POEMs
POEMs (patient-oriented evidence that matters) are provided by Essential
Evidence Plus, a point-of-care clinical decision support system published by WileyBlackwell. For more information, please see http://www.essentialevidenceplus.
com. Copyright Wiley-Blackwell. Used with permission.
For definitions of levels of evidence used in POEMs, see http://www.
essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.
To subscribe to a free podcast of these and other POEMs that appear in AFP,
search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.
A collection of POEMs published in AFP is available at http://www.aafp.org/
afp/poems.
▲
See related Putting
Prevention into Practice on page 117, U.S.
Preventive Services
Task Force Recommendation Statement at
http://www.aafp.org/
afp/2014/0715/od1.
html, and Editorials at
http://www.aafp.org/
afp/2014/0715/od2.html
and http://www.aafp.
org/afp/2014/0715/od3.
html.
Delayed Prescription Strategies
Decrease Antibiotic Use
Clinical Question
Is a method of delayed prescriptions for
respiratory tract infections effective for
decreasing antibiotic use?
Bottom Line
A delayed prescription approach in children
and adults with acute respiratory tract infections, combined with explicit instructions for
symptom control, is effective in decreasing
antibiotic use, while not adversely affecting
patient satisfaction or symptom duration or
severity. Asking patients to call, pick up, or
simply hold a prescription for a prescribed
time resulted in fewer than 40% of patients
receiving antibiotics. (Level of Evidence = 1b)
Synopsis
Primary care clinicians in 25 practices in
the United Kingdom participated in this
study. They enrolled 566 children (at least
three years of age) and adults with acute
respiratory infection evaluated for respiratory tract symptoms deemed to not require
antibiotic treatment (62.5% of eligible visits).
The patients were randomly assigned, using
concealed allocation, to one of five strategies:
(1) no prescription, (2) recontact the office if
symptoms persist, (3) a postdated prescription was given, (4) a prescription was left at
reception to be picked up if symptoms persisted, or (5) patients were given a prescription and asked not to fill it unless symptoms
110 American Family Physician
www.aafp.org/afp
persisted. The advice for length of delay was
tailored to the type of illness (e.g., three days
for ear infections, 10 days for acute cough).
In addition, patients were also randomized to
receive different advice for symptom control
(type of analgesic or use of steam inhalation).
Symptom severity on the second and
fourth days following the visit were similar
between the no-prescription group and any
of the delayed-prescription groups, as well
as between these groups and the patients
immediately treated with antibiotics. Patient
satisfaction with the visit was also similar
among all groups. The actual percentage of
patients in the no-prescription or delayedprescription groups that eventually took
antibiotics ranged from 26% to 39% (difference not significant). Follow-up visits and
complications were similar across all groups.
Study design: Randomized controlled trial
(nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Outpatient (primary care)
Reference: Little P, Moore M, Kelly J, et al.;
PIPS Investigators. Delayed antibiotic prescribing
strategies for respiratory tract infections in primary
care: pragmatic, factorial, randomised controlled
trial. BMJ. 2014;348:g1606.
ALLEN F. SHAUGHNESSY, PharmD, MMedEd
Professor of Family Medicine
Tufts University, Boston, Mass.
New Anticoagulants vs. Warfarin in
Atrial Fibrillation: No Clear Winner
Clinical Question
Are the newer anticoagulants safer or more
effective than warfarin (Coumadin) in
patients with atrial fibrillation?
Bottom Line
In this meta-analysis, newer anticoagulants
appear to be slightly more effective than
warfarin in the short term (two years) in
preventing strokes of all kinds in patients
with atrial fibrillation. However, they are
Volume 90, Number 2
◆
July 15, 2014
POEMs
no more effective than warfarin in preventing ischemic strokes, and they cause more
gastrointestinal hemorrhage. The short-term
nature of the included studies and a significant concern about publication bias suggests
that the newer agents are by no means a slam
dunk over warfarin. Because the patients taking warfarin only spent two-thirds of their
time in therapeutic range, perhaps efforts to
improve performance may be a wiser use of
resources. (Level of Evidence = 1a–)
▲
Synopsis
The authors of this study and the editors of
The Lancet did a fairly abysmal job in communicating how this study was conducted.
The abstract claims the authors searched a
single database to identify phase-randomized
trials comparing newer anticoagulants with
warfarin in patients with atrial fibrillation.
However, the methods section reports the
authors conducted a prespecified analysis of
four studies and does not describe a thing
about the search strategy. Additionally, the
authors do not include data on ximelagatran,
which was pulled because of safety concerns.
The authors pooled the data for nearly
72,000 patients with atrial fibrillation who
received one of the newer anticoagulants
(dabigatran [Pradaxa], rivaroxaban [Xarelto],
apixaban [Eliquis], or edoxaban; n = 42,411)
or warfarin (n = 29,272). The authors evaluated the outcomes by intention to treat when
possible, but made no adjustments for performing multiple analyses. Two of the four
trials included nearly one-third of the patients
with CHADS2 (congestive heart failure,
hypertension, age 75 years or older, diabetes
mellitus, and stroke or transient ischemic
attack) scores of 0 to 1, which is a group
that may not need anticoagulation. Overall,
approximately one-fourth of the patients had
paroxysmal atrial fibrillation. The median
duration of follow-up was 2.2 years, and the
warfarin-treated patients were in therapeutic
range only two-thirds of the time.
Code Confidently in ICD-10
Be properly compensated for the services you provide. Help your practice
through the ICD-10 transition with the AAFP Coding Toolkit.*
ICD-10 Educational Series
ICD-10 Flashcards
• Developed by coding experts, this 11-module voice-guided
PowerPoint series offers a comprehensive map to a
smooth ICD-10 conversion.
• Created to help physicians, practice managers,
coders, and those who work on office dictation easily
transition from ICD-9 to ICD-10.
AAFP
ICD-9 to ICD-10
Referential Flash Cards
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POEMs
Patients receiving the newer agents had
a lower risk of stroke or systemic embolic
events than patients taking warfarin (3.1% vs.
3.8%; relative risk = 0.81; number needed to
treat [NNT] = 148; 95% confidence interval
[CI], 103 to 261). There were no statistically
significant differences in the rate of ischemic
stroke or myocardial infarction. Patients taking the newer agents had fewer hemorrhagic
strokes (0.4% vs. 0.9%; NNT = 220; 95%
CI, 170 to 308) and intracranial hemorrhages
(0.7% vs. 1.4%; NNT = 132; 95% CI, 108 to
169). Furthermore, all-cause mortality was
slightly lower in patients receiving the newer
agents (6.9% vs. 7.7%; NNT = 129; 95% CI,
84 to 279). However, patients taking newer
agents had more gastrointestinal bleeding
(2.6% vs. 2%; number needed to treat to
harm = 185; 95% CI, 128 to 335). Although
the study was unfunded, the authors had
heavy ties to industry, which may explain
their sloppiness in describing their methods. For example, they do not even try to
evaluate the potential for publication bias, an
issue especially important because industrysponsored studies have a long track record of
not finding their way to publication.
Study design: Meta-analysis (randomized
controlled trials)
Funding source: Self-funded or unfunded
Setting: Various (meta-analysis)
Reference: Ruff CT, Giugliano RP, Braunwald E, et
al. Comparison of the efficacy and safety of new
oral anticoagulants with warfarin in patients with
atrial fibrillation: a meta-analysis of randomised
trials. Lancet. 2014;383(9921):955-962.
HENRY C. BARRY, MD, MS
Professor
Michigan State University, East Lansing, Mich.
One in Five Patients
Overdiagnosed with
Lung Cancer Screening
Clinical Question
In patients found to have lung cancer by
screening, what is the likelihood that the
identified cancer would never have affected
that patient?
112 American Family Physician
www.aafp.org/afp
Synopsis
Early detection of disease via screening usually makes sense, unless that earlier detection leads to identification of a disease that
is never destined to cause problems in the
patient. We cannot pinpoint which patients
are overdiagnosed; all we can do is understand the concept that some patients will
be identified and treated for a disease that
would never have become clinically apparent. This study is an analysis of the previously reported National Lung Screening
Trial using extended follow-up data. This
study enrolled 53,452 patients at high risk
of lung cancer (i.e., those between 55 and 74
years of age with at least a 30 pack-year history of smoking). Patients were randomized
to receive three annual screens with LDCT
or single-view posterior-anterior chest radiography. Patients were followed up for an
average of 6.4 years. More lung cancers
were reported in the LDCT arm of the study
(1,089) than in the chest radiography arm
(969). The excess number of cancers in the
LDCT arm (18.5%; 95% confidence interval,
5.4% to 30.6%) represents the total number
of cancers that would not have become clinically apparent during the screening period
had screening not been performed. Most
(78.9%) of the bronchioalveolar lung cancers found were an overdiagnosis, and 22.5%
of non–small cell lung cancers found were
an overdiagnosis.
Study design: Randomized controlled trial
(nonblinded)
Funding source: Government
Allocation: Uncertain
Setting: Outpatient (any)
Reference: Patz EF Jr, Pinsky P, Gatsonis C, et
al.; NLST Overdiagnosis Manuscript Writing Team.
Overdiagnosis in low-dose computed tomography
screening for lung cancer. JAMA Intern Med. 2014;
174(2):269-274.
ALLEN F. SHAUGHNESSY, PharmD, MMedEd
Professor of Family Medicine
Tufts University, Boston, Mass.
Volume 90, Number 2
▲
Bottom Line
In patients screened for lung cancer using
low-dose computed tomography (LDCT),
more than 18% of all lung cancers found
are slow-growing and will not cause symptoms or harm during an average 6.4 years of
follow-up. This risk of overdiagnosis should
be part of the discussion regarding whether
to screen. (Level of Evidence = 1b)
◆
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POEMs
Stable TSH Can Be Rechecked in
Two Years
Clinical Question
How much do seemingly stable thyroid tests
vary over time?
Bottom Line
Most patients receiving thyroid replacement
therapy with less than 125 mcg of levothyroxine per day can wait two years before monitoring thyroid-stimulating hormone (TSH)
levels if their results are normal. Fewer than
one in 10 patients who take less than 125
mcg of levothyroxine per day with a normal
TSH level will have an abnormal laboratory
value one year later. The likelihood goes up
to 26.7% if the dosage is higher than 125 mcg
of levothyroxine per day. Patients with TSH
levels closer to the upper or lower limits of
normal will also be slightly more likely to
have an abnormal value in one year. (Level
of Evidence = 1b)
Synopsis
These authors identified 715 patients (84%
women; average age = 54 years) in a single
primary care practice who were treated for
hypothyroidism and had a normal TSH value
(0.3 to 5.0 mIU per L). They recorded all
subsequent TSH levels in these patients for
the following six years. Age, sex, body mass
index, and history of chronic autoimmune
thyroiditis were not associated with the development of a subsequent abnormal TSH level,
but the dosage of levothyroxine was associated. Approximately one in four patients taking more than 125 mcg of levothyroxine per
day (26.7%) had an abnormal TSH level one
year later. Most of the patients taking lower
dosages (91.1%) had normal TSH levels one
year later.
Study design: Cohort (retrospective)
Funding source: Self-funded or unfunded
Setting: Outpatient (primary care)
Reference: Pecina J, Garrison GM, Bernard ME.
Levothyroxine dosage is associated with stability
of thyroid-stimulating hormone values. Am J Med.
2014;127(3):240-245.
ALLEN F. SHAUGHNESSY, PharmD, MMedEd
Professor of Family Medicine
Tufts University, Boston, Mass. ■