News Release 

Glucocorticoids associated with increased risk for infection, even at low doses

Embargoed news from Annals of Internal Medicine

American College of Physicians

Research News

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. Glucocorticoids associated with increased risk for infection, even at low doses

Abstract: https://www.acpjournals.org/doi/10.7326/M20-1594

Editorial: https://www.acpjournals.org/doi/10.7326/M20-6010

URL goes live when the embargo lifts

Glucocorticoids are associated with an increased risk for infection, even at doses as low as 5 mg or less per day. These findings are significant, as low-dose glucocorticoids are generally considered safe and are widely prescribed. Physicians should consider this information when weighing the benefits and risks of glucocorticoid treatment for patients with RA. An observational cohort study is published in Annals of Internal Medicine.

Glucocorticoids are effective for the treatment of RA when added to disease-modifying antirheumatic drugs (DMARDs). The goal is short-term use, yet up to 60 percent of patients with RA remain on long-term glucocorticoids, especially at low doses. While the risk for infection at high doses is well-established, the risk with low-dose glucocorticoid therapy is less clear.

Researchers from the University of Pennsylvania used claims data to study more than 200,000 patients with RA who had been receiving stable DMARDs, including biologics, for the preceding 6 months and then compared them to patients not receiving glucocorticoids. The study population included an older, Medicare population and a younger, generally healthier, mostly commercially insured population. They found that patients receiving higher dose glucocorticoids (>10 mg/day) had more than twice the risk of serious infection as patients not receiving glucocorticoids, although few patients were on these doses. Even patients on the lowest dose had about a 30 percent increase in the risk of infection. According to the study authors, glucocorticoids may continue to be an important part of treatment for many patients, especially if other treatments are not fully controlling their RA, but these findings should help physicians better understand their potential risk.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, Michael George, MD, please contact Frank Otto at Frank.Otto@pennmedicine.upenn.edu.

2. National vaccination program virtually eliminates vaccine-targeted HPV in Bhutan

Abstract: https://www.acpjournals.org/doi/10.7326/M20-2849

Editorial: https://www.acpjournals.org/doi/10.7326/M20-6011

URL goes live when the embargo lifts

A national vaccination program significantly decreased the prevalence of vaccine-targeted HPV types in the south-central Asian country of Bhutan. These results provide the first evidence of the effectiveness of a high-coverage national HPV vaccination program in a lower middle-income country. Findings from a cross-sectional study are published in Annals of Internal Medicine.

Approximately 570,000 new cervical cancer cases occur every year worldwide mainly in low-middle-income countries where targeted vaccination against carcinogenic HPV types, the cause of cervical cancer, is still poorly adopted. Bhutan launched a national vaccination program against HPV infection (quadrivalent vaccine) in 2010. Reported initial coverage of both routine vaccination for 12-year-old girls and catch-up vaccination for 13 to 18-year-old girls was around 90 percent.

Researchers from the International Agency on Cancer Research and Ministry of Health of Bhutan assessed cervical cells for sexually active vaccinated and unvaccinated women aged 17 to 29 years at baseline (2011-2012) and again in 2018 to evaluate the impact of the vaccination program. In Thimphu, the capital of Bhutan, the prevalence of HPV types targeted by the vaccine in the vaccinated population was shown to decrease by 93 percent. In addition, the "herd" effect (vaccine-induced indirect protection) led to an 88 percent decrease in prevalence among unvaccinated women. According to the authors, this approach could be adopted by other low-middle-income countries, as it is relatively simple to implement within existing health-care systems and would be informative in countries where cancer registries are scarcely deployed.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, Iacopo Baussano, MD, please contact Véronique Terrasse at TerrasseV@iarc.fr.

3. Measures of physician panel size vary widely based on method used to assess

Abstract: https://www.acpjournals.org/doi/10.7326/M20-3091

URL goes live when the embargo lifts

A brief research report published in Annals of Internal Medicine shows that physician panel sizes vary widely depending on the measurement rules used in the calculation. This is important as panel size plays an increasing role in measuring primary care provider workload, setting limits on practice capacity, and determining pay. Panel size may also affect quality of care and contribute to physician burnout.

The author from Dartmouth Geisel School of Medicine reviewed documents from major medical organizations to identify decision points involved in measuring panels. The author then calculated panel sizes for a prototypical physician practice using two different sets of measurement rules. The prototypical physician described the author would have a reported panel of 700 patients with one set of rules but 5,004 patients with another. According to the author, these findings suggest that a standardized method is needed to calculate panel size. A standard approach would reduce confusion about appropriate panel targets, decreasing the risk for both inappropriately large panels, with negative effects on quality, access, and provider burnout, and inappropriately small panels, with waste of scarce primary care resources.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, Michael F. Mayo-Smith, MD, MPH, please email mfmayosmith@va.gov or call (603) 856-1298.

4. Composite measure using publicly reported data provides reliable assessment of health system quality

Abstract: https://www.acpjournals.org/doi/10.7326/M20-0718

Editorial: https://www.acpjournals.org/doi/10.7326/M20-6095

URL goes live when the embargo lifts

A composite measure using publicly reported data to produced valid, reliable, and stable ranks of ambulatory care quality for health care systems in Minnesota and California. The measure provides a potential way to simplify measurement to rank health systems and could be widely adapted. Findings are published in Annals of Internal Medicine.

Quality measurement has become an important tool by which payers and policymakers push to improve health care outcomes; lower cost; improve clinician experience; and improve patient experience. High-stakes applications of quality measures, such as in paying for performance or steering patients to preferred providers, may not be subject to methodological scrutiny.

Researchers from RAND Corporation ranked 55 health systems in Minnesota and California between 2014 and 2016 using a composite model that summarized individual measures of quality, accounted for their correlation, and did not require health care systems to report every measure. They then assessed the model's validity, reliability, and stability. The researchers found that their method was valid in that it was broadly representative of the component measures and was not dominated by any single measure. The measure was reliable because the ranks for 93 percent of California systems and 80 percent of Minnesota systems were unlikely to be more than 2 places lower or higher. The measure was stable because fewer than half of systems changed ranks by more than 2 ranks from year to year. According to the researchers, these findings suggest that their model could be used to reliably classify health systems based on their quality.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, Denis Agniel, PhD, please contact Warren Robak at robak@rand.org.

5. Synopsis of VA/DoD recommendations focuses on dyslipidemia management and prevention strategies relevant to primary care

Abstract: https://www.acpjournals.org/doi/10.7326/M20-4648

Review: https://www.acpjournals.org/doi/10.7326/M20-4680

Edtorial: https://www.acpjournals.org/doi/10.7326/M20-6125

URL goes live when the embargo lifts

Authors from Uniformed Services University present a synopsis of the clinical practice guideline updated by the U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD) for managing dyslipidemia to reduce cardiovascular disease (CVD) in adults. While the final document contains 27 recommendations, the authors highlight seven areas that are especially relevant to primary care. Their synopsis is published in Annals of Internal Medicine along with a supporting evidence review.

The updated guideline continues to focus on CVD risk reduction through management of lipid levels among persons most likely to benefit. The primary critical outcome of interest in grading the evidence was cardiovascular mortality, with cardiovascular morbidity considered an important but less critical outcome by which to grade evidence. The synopsis summarizes key features of the guideline in 7 crucial areas:

  • treating to target dose (not low-density lipoprotein cholesterol goals);
  • no additional tests for risk prediction;
  • primary prevention with moderate-dose statin therapy; no to proprotein convertase subtilisin/kexin type 9 inhibitors;
  • secondary prevention with moderate statin doses initially, then stepped intensification in higher-risk patients;
  • laboratory testing with no routine fasting or monitoring;
  • increased aerobic exercise for all; cardiac rehabilitation after a recent CVD event;
  • for primary and secondary CVD prevention, a dietitian-led Mediterranean diet

According to the authors, the most noteworthy recommendation that goes against common practice is the concept of ordering much less lipid testing. They ascertain that if followed, this has the potential of saving a substantial amount of resources, and reducing patient inconvenience.

Intensified patient care recommended for increasing statin tolerability and adherence

Statin treatment is an important aspect of dyslipidemia management. In a supporting evidence review, the authors studied published research to assess the benefits and harms of interventions to improve statin adherence in patients at risk for CVD. The evidence suggests that intensified patient care that includes combinations of education, telephone interaction with providers, pharmaceutical care programs, and other interventions can be individually tailored on the basis of a patient's specific reasons for nonadherence. For most patients, the potential benefits of statin adherence outweigh the risks for adverse events from continued statin use.

According to an editorial from Centennial Heart at Parkridge, Chattanooga, Tennessee, the guideline offers an approach to managing dyslipidemia that is practical, reflects evidence from large clinical trials, and is based on an unambiguous endpoint: CVD mortality. The VA/DoD guidelines differ from other published guidelines and the author provides insight into some of the rationale.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author of the guideline synopsis, Patrick G. O'Malley, MD, MPH, please contact Sharon Holland at sharon.holland@usuhs.edu.

Also in this issue:

Silence

Shen

Graphic Medicine

Abstract: https://www.acpjournals.org/doi/10.7326/G20-0013

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