1. Improved calculations suggest major changes to statin, aspirin, and blood pressure medication prescribing
Eleven million Americans, especially African Americans, may need to talk to their doctor about their prescriptions
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Researchers have developed an improved method for calculating risk for heart attack or stroke that challenges current prescribing methods for statins, aspirin, and blood pressure medications. According to the researchers, 11 million Americans may need to discuss taking different prescriptions with their doctor. For many, these medications are overprescribed, but for African Americans, older risk calculations from 2013 may underestimate their risk. Findings are published in Annals of Internal Medicine.
In 2013, researchers derived Pooled Cohort Equations (PCEs) to help physicians weigh patients' risk factors and decide whether to prescribe statins, aspirin, or blood pressure medications to prevent heart attack or stroke. While the PCEs were widely accepted, many users questioned whether the outdated data used to create the PCEs may put patients at risk for over- or under-treatment. According to the authors, one of the main datasets used to derive the original equations had information from people who were 30 to 62 years old in 1948, and who would therefore be 100 to 132 years old in 2018 -- or likely dead. The old data also underrepresented African Americans and physicians may have been estimating their risks as too low.
A team of researchers lead by Stanford University, created an updated set of calculations using modern cohorts and updated methodologies. Using their new calculations, the researchers found that 2013 PCEs overestimated 10-year risk for atherosclerotic cardiovascular disease by an average of 20 percent across risk groups, but for some Americans, particularly African-Americans, risk estimates were too low. This means that many patients may have been prescribed medications that they do not need, while others may have been given false reassurance.
2. Intensive management for sicker patients increases outpatient care but not costs
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Intensive management of patients at high-risk for hospitalization increases use of outpatient care but does not increase overall costs. While the costs associated with caring for these patients were not reduced, researchers found that the costs shifted from inpatient to outpatient services. Findings from the Department of Veterans Affairs study are published in Annals of Internal Medicine.
Primary care models that offer comprehensive, accessible care to all patients may not have sufficient resources to meet the needs of patients with complex chronic conditions, or the "sickest of the sick." These patients often need more intensive services, such as psychosocial care. To address their needs, many health systems are piloting intensive management models that include interdisciplinary teams, care coordination, and support for care transitions. It is believed that these interventions may reduce hospitalizations and emergency department visits if they are implemented early when patients are first identified as high-risk. However, it is not known whether augmenting primary care would actually lower utilization and costs for these high-risk patients.
Researchers from the VA medical centers in Palo Alto and Los Angeles, CA conducted a randomized, controlled, quality improvement trial to test the effectiveness and costs of intensive outpatient primary care targeted to patients at high risk for hospitalization. High-risk patients at five different VA sites were randomly assigned to intensive management or usual care. Intensive management teams provided services such as mental health, social work, home visits, and coordination of care with specialists. They also promoted use of other needed services such as geriatrics and palliative care. The researchers found that intensive management increased outpatient care usage, but did not increase costs. According to the authors, these findings suggest that intensive management shifted patients' care towards appropriate types of care.
Media contact: For an embargoed PDF, please contact Lauren Evans at firstname.lastname@example.org. To interview the lead author, Jean Yoon, PhD, MHS, please contact the VA Palo Alto public affairs office at Va.email@example.com.
3. Physicians debate osteoporosis treatment and monitoring for a patient who falls outside current guidelines
Annals 'Beyond the Guidelines' discussions are based on real Beth Israel Deaconess Medical Center Grand Rounds
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Current guidelines offer no consensus on how long patients with osteoporosis should be treated and whether bone density should be monitored during and after drug treatment. A primary care physician and an endocrinologist, both from Beth Israel Deaconess Medical Center (BIDMC), debate care for an osteoporotic patient in a multicomponent educational article being published in Annals of Internal Medicine.
Osteoporosis is a skeletal disorder characterized by compromised bone strength that increases risk for fracture. Current guidelines for treatment of osteoporosis agree that patients should be offered pharmacologic treatment with agents that have been shown to reduce hip and vertebral fractures. Guidelines disagree on how long patients with osteoporosis should be treated and what monitoring should be done, if any, during and after the treatment period. The American College of Physicians (ACP) recommends against bone density monitoring during treatment, as there is little evidence that monitoring improves outcomes. The American Association of Clinical Endocrinologists (AACE) recommends bone density monitoring during and after treatment to make sure bone density remains stable.
In a recent BIDMC Grand Rounds, two experts debated care for a 71-year-old woman with osteoporosis who had completed five years of treatment with alendronate. While both discussants agreed with the pharmaceutical course of treatment, they had differing ideas on monitoring and follow-up. Sarah Berry, MD, a primary care physician, agreed with the ACP guidelines and would not recommend monitoring bone mineral density during treatment. Harold Rosen, MD, an endocrinologist, agreed with the AACE guidelines and would monitor the patient's bone mineral density during her five years of treatment. If she seemed to be losing bone mass, he would offer a more potent treatment. Both Dr. Berry and Dr. Rosen agreed that the patient should have periodic monitoring after treatment and should take calcium and vitamin D supplements. Dr. Rosen said that he would reinstitute treatment, as well, if the patient developed convincing bone loss.
All 'Beyond the Guidelines' papers are based on the Department of Medicine Grand Rounds at BIDMC in Boston and include print, video, and educational components. A list of topics is available at http://www.annals.org/grandrounds.
Media contact: For an embargoed PDF, please contact Lauren Evans at firstname.lastname@example.org. To speak with someone regarding BIDMC Beyond the Guidelines, please contact Jennifer Kritz at email@example.com.
Also new in this issue:
Fulfilling the Promise of Unique Device Identifiers
Sanket S. Dhruva, MD, MHS; Joseph S. Ross, MD, MHS; Wade L. Schulz, MD, PhD; Harlan M. Krumholz, MD, SM
Ideas and Opinions
Annals of Internal Medicine