News Release 

SGLT2 inhibitors may reduce the risk of gout in patients with type 2 diabetes

American College of Physicians

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. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

1. SGLT2 inhibitors may reduce the risk of gout in patients with type 2 diabetes

Abstract: http://annals.org/aim/article/doi/10.7326/M19-2610

URLs go live when the embargo lifts

Adults with type 2 diabetes newly prescribed a sodium-glucose cotransporter-2 (SGLT2) inhibitor had a lower rate of gout than those newly prescribed a glucagon-like peptide-1 (GLP1) agonist. Findings from a longitudinal study are published in Annals of Internal Medicine.

Hyperuricemia is common in patients with type 2 diabetes mellitus and is known to cause gout. Diet and exercise can prevent gout, but many patients require long-term pharmacologic therapy. Febuxostat and allopurinol may reduce the risk for gout, but a recent randomized trial found a higher risk for cardiovascular death and all-cause mortality in patients taking febuxostat. As such, it is important to identify other medications that help reduce the risk for gout. SGLT2 inhibitors prevent glucose reabsorption and slower serum uric acid levels, which suggests they could be effective.

Researchers from the Division of Pharmacoepidemiology and Pharmacoeconomics at the Brigham and Women's Hospital in Boston and Sinai Health in Toronto studied a U.S. nationwide commercial insurance database from March 2013 to December 2017 to compare the rate of gout between nearly 300,000 adults prescribed either an SGLT2 inhibitor or a GLP1 receptor agonist. They found that gout incidence rate was significantly lower among patients prescribed an SGLT2 inhibitor than those prescribed a GLP1 agonist. These finding suggest that SGLT2 inhibitors may reduce the risk for gout among adults with type 2 diabetes, although future studies are necessary to confirm this observation.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the lead author, Michael Fralick, MD, PhD, SM, please contact mike.fralick@mail.utoronto.ca.

2. Physicians spend about 16 minutes per patient encounter using electronic health records

Whether or not this is a good use of physician time was not studied

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3684

Editorial: http://annals.org/aim/article/doi/10.7326/M19-3921

URLs go live when the embargo lifts

Internal Medicine Physicians spend an average of about 16 minutes per patient encounter using electronic health records (EHRs), which constitutes a significant portion of their day. Researchers did not study whether or not this was a good use of physician time, but found variations in use within medical specialties suggests opportunities to optimize systems and processes. Findings from a descriptive study are published in Annals of Internal Medicine.

The amount of time that providers spend using EHRs to support the care delivery process is a concern for the U.S. health care system, not only for cost related to patient care but also because of physician burnout and job dissatisfaction. Some experts suggest that EHRs have turned physicians into data entry clerks and some argue that data entry criteria are too cumbersome. Research is needed to measure how much time physicians spend using EHRs.

Researchers from the Cerner Corporation, a health information technologies company, extracted data from software log files in the Lights On Network for approximately 100 million patient encounters among 155,000 U.S. physicians in 417 health systems for 1 year to describe how much time was spent on various EHR functions. The researchers found that physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33 percent), documentation (24 percent), and ordering (17 percent) functions accounting for most of the time. The distribution of time spent by providers using EHRs varied greatly within specialty, and the proportion of time spent on various clinically focused functions was similar across specialties. According to the researchers, the study documents the time physicians spend indirectly caring for their patients.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the lead author, J. Marc Overhage, MD, PhD, please contact him directly at overhage@gmail.com.

3. NIH panel says more research is needed to understand and address the factors that contribute to disparities in health care access and utilization

Multiple factors contribute to disparities in preventive health services; health system interventions in disadvantaged populations improve screening

Policy paper: http://annals.org/aim/article/doi/10.7326/M19-3171

Review: http://annals.org/aim/article/doi/10.7326/M19-3199

Editorial: http://annals.org/aim/article/doi/10.7326/M19-3899

URLs go live when the embargo lifts

An independent panel convened by the National Institutes of Health (NIH) Pathways to Prevention Workshop offers 26 recommendations for further research to achieve more equal use and access to 10 preventive health services recommended by the U.S. Preventive Services Task Force (USPSTF). The panel identified multiple factors, including insurance coverage, care access, and community, health system, and provider engagement as key to securing equal access to preventive services and thus reducing disparities. The policy paper and accompanying systematic evidence review are published in Annals of Internal Medicine.

Chronic diseases, such as heart disease, cancer, and diabetes are responsible for seven of every 10 deaths among Americans each year and account for 75 percent of the nation's health spending. Many of these chronic conditions can be prevented, delayed, or caught and treated early when patients work closely with their primary care providers. However, differences in the use of these services by racial and ethnic minority groups, rural residents, and individuals of lower socioeconomic status are significant and may contribute to disparities in disease burden and life expectancy.

Researchers from the Pacific Northwest Evidence-based Practice Center at the Oregon Health & Science University reviewed 120 published articles to evaluate the effects of barriers that create health disparities in the 10 preventive services and the effectiveness of interventions to reduce them. This work was funded by the NIH Office of Disease Prevention in collaboration with the Agency for Healthcare Research and Quality (AHRQ). The researchers found that patient navigation, telephone calls and prompts, and reminders involving lay health workers increased cancer screening. However, evidence was lacking to determine the effectiveness of interventions for other preventive services. The report also identified research gaps related to patient and provider barriers and the role of health information technology that should be addressed in the implementation of preventive services. The authors highlighted three cross-cutting themes to enhance future research: community engagement and systems approaches; integration of services and new delivery models; and the need for innovative methods, for example, pragmatic trials conducted in settings where at-risk populations are commonly treated.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the lead author of the policy paper, Timothy S. Carey, MD, MPH, please contact Lauretta Barrett at lauretta_barrett@med.unc.edu. To reach the lead author of the systematic review, Heidi D. Nelson MD, MPH, please contact Tracy Brawley at brawley@ohsu.edu.

4. Physicians entering large and hospital-owned practices at more than twice the rate as those exiting

Abstract: http://annals.org/aim/article/doi/10.7326/M19-2838

URLs go live when the embargo lifts

Physicians entering the Medicare program are more likely to work at large group or hospital-owned practices than small or independent practices, where the ratio of entering physicians is more than double that of exiting physicians. Findings from a brief research report are published in Annals of Internal Medicine.

Physicians increasingly work in large practices that are integrated into hospital systems. Although the role of mergers and acquisitions in driving this trend has received much attention, changes in practice composition may also play a role if older physicians are more likely to leave small practices and newer physicians are more likely to join larger ones.

Researchers from the University of Minnesota and Harvard Medical School analyzed Medicare carrier claims for a random 20 percent sample of beneficiaries from 2008 to 2017 to quantify how practice size and hospital ownership differ between physicians who entered versus exited the Medicare program. The researchers found that among 630,979 physicians, the share of physicians in the largest practices increased from 32.1 percent in 2009 to 48.8 percent in 2016. The share of physicians in hospital-owned practices increased from 18.8 percent to 25.8 percent. Compared with exiting physicians, entering physicians were more likely to practice in large group or hospital-owned practices versus small or independent practices and turnover rates were much higher at those large practices. In the largest and hospital-owned practices, entering physicians preplaced exiting physicians at ratios of 2.58:1 and 2.80:1, respectively. According to the researchers, these findings suggest that policymakers aiming to promote competition may consider payment policy that makes independent practice more appealing.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the lead author, Hannah T. Neprash, PhD, please email hneprash@umn.edu.

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Also new in this issue:

Tenofovir Alafenamide for HIV Preexposure Prophylaxis: What Can We DISCOVER About Its True Value?

Douglas S. Krakower, MD; Demetre C. Daskalakis, MD; Judith Feinberg, MD; and Julia L. Marcus, PhD

Ideas & Opinions

Abstract: http://annals.org/aim/article/doi/10.7326/M19-3337

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