Recent Papers thatShaped My PracticeAlan Dow, MD, MSHAVirginia Commonwealth University

March 1st, 2013

Disclosures Employment

Virginia Commonwealth University and MCV Physicians

Grant funding Josiah H. Macy, Jr Foundation Donald W. Reynolds Foundation

Other compensation The Frontier Project and Critical

Communications Group

None of the above should have implications for my talk.

Question

For patients on dialysis, statin therapy decreases mortality by:

1. 0%2. 15%3. 33%4. 50%5. 75%

CKD & Statin vs control:

86 comparisons (51,099 pts)

CKD w/o dialysis: 48

comparisons (39,820 pts)

CKD w/ dialysis: 21

comparisons (7982 pts)

Renal transplant:

17 comparisons (3297 pts)

All-cause and cardiovascular mortality

Palmer SC et al. Ann Intern Med. 2012;157(4):263-275.

Palmer SC et al. Ann Intern Med. 2012;157(4):263-275.

Statin benefit:• ~20% for non-dialysis pts• No benefit for dialysis patients• Uncertain benefits for transplant patients

Statins and kidney disease Clear benefit prior to dialysis

After dialysis is initiated, the benefits no longer accrue

Unclear if the lack of benefit is due to the advanced state of existing disease or statin effects being muted by dialysis

Consider stopping statins in ESRD patients to decrease the risk of polypharmacy

Question

For pregnant women with periodontal disease, using antimicrobial mouthwash cuts the risk of preterm birth by:

1. 0%2. 10%3. 33%4. 50%5. 75%

226 pregnant women

• 6-20 weeks gestation • Periodontal disease• Refused mechanical dental care• Matched by smoking status, prior preterm birth (< 35 wks)

71 antimicrobial mouth

rinse155 control

• 5.6% preterm births

• Mean gest age = 38.4

weeks• Mean wt =

3100 g

• 21.9% preterm births• Mean gest

age = 36.8 weeks

• Mean wt = 2625 g

Jeffcoat M et al. Am J of OB and Gyn. 2011

p < 0.01 for all

comparisons

Tonetti MS et al. N Engl J Med. 2007.

Organizing Principles for a New Oral Health Initiative

1. Establish high-level accountability.2. Emphasize disease prevention and oral health promotion.3. Improve oral health literacy and cultural competence.4. Reduce oral health disparities.5. Explore new models for payment and delivery of care.6. Enhance the role of nondental health care professionals.7. Expand oral health research, and improve data collection.8. Promote collaboration among private and public stakeholders.9. Measure progress toward short-term and long-term goals andobjectives.10. Advance the goals and objectives of Healthy People 2020.

Advancing Oral Health in America. IOM. 2011

Periodontal Disease

Clear association with systemic disease; causality less certain

Antimicrobial mouth rinse may be a cheap, over-the-counter way to improve oral health and systemic disease

How do I screen for periodontal disease?

How do I treat and follow periodontal disease?

QuestionCompared to usual practice for partner

violence assessment, using a computerized program to screen and refer patients resulted in how great a decrease in partner violence?

1. No change2. 10% decrease3. 25% decrease4. 50% decrease5. 75% decrease

2708 women in primary

care settings

No resources;

no screening

Resource list; no

screening

Computerized screening

video/resource list

• 3 question Partner Violence Screen• + support video and resources

Quality of life, lost days of work and household activities, hospitalizations, ED visits, annual

incidence of partner violence

Klevens J et al. JAMA. 2012

Results at one year follow-up 9.9% of women experienced partner

violence in the preceding year 4.4% contacted a partner violence

resource No significant difference among groups for:

Partner violence incidence Partner violence resource use Quality of life Lost days of work or household activities Healthcare utilization

Klevens J et al. JAMA. 2012

Partner violence

High annual incidence

About 40% of women affected by partner violence seek help annually

The interventions in this study had little effect on outcomes related to partner violence

Question

A patient presents with recurrent C. diff. He has previously been treated with a course of PO vancomycin and is non-toxic. What is the next best step in treatment?1. Repeat course of PO vancomycin2. A course of PO fidaxomicin3. Duodenal infusion of donor feces4. PO and IV metronidazole

43 Patients with recurrent

C. Diff

• Failed 1 course of PO vancomycin or flagyl

13 pts: PO vancomycin

13 pts: PO vancomycin and bowel

lavage

17 pts: donor-feces infusion

Cure without relapse in 10 weeks

van Nood E et al. NEJM. 2013. 368:407-15.

Infusion protocol Donor stool screened for C. diff,

parasites, enteropathogenic bacteria Donor blood screened for HIV,

hepatitis, HTLV 1&2, CMV, EBV, syphilis, Strongyloides, & Entamoeba

Stool combined with saline and infused per tube into duodenum

Patients who had recurrence after infusion had a repeat infusion from a different donor

van Nood E et al. NEJM. 2013. 368:407-15.

Fidaxomicin and C. diff

629 pts withC. diff

Vancomycin 125 mg PO

every 6 hours

Fidaxomicin 200 mg PO every 12

hours

Cure and recurrence

Louie TJ et al. NEJM. 2011. 364(5):422-31.

Louie TJ et al. NEJM. 364(5):422-31.mITT: Modified Intention-to-TreatPP: Per protocol

Evolving C. diff Treatment Possible rank of C. diff therapies:Duodenal feces infusion >> fidaxomicin >

vancomycin >> metronidazole IDSA Guidelines update in progress Cost:

Fidaxomicin course: $2800 Vancomycin course: $1194.63 Metronidazole course: $25.99 Duodeneal feces infusion: ???

Evolving Appreciation of Gut Flora

Probiotics may have benefits for: C. diff prevention (Johnston BC et al. Annals Int Med.

2012) NASH (Wong VW et al. Ann Hepatol. 2013) Hepatic enchephalopathy prevention

(Agrawal A et al. Am J Gastroenterology. 2012) Candida colonization/candiduria in

critically kids (Kumar S et al. Crit Care Med. 2013) Postoperative infections (Zhang JW et al. Am J Med

Sci. 2012)

Question

In order to decrease hospitalizations in high-risk Medicare patients, care coordination programs should:1. Provide intense medication

management2. Focus on transitions of care3. Act as a communication hub for all

providers4. Educate patients about their

disease states5. Provide all of the above services or

the program will not be successful

CMS Care Coordination

Demonstration Projects: Decrease

utilization in high-risk Medicare patients

Four successful:8-33% decrease in

hospitalizations

11 unsuccessful:No change or

increasein hospitalizations

• Wash U in St. Louis (urban, academic)

• Mercy Medical Center (rural, intergated)

• Hospice of the Valley (Phoenix, hospice and home health)

• Health Quality Partners (non-profit, PCP adjunct in SE PA)Features of successful programs (3+ of 4; absent in

most or all of unsuccessful programs):• Care coordinator as communication hub• Face-to-face contact between patients and care

coordinators• Face-to-face contact between physicians and care

coordinators• Patient education• Medication management• Comprehensive transitions of care

Brown RS et al. Health Affairs. 2012. 31:1156-66.

Care Coordinat

orPatient

PCP

Hospitalist

Pharmacist

Implementing the model

What are the implications of the care coordination role for physicians?

How does the care coordinator get empowered to work across silos?

Will programs be funded by health systems or Medicare managed care programs?

Question

How many additional adults would need to be covered by Medicaid to prevent 1 death per year?

1. 142. 1763. 8984. 156,3585. Expanding Medicaid does not

reduce mortality.

Adjusted comparisons five years before and after Medicaid expansion of CDC mortality data

Sommers BD et al. NEJM. 2012;367:1025-1034

−25.4 deaths per 100,000 population (p=0.02)

A significant increase in Medicaid coverage (p=0.01)

Self-rated health significantly increased (p<0.01)

Sommers BD et al. NEJM. 2012;367:1025-1034

Puzzling findings

Deaths from both internal and external causes decreased

Non-Medicaid patients had increased insurance rates and access to care in expansion states as well

Medicaid expansion

Expanded insurance coverage is associated with decreased mortality. Causality uncertain

If a similar benefit is seen with PPACA expansion, about 170,000 lives will be saved annually.

Question

When Medicaid was expanded in Massachusetts in a fashion similar to the PPACA, which of the following was not observed?1. For the first 3 years, only administrative

positions were added to the healthcare workforce

2. The wait time for primary care almost doubled

3. Costs were as budgeted4. Patient satisfaction improved

Massachusetts Medicaid Expansion During the first three years, only

administrative positions were added to the healthcare workforce (Staiger, Auerbach, & Buerhaus. NEJM. 2011)

The wait time for new primary care visits doubled (Shorob & Bodenheimer. NEJM. 2012)

Costs were higher than budgeted (Steinbrook. NEJM. 2009)

Patient satisfaction was high (Long. Health Affairs. 2008)

Implications in Virginia

487,000 newly insured 407,000 from Medicaid expansion 80,000 from insurance exchanges

5.2% increase in state spending on Medicaid

31.4% increase in federal spending on Medicaid

How will we provide the healthcare workforce to care for these patients?

How will we adjust to cost pressures?

Holahan et al. Kaiser Family Foundation. November, 2012

Questions and

Discussionawdow@vcu.e

du@alan_dow