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. Early referral to physical therapy improves function and other symptoms of back pain with sciatica
Editorial: https://www.acpjournals.org/doi/10.7326/M20-6545
URL goes live when the embargo lifts
Starting physical therapy right away, rather than taking the usual watch and wait approach, helps to improve function and other outcomes for patients experiencing recent-onset back pain with sciatica (pain that radiates into the leg). Findings from a randomized controlled trial are published in Annals of Internal Medicine.
In the clinical trial led by researchers at the University of Utah Health, 220 adults who consulted their primary care physician for back pain with sciatica which had begun within the past 90 days were randomly assigned to either 4 weeks of physical therapy or usual care for 4 weeks. Physical therapists primarily used exercises and manual techniques such as hands-on spinal mobilization, tailoring the specifics of the treatment to individual patients. Those in the other group received no therapy but were advised to remain active and seek additional care if needed after 4 weeks. Patients reported on their level of pain and its impact on their lives--such as their ability to care for themselves and participate in social activities-- after 4 weeks, then again at 6 months and 1 year. At every point, patients who had completed physical therapy immediately after their primary care visit reported less disability than patients who took the wait-and-see approach. During the one-year study, a small percentage of participants chose to receive steroid injections or undergo surgery to treat their pain. These interventions were equally common whether or not patients received early physical therapy. The differences in outcomes between the two treatment groups were generally large enough to be considered clinically meaningful.
According to the authors and an accompanying editorial from Keele University, Keele United Kingdom, these findings are important because they provide an evidence-based treatment option for patients who seek care for back pain from their primary care physician.
Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, Julie Fritz, P.T., Ph.D., please contact Julie Kiefer, Ph.D. at julie.kiefer@hsc.utah.edu.
2. ACP Best Practice
Abstract: https://www.acpjournals.org/doi/10.7326/M19-3860
URL goes live when the embargo lifts
The American College of Physicians (ACP) has issued Best Practice Advice aimed at simplifying and improving treatment of patients diagnosed with chronic hepatitis C virus (HCV). ACP Best Practice Advice is based on the World Health Organization's Guideline and is authored by the ACP Scientific Medical Policy Committee and published in Annals of Internal Medicine.
HCV is a communicable disease that is associated with cirrhosis and liver cancer. In the United States, the annual incidence of HCV infection is 1.2 per 100,000 persons, the prevalence is 2.4 million cases, and annual mortality is more than 15,000 deaths.
The World Health Organization (WHO) recommendations have implications for high-value care. ACP defines high-value care as the delivery of services providing benefits that make their harms and costs worthwhile. While the WHO guideline is primarily targeted toward policymakers in low- and middle-income countries, recommendations are relevant to the United States, where equity and resource allocation issues are also important considerations.
The ACP Best Practice Advice paper says that viral genotyping is unnecessary when treating HCV with pangenotypic medications unless planning treatment with glecaprevir-pibrentasvir (GLE-PIB), and asserts that invasive testing to establish the degree of fibrosis is not necessary, and inexpensive laboratory tests can reliably identify patients with cirrhosis. Further, ACP advises that laboratory monitoring can be limited to the beginning and end of the treatment in adults with no or compensated cirrhosis. ACP also says patients with decompensated cirrhosis will need closer monitoring.
Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with someone from ACP, please contact Andrew Hachadorian at AHachadorian@acponline.org.
3. About one in five older gun owners has a plan for future gun transfer in case of impairment
Approximately half have a plan for transferring ownership after death
Abstract: https://www.acpjournals.org/doi/10.7326/M20-2280
URL goes live when the embargo lifts
About one in five older gun owners has a plan for transferring gun ownership in case of dementia or other impairment that may limit their capacity to handle firearms safely. Only about one half have a plan for transferring their guns after death. Findings from a nationally representative survey are published in Annals of Internal Medicine.
Approximately one-third of adults 65 years and older in the United States own a gun. Because some of those older gun owners will develop some sort of impairment in their lifetime, it is important for them to consider future firearm transfers.
A team led by researchers from the University of Colorado used data from the second National Firearms Survey to describe the frequency of advance planning by older gun owners. Questions assessed whether respondents had a plan for transferring their firearms to someone else in event of death or their inability handle guns safely. Participant characteristics included demographics, caregiving for someone with dementia, and firearm-related measures (such as type and number of guns owned, reasons for ownership, training, and frequency of handling). The researchers extracted data for persons 65 and over. About one-fifth of the participants had a plan for transferring their firearms in case of impairment and one half had a plan for transferring their firearms at death. Of those with a plan in case of impairment, nearly all (87 percent) of them had a plan for transferring their firearms at death. According to the researchers, these findings suggest an opportunity for health care providers to discuss firearm advance planning with appropriate patients.
Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, Marian Betz, MD, MPH, please contact Julia Milzer at JULIA.MILZER@CUANSCHUTZ.EDU.
4. Productivity gained from medical scribe program may offset costs
Abstract: https://www.acpjournals.org/doi/10.7326/M20-0428
URL goes live when the embargo lifts
Across all specialties, the productivity gained from a medical scribe program may offset the cost. In addition to costs saved, scribe programs have been shown to improve physician satisfaction and allow more face-to-face time with patients. How this impacts physician burnout is not known, but could be an important topic for future research. Findings from a modeling study are published in Annals of Internal Medicine.
Electronic health record documentation has replaced paper records for most physicians, creating new challenges for the medical practice, including decreased face-to-face interaction time with patients, increased documentation burden, and increased burnout. Medical scribe programs can ease some of the burden on physicians, but whether practices can justify the additional expense remains unclear.
Researchers from the University of Chicago developed a model using Medicare fee-for-service data to determine the number of additional patient visits various specialties would need to recover the costs of implementing scribes in their practice at 1 year. They found that only a modest increase in patient visits per day was needed to recover costs in all specialties. Just 2 extra new patients or 3 returning patients is all that would be needed, according to the model. For health care providers seeing an average of 20 patients per day, this represents a 10 to 15 percent increase in visits, which approximates the 10 percent to 20 percent average productivity increases reported by previous studies of scribe programs.
Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, Neda Laiteerapong, MD, MS, please contact Lorna Wong at Lorna.Wong@uchospitals.edu.
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Also in this issue:
Should You Recommend Direct-to-Consumer Genetic Testing for This Patient?
Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Gerald W. Smetana, MD; Jason L. Vassy, MD, MPH; Erin Hofstatter, MD; and Howard Libman, MD
Beyond the Guidelines
Abstract: https://www.acpjournals.org/doi/10.7326/M20-5419
Delirium
Melissa L.P. Mattison, MD
In the Clinic
Abstract: https://www.acpjournals.org/doi/10.7326/M20-0850
Journal
Annals of Internal Medicine