The Best of Primary Care Research from NAPCRG 2015
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The top research studies in family medicine that will impact clinical practice for primary care providers
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The Best of Primary Care Research from NAPCRG 2015
- 3. Disclosure – Dr. David Kaplan • Dr. Kaplan is a Board Member of NAPCRG and is the Chair of the Community Clinician Advisory Group • Dr. Kaplan is the Provincial Primary Care Lead at Health Quality Ontario, the provincial advisory on healthcare quality.
- 8. NAPCRG 2015 – Pearl 1 Physical Exercise for Late Life Depression: Tailored Treatments Between Psychiatry and Primary Care Klea Bertakis, MD, MPH; Mario Amore; Fabrizio Asioli; Luigi Bagnoli; Marco Menchetti; Martino Murri; Micro Neri; Francesca Neviani; Matteo Siena; Guilio Toni; Ferdinando Tripi; Stamatula Zanetidou; Donato Zocchi
- 10. What the Researchers Did • SEEDS study compared the antidepressant efficacy of sertraline plus physical exercise (24 weeks, 3 times per week) vs. sertraline alone. • Setting: consultation liaison program for primary care • post-hoc analysis: identified factors predicted higher chances of remission in the experimental group; contextual factors and PCPs opinions were also explored
- 11. What the Researchers Found • Ideal candidate to receive sertraline plus exercise: patient who is older than 75, has retained a good aerobic fitness, displays psychomotor retardation but not severe anxiety • Long standing consultation liaison program is important for the recruitment and follow up of patients: PCPs expressed very favorable views re: adding exercise as an antidepressant
- 14. The Research Question 1. Calculate the proportion of strokes/TIAs with prior missed opportunities for prevention 2. Determine if the proportion of missed opportunities has changed over time 3. Investigate the association with patient or demographic characteristics
- 15. What the Researchers Did Retrospective analysis of anonymised, electronic UK primary care records Population • First-stroke/TIA • ≥18 years • 2009-2013 Outcomes Anticoagulant, Antihypertensive or Lipid Lowering drugs NOT prescribed when clinically indicated Analysis • % of patients with missed prevention opportunities • Logistic regression
- 16. What the Researchers Found % Missed opportunities: • Any prevention drug: 54% (9,579/17,680) – Anticoagulants: 52% (1,647/3,194) – Lipid lowering drugs: 49% (7,836/16,028) – Antihypertensives: 25% (1,740/7,008) Change over time (2009-2013) • Only anticoagulant drug prescribing improved Predictive patient/ demographic characteristics • Different profile for each drug
- 17. What This Means for Clinical Practice Primary stroke prevention is inadequate • Ageing population • Guideline changes • Legal considerations Barriers to prescribing Patient MD Organizational
- 20. What the Researchers Did • Retrospective cohort design from: – Veterans Administration (VA), n= 70,997 – Baylor Scott & White (BSW), n=13,777 – Henry Ford Health System (HFHS), n=22,981 • Variables created from ICD-9-CM codes, pharmacy records, vital signs, lab results etc. • Separate Cox models computed to estimate association between opioid duration, morphine equivalent dose and new diagnosis of depression
- 21. What the Researchers Found • Risk of new onset depression increased with opioid duration in each patient sample. >90 day use was associated with 35% to 105% increased risk of new onset depression compared to 1-30 day use. • Dose was not associated with new onset depression
- 22. What This Means for Clinical Practice • Baseline depression screening insufficient, consider depression screening at each opioid refill • Add depression to risk:benefit discussion • Short term euphoria but long term depression • Opioid taper if new onset depression in chronic pain • Consider opioid, not just pain, as source of depression
- 26. What the Researchers Found • No studies of breast cancer morbidity or mortality • Hand-held US • Sensitivity 80-83%; specificity 86-94%; PPV 3-8% • Additional cancer detection 4.4 per 1,000 exams; recall rates 14% (one study) • MRI • Sensitivity 75-100%; specificity 78-89%; PPV 3-33%. • Additional cancer detection 4 to 29 per 1,000 exams; recall rates 12%-24% per 1,000 exams • DBT • Additional cancer detection: Increased by about 1 cancer per 1000 exams (4/1000 to 5/1000) • Recall rates: 7-11% with DBT + mammography vs 9-17% with mammography alone
- 27. What This Means for Clinical Practice • No evidence on whether supplemental screening reduces breast cancer mortality or morbidity • Rigorous studies with long term follow-up are needed • Supplemental US and MRI increased cancer detection but had high false positive rates • DBT may reduce recall rates but evidence for women with dense breasts is very preliminary
- 31. What the Researchers Did • Multicentre, placebo controlled, dbl blinded RCT • Intervention: continuation of maintenance SSRI vs discontinuation (taper to placebo) • Population: primary care treated patients currently taking fluoxetine for maintenance to prevent recurrence • Primary outcome: occurrence of moderately severe depression over 18 months
- 32. What the Researchers Found • Maintenance treatment prevented a depression episode in 12.8% (23.3% vs 10.5%) p=0.005 NNT(18 mo)=8 • 7/8 patients experienced no benefit over 18 months • 6% of patients had to restart because of intolerable discontinuation symptoms, despite tapering NNH=16 • There was no harm in trialing discontinuation: no suggestion of poorer outcomes at 18 months in the taper arm • (Patient relevant measures including mood, quality of life, overall psychological distress/symptoms, social and occupation functioning)
- 33. What This Means for Clinical Practice • The absolute benefit of SSRIs in preventing depression recurrence in primary care is much smaller than that previously estimated • It seems reasonable to discuss these data with patients on maintenance treatment and offer a discontinuation trial to patients • This provides good primary care data for shared decision making when considering initiation of maintenance treatment
- 36. What the Researchers Did Developed a childhood obesity behavior mod program, based on “5-2-1-0” (per day) • 5+ servings of fruits and vegetables; • 2 or fewer hours of screen time; • 1 hour or more of physical activity; • 0 servings of sugar-sweetened beverages – “Shelf-ready” program with curriculum for 18 group visits (available in Spanish)
- 37. What the Researchers Did • Enrolled 20 primary care practices in Colorado: – Offered 1-day training and bi-annual Learning Collaboratives; on-going technical support • 290 children ages 6-12 years + family members enrolled • Collected monthly data for 12-15 months for BMI %ile & lifestyle factors related to 5-2-1-0
- 38. What the Researchers Found • Baseline to 9-15 months of participation: – Decrease in BMI %-tile (p<.04); BMI z-Scores (p<.02) • Lifestyle Factors: significant improvements for – Daily fruit and vegetable intake (p<.0001); days of physical activity of 1 hour+ (p<.0001); family activity/week (p<.0001); daily screen time (p<.05); intake of sugar sweetened beverages (p<.0003); # of times eating out each week (p<.001)
- 40. What This Means for Clinical Practice • It is feasible to implement a childhood obesity behavior modification program in primary care practices, which can produce clinically meaningful improvements in BMI %-tile and lifestyle factors • Families reporting food insecurity issues may be less likely to follow-up and stay engaged in the program.
- 42. The Research Question • TIA is defined by short-lasting symptoms • Medical management focuses on stroke prevention Investigate the association between TIA and consultations for fatigue, cognitive, or psychological impairment in primary care
- 45. What This Means for Clinical Practice • Challenges the ‘transient’ definition of TIA • Current management of TIA may not be adequate • Impact on quality of life and stroke prevention • Future research • Mechanism • Identification of impairments • Treatment of impairments
- 47. The Research Question Are non-sterile gloves worse than sterile gloves for minor skin excisions?
- 48. What the Researchers Did • Prospective randomised controlled non-inferiority trial • Single Australian General Practice • 478 participants
- 49. What the Researchers Found Infection rates: • Sterile gloves 9.3% (22/237) • Non sterile gloves 8.7% (21/241) • Difference in Infection -0.6% (95% CI -4.0 to +2.9) Infection actually lower in the non-sterile glove group!