Clinical Conversations

Dr. Eric Caine’s editorial in the Annals of Internal Medicine offers a skeptical, yet respectful, take on the evidence supporting the recent suicide-prevention guidelines from the U.S. Department of Veterans Affairs.
What are other countries doing to address suicide? It has increased in the U.S. from about 10.4 per 100,000 residents in the year 2000 to about 14.5 in 2017. Do firearm restrictions help? Better household safety? And how does the U.S. rate compare internationally?
Links:
Annals of Internal Medicine editorial
VA guidelines as published in the Annals
OECD stats on international suicide rates
The post Podcast 231 — The evidence behind VA’s suicide-prevention guidelines first appeared on Clinical Conversations.

The Hospital Readmissions Reduction Program (HRRP for short) seems to be reducing 30-day readmissions — but what about revisits to facilities within those 30 days?
Rishi Wadhera and his co-authors measured readmissions, plus treat-and-discharge ER visits, plus stays in observation units among some 3 million Medicare discharges of a near-4-year span. They found that broadening the definition of readmissions to include not only formal returns to the hospital for a standard stay but also those ER and observation-unit encounters tells a different story. It’s a story that should make HRRP’s administrators rethink what should be measured and how expanding the definition of readmissions could benefit patients by truly promoting better quality-of-care.
Links:
Article in The BMJ on readmissions
Earlier article in JAMA on readmissions for heart failure
The post Podcast 230 — Hospital-readmissions gaming? first appeared on Clinical Conversations.

Patients with atrial fibrillation who undergo surgical procedures need special attention because their anticoagulant medications, if not adjusted, increase their risk for bleeding. Those on direct-acting oral anticoagulants — or “DOACs” — face special problems because assays for the amount of drug on-board before surgery are not routinely available.
Dr. James Douketis and international colleagues have a simpler approach in their PAUSE study. On the basis of the known pharmacokinetics of DOACs, they dispense with coagulation testing and heparin bridging. Their approach involves assessing the likelihood of the procedure to cause bleeding. For low-risk procedures, DOACs are suspended a day before and resumed a day after; for riskier procedures, like resections, it’s two days before and two after.
The drugs under study were apixaban, dabigatran, and rivaroxaban.
We discuss the PAUSE results with Dr. Douketis.
LINKS:
JAMA Internal Medicine paper on PAUSE study
Physician’s First Watch summary (with links to other resources)
The post Podcast 229: Simplifying perioperative anticoagulation in AF first appeared on Clinical Conversations.

Matthew Nielsen and colleagues found almost 80 diagnostic algorithms for working up a finding of hematuria. From these, they chose five representative approaches, ranging from those based on the patients’ risk factors to more aggressive ones that stress CT imaging for all.
Using a 100,000-patient simulated cohort, Nielsen’s group found that more intensive imaging found more cancers than the other approaches. However, radiation-induced cancers from CT wiped out that advantage.
Join us as Dr. Nielsen walks through his findings and their clinical implications. The work appeared in JAMA Internal Medicine.
Links:
JAMA Internal Medicine article
NEJM Journal Watch General Medicine summary of ACP guidance on evaluating hematuria (from 2016)
American Urological Association guideline (from 2012)
The post Podcast 228: Hematuria — should the workup include imaging? first appeared on Clinical Conversations.

Chronic kidney disease, being a “prothrombic state,” would seem to warrant use of anticoagulants, yet they aren’t often used — why? The problem seems to be a lack of data with which to evaluate their effectiveness and possible harms. Big drug trials seem to avoid recruiting these patients, especially those in the later stages of CKD, where, for example, the risk for thromboembolism is two- to three-fold greater than in patients with normal kidney function.
We talk with Dr. Sunil Badve, senior author of a meta-analysis in a recent Annals of Internal Medicine. His findings? Non-vitamin K oral anticoagulants (or “NOACs”) seem better suited for those with early-stage disease than vitamin K antagonists like warfarin. In later-stage CKD, there just isn’t enough data available yet, and so the choice of therapy — if any — must weigh benefits against harms carefully.
Links:
Annals of Internal Medicine meta-analysis
Physician’s First Watch coverage
The post Podcast 227: Chronic kidney disease and anticoagulants first appeared on Clinical Conversations.

Length: 18 minutes
Sandro Galea, dean of Boston University’s School of Public Health, has written a new book. It’s called “Well: What we need to talk about when we talk about health,” and it’s the centerpiece of our discussion.
Dr. Galea, who trained as an emergency physician, believes that health is a public good and thus worthy of public investment in the things that will promote health in the future, like public education, breathable air, drinkable water, and the like.
Listen in.
The book is available through Amazon or your local bookseller. It’s published by Oxford University Press.
The post Podcast 226: What we need to talk about when we talk about health first appeared on Clinical Conversations.

Does the diabetes care afforded by NPs and PAs match that of MDs? According to a careful analysis among Veterans Affairs patients there are no clinical differences in intermediate outcomes — hemoglobin A1c, systolic pressure, or LDL cholesterol.
The principal and senior authors of that analysis are our guests this time.
Links:
Annals of Internal Medicine study (free abstract)
Annals editorial (Annals subscription required)
The post Podcast 225: Managing diabetes in primary care — are there quality differences among NPs, PAs, and MDs? first appeared on Clinical Conversations.

Rohan Khera wrote an editorial in The BMJ to accompany his own paper on guidelines for hypertension treatment. In it, he wrote, not about his research, but about the way biomedical articles are published now, and how preprint servers could change that. (In essence, pre-print servers are online repositories of rough drafts of research available for all to see; articles on such servers have not been subjected to peer review.)
Khera’s research article, it should be noted, originally appeared months earlier in draft form on BioRxiv, a biomedical preprint server.
Khera argues that the “official” journals are too slow. He fears their slowness. for instance, can prevent important data from reaching policymakers when it’s most needed — while they are making decisions based on new research languishing in the standard publication process.
Khera’s BMJ commentary
Khera et al.’s preprint on BioRxiv
Khera et al.’s resarch article as published in The BMJ
Conversation with Harlan Krumholz (from 2016): “Rethinking what medical journals do”
The post Podcast 224: What’s a “preprint server,” and how might it change how we think about journals? first appeared on Clinical Conversations.

If adopted, last December’s ACC/AHA guidelines on what pressure levels signal hypertension would label almost two thirds of the U.S. population between ages 45 and 75 as having the condition. The number of people who would be candidates for treatment would almost double — from 8 million to about 15 million.
What are the implications of this for clinicians?
Harlan Krumholz, senior author of an analysis in The BMJ, talks about the problems and the opportunities for collaboration with patients.
BMJ article (free)
The post Podcast 223: What are the implications of the BP guidelines? first appeared on Clinical Conversations.

This time we talk with Dr. Hilary Barnes, first author of a Health Affairs paper: “Rural and Nonrural Primary Care Physician Practices Increasingly Rely on Nurse Practitioners.”
I thought listeners might want to know more about the dramatic change in the way primary care is acquiring, in Barnes’s words, an “increasing interdisciplinary character.”
Health Affairs abstract
The post Podcast 222: Growing prominence of NPs in primary care first appeared on Clinical Conversations.