Seriously, URI?• Um, Who cares?• It’s self-limiting…• This isn’t even important enough to score a chapter in my Pathology book
Primary Care disruption• November 2011: Wal-Mart has plans to go into Primary Care. (npr.org)• From 2007 to Now: 10x increase in retail clinic visits. (advisory.com)
#FMRevolution • FPs are just gatekeepers to proceduralists • FPs are wasting their talents • FPs will be replaced by mid-levels • Or: FPs are the center of a modern, high- quality, efﬁcient health-care system.URI is a perfect example of ‘wasting talent’ or being replaceable, right?
Is Dr. Ploudré an Expert on URI?500375250125 0 URI Cough Sinusitis Pharyngitis ETD Strep Conjunctivitis Bronchitis AOMI’ve diagnosed these things a lot in the past 3 years…
OK-plateau?• Joshua Foer: How many of you are faster at typing than you were a year ago?• Autopilot or Deliberate Practice?• I can diagnose and treat URI-related illness 1000x in the past few years but unless I’m deliberately practicing, I may not be an expert.
Non Deliberate Medicine• In Med school/Residency everyone had an ‘Allegra’ Pen or ‘Claritin’ notepad.• Non-sedating antihistamines cost $100/ month then.• How did I get to be a 3rd year FP resident before I learned nasal corticosteroids were dramatically more effective than non- sedating antihistamines?
Deliberate EBM PICO • Patient / Population / Problem (among _____) • Intervention / Exposure (does _____) • Comparison (versus ______) • Outcome (affect _______)Keep asking questions. Check things you think you know.
54yo Female presents with 5 day history ofillness. Initially started with a sore throat. Onthe second day she developed a runny noseand some nasal congestion. She’s justdeveloped a nonproductive cough.Exam: Afebrile, Unremarkable.
Among healthy adults with viral URIdoes antibiotic treatmentvs watchful waitingaffect length of illness?
“Sure.” (55% of Patients) J Gen Intern Med 1999“Oh, last time I got that 5 day prescription that works for 10 days. It was great.”
2 prescriptions for antibiotics (Respiratory/UTI) in primary care results in measurable increase in antibiotic resistance that can last as long as 12 months. BMJ 2010We know antibiotics are ineffective. And potentially harmful.
Antibiotics: Number Needed to Harm = ~16 Lancet, 2004Not to mention population level issues like MRSA and VRE…
27yo Male presents with 10 day history ofillness. Initially started with a sore throat,then runny nose then cough. Started toimprove until 3 days ago when he started todevelop purulent nasal discharge and mildchills.Exam: Afebrile, Unremarkable except facialtenderness over the left maxilla.
Among adults with classic sinusitisdoes antibiotic treatmentvs watchful waitingaffect length of illness?
Yes. But NNT = 8. No symptom clearlyseparates bacterial from viral sinusitis.(Green discharge, ie, doesn’t matter.)Without Purulent Discharge NNT = 15.(Remember: NNH = 16.)Prevalencee studies: ~97% of sinusitis isnot bacterial. No treatment in somestudies for up to 3 week unless febrile. Lancet, 2008
Effective for Chronic SinusitisProbably effective for URI, AllergicRhinitis, Irritant Rhinitis.Ploudre Opinion: Whoa. Thatseriously gets snot out of my nose. But50% of patients dislike it. Am Fam Phys, 2009
Among adults with hx of recurrent sinusitisdoes adding nasal corticosteroids to abxvs antibiotics aloneaffect length of illness?
Yes 93% vs 73% clinical success rate. Median of 6 days vs 9 days. “If you take this nasal spray, you’ll probably get better about 3 days earlier.” JAMA, 2001I seriously just looked this up in PubMed in ~ 90 seconds.
43 yo Female presents with cough. Illnessstarted with a mild runny nose but coughquickly became main issue. Now 16 days intothe illness with nonproductive cough. Coughdisrupts sleep now.Exam: 98% pulse ox, afebrile. Otherwiseunremarkable.
rld Ethical Practice Wo ie rePrem E= E 3 Ethical = Evidenced x Economic x Etiquette
Ethical Azithromycin? Well: It doesn’t really work It used to cost $75 But patients love it’s tolerability and convenience.Contrast: Bronchitis, Smokers with Bronchitis, Smoker with COPD exacerbation
Bronchitis Etiquette“Bronchitis” vs “Chest Cold”26% vs 13% of Patients disatisﬁed aboutnot getting antibiotics. J. Am Board Fam Practice, 2005
See One, Do One, Teach One.Just this week I learned why I always use Nystatin for newborn thrush.
Is URI a waste of time?Yes: It might take a good programmer aweek to create a good statistical predictionrule to outperform most doctors inproviding evidence-based care.Yes: Another case of the US spending morethan anyone with little to show for it.
Is URI a waste of time?No: URI visits are a chance to ‘calibratesensors’ for patients through education.No: URI visits can be used to reduce ourdangerous habit of overprescription ofantibiotics.No: URI is a source of rapport and a deeperdoctor-patient relationship.