response dramatically decrease risk of hepatocellular cancer (by 75%) and developing advanced fibrosis/cirrhosis (by 75% also)

and… there are some really impressive treatment regimens on the horizon (and seem to be getting closer to being available generally), with dramatically improved response rates and several with interferon-free regimens.

— recommendation: 1-time sceening if born between 1945-1966. more often if indicated.

for HIV screening (see http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivsumm.htm for summary of HIV screening recommendations from USPSTF, http://www.ncbi.nlm.nih.gov/books/NBK114872/ for full report):

–high risk (men who have sex with men, injection drug use are highest risk; also people with multiple sex partners, esp with recurrent sexually transmitted infections)

–recommendation: all individuals aged 15-65 and at low risk should get a single screen. also anyone of any age with increased risk for infection and pregnant women (at each pregnancy).

–screening intervals. data not great on this. those at low risk, prob one screen sufficient. for those in high-prevalence setting (>1% seroprevalence, as in STD clinics, correctional facilities, homeless shelters, TB clinics, clinics serving MSM, and adolescent clinics with high prevalence HIV) — screen at least annually.  more frequently as risk is higher

–rationale: limited data suggest that universal testing finds HIV-positive people have higher CD4 counts than with targeted screening. still more than 1/2 of HIV patients present with CD4 <350 and 75% with CD4 <500.  implementing antiretroviral therapy is good for the patient (better clinical outcomes when start with higher CD4 count), and perhaps most importantly, dramatically decrease risk of HIV transmission to others

just a note of caution: we have found some HIV cases in seemingly very low-risk patients (eg, a man and wife in their 70s). the fact that one partner is low risk does not necessarily dictate that his/her partner is low-risk (ie, i think the one-time screen for low-risk is reasonable on a population basis, but we should always keep in mind the possibility of HIV even after a negative screen)

geoff

Primary Care Corner with Geoffrey Modest MD: Opioids, yet again

28 Jun, 13 | by EBM

new york times with article this past sunday on use of prescription opoids (see http://www.nytimes.com/2013/06/23/sunday-review/profiting-from-pain.html?nl=todaysheadlines&emc=edit_th_20130623&_r=0), focusing on an economic analysis but in a broader context. major points:

–in past 10 years, huge increase in use of opioids (sales increased 110% to $8.34B) and number of prescriptions increased 33%. oxycontin has increased 4-fold.  narcotic painkillers are the most widely prescribed class of meds in the US (i think it used to be statins)

–this huge increase, along with the potential for diversion etc, has led to dramatic collateral costs: medical, legal, and social.  Eg

–use of urine tox screens (increased from $800M in 2000 to $2B om 2013) – we have some patients in drug treatment programs getting tox screens 3+ times/week. rather exorbitant….., and medically unnecessary

–with the increase in accessibility of prescription opioids, there has been a dramatic increase in using expensive drugs to deal with the associated increase in addiction, esp bupreoprphine/naloxone (suboxone) and naltrexone.  at our health center, most of my suboxone patients have addictions to prescription narcotics. Suboxone is a really great drug for appropriate addicted patients and many of my patients have done fantastically on it, but its necessity (and high cost) are largely a result of the epidemic of prescription opioids,

–20 states apparently allow MDs to prescribe and sell drugs, noting eg that the price paid to physicians in illinois is about 3x that in the pharmacy; in connecticut the factor is 4x.

–hospitalizations have increased dramatically: with a 3-fold increase from 2004 to 2011 in ER costs for opioid-related issues (non-heroin); a 4x increase in overdose deaths from 1999 to 2010, to 16,651

–for legal issues: dramatic increase in states with (expensive) drug monitoring programs, from 16 in 2002 to 46 in 2012; explosion of “pain clinics”, basically pill  mills, leading to dozens of doctors being arrested and, eg in florida (one of the worst states) ultimately to closing down many of these clinics (from 921 to 441 in 2 years after a crackdown). –as many of you know, there was a cape cod “pain clinic” which closed and sent many patients to us, prescribing unbelievable quantities of opioids (one patient on oxycontin 80 tid plus oxycodone 30mg 1-2 tablets every 6 hours plus fentanyl patch).

— and the data are not so good that these drugs are effective in treating long-term pain.  unfortunately, many of the real pain clinics in boston, which had included a multi-disciplinary approach (psychologists, neurologists, anesthesiologists) have devolved into just giving injections (anesthesiology clinics), or just giving recommendations for primary care to give opioids, perhaps with adjuvants (tricyclics, gabapentin….). these patients typically need a very multi-disciplinary approach even when the use of opioids seems totally appropriate, though the accessibility to these services in the community is often poor

Pretty striking data. Opioid-seeking is by far the most difficult issue we discuss in our case conferences at the health center, and we do so regularly and repeatedly. opioid prescribing frequently sets up an antagonistic/distrustful relationship (providers being concerned about the true degree of pain/fear of diversion/etc — all very real issues in our community where diversion can lead to opioid deaths; patients who really feel they need opioids think the provider distrusts them and focuses all of their attention on getting these meds). these provider-patient relationships often are the antithesis of the therapeutic relationships we try to establish with our primary care patients.

geoff

Primary Care Corner with Geoffrey Modest MD: Evidence-based medicine and implantable defibrillators

28 Jun, 13 | by EBM

recent JAMA article which contrasts evidence-based medicine with “personalized” medicine (see evidencebased medicine jama 2013 doi below). basically contrasts EBM and its focus on randomized controlled trials with targeted therapies (not just genomics, but trying to contour therapy to the specific patient being treated).  one of the obvious problems with EBM is through the basic reductionism of medical studies: enrolling many patients who are x% male of x average age and x% white who have a specific disease but with specified inclusion and exclusion criteria and get a medication vs placebo. so, it is often a bit of a leap to apply the conclusion of the study to a young mostly healthy capeverdean woman (not part of the cohort of the study) or an older latino man with chronic kidney disease and lung cancer in remission (excluded by ethnicity and chronic diseases). and one of the issues is that guidelines are based on these studies and providers are evaluated/held accountable according to adherence to these guidelines, without clear evidence they really apply to the individual patient being treated. one other issue is that many of the RCTs end up having secondary/subgroup analyses done afterwards, which do give some insight into more specific and patient-based questions (more pesonalized), but these conclusions (correctly) are not considered to be statistically rigorous and are not generally incorporated into guidelines.  this JAMA article gives the example of the MADIT-II study, which when it came out created some consternation since it seemed to me that several of my patients should have an implantable defibrillator (ICD). in brief,

MADIT-II enrolled 1200 pts s/p MI and EF<30% into getting ICD vs placebo and found a 31% decreased mortality in those with ICDs.  however, a subsequent analysis (see cad madit2 risk stratification jacc 2008 doi below) did a detailed analysis of many variables to assess outcomes, boiling it down to 5 which were statistically associated with mortality (age>70, BUN>26, NYHA class >2, afib, and QRS>0.12). then they looked at the number of these risk factors and efficacy of ICDs.  they found:

–those at very high risk (5% of cohort, basically those with many of the above risk factors) had a 48% mortality over about 2 years, independent of whether they got an ICD

–those with no risk factors (1/3 of their group) also had no better results with ICD.

–but those with 1-2 risk factors had a 49% mortality benefit

–although there was low mortality and short followup of the low risk group, there are other studies (DINAMIT, IRIS) which do not show ICD benefit and (again) posthoc analysis shows most of the benefit occurs early on (eg in first 18 months, with no clear benefit after 1-2 years)

so, this type of posthoc analysis added huge clinical information about an expensive and risky intervention, though is not statistically rigorous and is not included in the current guidelines. but the design of the original trial concluded (and is incorporated into guidelines) that pts s/p MI and EF<30% should have ICDs. not so helpful to us in primary care. should we really refer all of these patients? what if they have significant renal failure (not included in MADIT-II study, and we know they have much higher mortality rates?) what if we decide not to treat either a very low or high risk patient in spite of the guidelines — what about the malpractice risk if there is an adverse event?  the ICD manufacturer was a major sponsor for the study – what is their role in designing the study to create the most favorable, generalizable conclusion (ie, not in their direct interest to have a very narrow, limited cohort of patients)?

geoff

cad madit2 risk stratification jacc 2008 – doi:10.1016/j.jacc.2007.08.058

evidencebased medicine jama 2013 – doi: 10.1001/jama.2013.6629

(search the doi to locate the article)

Primary Care Corner

28 Jun, 13 | by EBM

Allow me to introduce Dr. Geoffrey Modest, Professor of Clinical Medicine at Boston University and Clinical Instructor at Harvard Medical School.  He has taught many and practices at Upham’s Corner Health Center.  EBM is proud to have Dr. Modest to contribute to this blog, to be called PRIMARY CARE CORNER.  I’ll let him introduce himself here.

From Primary Care Corner, Geoffrey Modest, MD:

I am a primary care physician, trained in family medicine, who has been practicing for the past 30+ years in a neighborhood health center in an inner-city, underserved, multiethnic area of Boston. The health center has a multi-disciplinary approach to providing health care services, with an emphasis on social, psychological, and community-oriented care, as well as direct medical services.  During this time I have been involved in teaching medical residents from two of the major Boston teaching hospitals, both in the hospital and in our health center. About 3 years ago, I began sending emails (more than 500 to date) to the staff of our health center, many of the residents of these hospitals and physician staff there as well.  The goal of these emails was to provide a summary of what I considered to be important articles in primary care, with enough information to be useful in clinical practice and with a link to the full article, along with my own commentary.  I wanted to share these emails in a wider audience and so began this blog.  I will post a few of my more recent emails and all future ones to this blog.  Please let me know if you have suggestions/questions.

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