Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.
1. New guidelines: No need to reduce red or processed meat consumption
A rigorous series of reviews of the evidence found little to no health benefits for reducing red or processed meat consumption.
Note: HD video soundbites of the authors discussing the paper are available to download at http://www.dssimon.com/MM/ACP-red-meat.
URLs go live when the embargo lifts
Based on a series of 5 high-quality systematic reviews of the relationship between meat consumption and health, a panel of experts recommends that most people can continue to consume red meat and processed meat at their average current consumption levels. Current estimates suggest that adults in North America and Europe consume red meat and processed meat about 3 to 4 times per week. The evidence reviews and recommendations are published in Annals of Internal Medicine.
Researchers from Dalhousie University and McMaster University in Canada, together with the Spanish (Iberoamerican) and Polish Cochrane Centers, performed four parallel systematic reviews that focused both on randomized controlled trials and observational studies addressing the possible impact of red meat and processed meat consumption on cardiometabolic and cancer outcomes. A fifth systematic review addressed people's health-related values and preferences on meat consumption. Based on those reviews, a panel comprised of fourteen members from seven countries voted on recommendations for red and processed meat consumption. Their conclusion that most adults should continue to eat their current levels of red and processed meat intake, is contrary to almost all other guidelines that exist.
Among 12 randomized trials enrolling about 54,000 individuals, the researchers did not find statistically significant or an important association between meat consumption and the risk of heart disease, diabetes, or cancer. Amongst cohort studies following millions of participants, the researchers did find a very small reduction in risk amongst those who consumed three fewer servings of red or processed meat per week. However, the association was very uncertain.
In addition to studying health effects, the authors also looked at people's attitudes and health-related values surrounding eating red and processed meat. They found that people ate meat because they liked it or perceived it as healthy and would be reluctant to change their habits. The authors say they did not consider ethical or environmental reasons for abstaining from meat in their recommendations, however, these are valid and important concerns, though concerns that do not bear on individual health.
The researchers used the Nutritional Recommendations (NutriRECS) guideline development process, which includes rigorous systematic review methodology, and GRADE methods to rate the certainty of evidence for each outcome and to move from evidence to dietary recommendations to develop their guidelines. According to the authors, this is important because dietary guideline recommendations require close consideration of the certainty in the evidence, the magnitude of the potential harms and benefits, and explicit consideration of people's values and preferences. Most nutritional recommendations are based on unreliable observational studies. However, the authors note that their recommendations are weak, based on low-certainty evidence. Of note, there may be reasons other than health concerns for reducing meat consumption.
The authors of an accompanying editorial from Indiana University School of Medicine say that while the new recommendations are bound to be controversial, they are based on the most comprehensive reviews of the evidence to date. Those that seek to dispute the NutriRECS findings will be hard-pressed finding appropriate evidence with which to build an argument.
Notes and media contacts: The meat recommendations include 5 reviews, a recommendation, and an editorial. For embargoed PDFs please contact Lauren Evans at firstname.lastname@example.org. To speak with the lead author of the recommendations, Bradley Johnston, PhD, please contact him directly at BJohnston@dal.ca. To reach Aaron Carroll, MD, MS, author of the accompanying editorial, please contact Christine Drury at email@example.com.
2. Big box pharmacies offer lowest cash prices for generic drugs
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Compared with large chains, independent pharmacies and small chains had the highest cash prices for generic drugs and big-box pharmacies the lowest. Cash prices for brand-name drugs were similar across all types of retail pharmacies. Findings from a national cross-sectional study are published in Annals of Internal Medicine.
Researchers from Brigham and Women's Hospital used data from GoodRx, an online tool for comparing drug prices, to compare cash prices for 10 generic and 6 brand-name drugs across different types of retail pharmacies within the same ZIP code. The researchers assessed cash prices for a 1-month supply of each drug purchased at big box, grocery-based, small chain, and independent pharmacies compared with a reference group of large chain pharmacies. Across 16,325 zip codes, 68,353 unique pharmacy stores contributed cash prices, showing substantial variation in drug prices by type of retail pharmacy. Independent pharmacies and small chains had the highest prices for generic drugs and big-box pharmacies had the lowest prices. Relative differences in cash prices for brand-name drugs were modest across types of retail pharmacies. The results did not account for price matching, coupons or other discount programs that may be available through individual pharmacies or drug manufactures.
The researchers say their study may be the largest study ever conducted on variation in prescription drug prices. Their findings suggest that online access to transparent, reliable drug prices that are specific to a patient's ZIP code may increase consumer choice and help mitigate the financial impact of certain drug prices and may be especially meaningful to the approximately 8 percent of Americans who do not have prescription drug coverage or those with high deductibles.
Notes and media contacts: For an embargoed PDF please contact Lauren Evans at firstname.lastname@example.org. To speak with the corresponding author, Jing Luo, MPH, please contact Elaine St. Peter at email@example.com. To speak with someone from GoodRx, please email firstname.lastname@example.org.
3. Unconscious bias against higher drug doses may cause physicians to prescribe lower-than-needed doses of some heart medications
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Physicians may be unconsciously biased against higher dosages, which may cause them to prescribe less medication than is needed. Findings from a brief research report are published in Annals of Internal Medicine.
Various drugs in the same class have different potencies and thus different recommended dosages. Current guidelines recommend specific dosages of beta-blockers and renin-angiotensin system inhibitors for patients with heart failure with reduced ejection fraction because patients who receive this treatment have fewer hospitalizations and live longer. However, many patients do not receive the recommended dosage. Recently published data show, that during an observation period of 12 months, <1 percent of patients were simultaneously treated with target doses of renin-angiotensin system inhibitors, beta-blockers and mineralocorticoid-receptor antagonists. Researchers wondered if this could be due to unconscious bias on the part of physicians.
Researchers from the Medical University of Vienna used an existing registry to examine data from 3,737 outpatients with heart failure with reduced ejection fraction to determine whether uptitration stopped when the dosage was further away from the recommended dosage for drugs with higher than those with lower recommended dosages. The authors found that for a large number of patients with chronic systolic heart failure, the uptitration of drugs stopped when the dosage was further away from the recommended dosage for drugs with higher versus those with lower recommended dosages. If these findings are confirmed by other studies, the authors propose supplementing milligram-based recommendations with guidelines based on relative dosages. The authors are convinced that this problem is not restricted to heart failure therapy, but affects a significant number of other diseases.
Notes and media contacts: For an embargoed PDF please contact Lauren Evans at email@example.com. To speak with the lead authors, Henrike Arfsten, MD or Martin Huelsmann, MD, please contact Mr. Man. Johannes Angerer at firstname.lastname@example.org.
4. CDC's STRIVE initiative aims to reduce health care-associated infections at the local level through national program
Special supplement to Annals of Internal Medicine
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A new supplement to Annals of Internal Medicine describes the Centers for Disease Control and Prevention's (CDC) States Targeting Reduction in Infections Via Engagement (STRIVE) initiative and some of its key results. STRIVE was developed in partnership with the Health Research & Education Trust and state, hospital, and academic institutions to improve infection prevention and control practices for hospitals in the United States that struggle with a disproportionately high burden of health care-associated infections (HAIs).
Assistance from external sources, such as local, state, and national groups, can help reduce HAI in low-performing hospitals, but such efforts are rarely connected or coordinated. The overall objective of STRIVE was to identify, partner with, and collaborate with hospitals struggling to reduce HAI by pairing national subject matter experts with state, regional, and local organizations to effect sustainable change. STRIVE educational and training components were implemented through webinars, Web-based infection prevention modules with site visits from national subject-matter experts; monthly coaching by state partners; and monthly learning action forums. Reductions in C difficile infection (CDI), CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection in participating hospitals were chosen as key targets and measures developed by the CDC were used to determine initiative success.
Notes and media contacts: The supplement includes 14 articles describing the initiative and key successes. For a PDF of any or all of the supplement articles, please contact Lauren Evans at email@example.com. To speak with the lead author of the summary article, Vineet Chopra, MD, MSc, please contact Kara Gavin at firstname.lastname@example.org.
Also new in this issue:
Fool Me Twice? The Reemergence of Rofecoxib and the Orphan Drug Act
Theodore T. Lee, JD; Daniel H. Solomon, MD, MPH; and Aaron S. Kesselheim, MD, JD, MPH
Ideas and Opinions
Cases in Precision Medicine: Should You Participate in a Study Involving Genomic Sequencing of Your Patients?
Paul S. Appelbaum, MD; Deborah F. Stiles, JD; and Wendy Chung, MD, PhD
In The Clinic: Asthma
Melissa B. King-Biggs, MD
In The Clinic
Annals of Internal Medicine