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For Patients with Drug-Eluting Stents, Extending Duration of Dual Antiplatelet Therapy from 12 to 30 Months May Decrease the Risk of Stent Thrombosis and Myocardial Infarction, but May Increase the Risk of Major Bleeding and Might Increase Noncardiovascular Mortality
Dual antiplatelet therapy is recommended for at least 12 months in patients having a percutaneous coronary intervention with a drug-eluting stent to reduce the risk of restenosis (Circulation 2011 Dec 6;124(23):e574-651). Extending the duration of DAPT may decrease the risk of stent thrombosis, but evidence on the efficacy of DAPT for > 1 year has been inconsistent (Am J Cardiol 2014 Jul 15;114(2):236, Am J Cardiol 2013 Feb 15;111(4):486). A recent randomized trial compared 12 vs. 30 months of treatment with thienopyridine (clopidogrel or prasugrel) plus aspirin (DAPT) in 9,961 patients (mean age 62 years, 75% male) having drug-eluting stent implantation.
All patients were treated with DAPT for 12 months before being randomized to a thienopyridine vs. placebo for an additional 18 months while aspirin therapy was continued indefinitely. Only patients adherent to therapy and without major adverse events during the first 12 months were eligible for randomization. Of the eligible patients, 50.9% had at least 1 risk factor for stent thrombosis. Between study months 12 and 30, extended 30-month DAPT was associated with reduced stent thrombosis (0.4% vs. 1.4%, p < 0.001 NNT 100) and reduced major adverse cardiovascular and cerebrovascular events (4.3% vs. 5.9%. p < 0.001 NNT 63) compared to standard 12-month DAPT. Extended 30-month DAPT was not without risks, however, as extended DAPT was associated with increased risk of moderate-to-severe bleeding (2.5% vs. 1.6%, p = 0.001 NNH 111). On further analysis, an increased risk of bleeding was observed for moderate bleeding only, with no significant differences in severe bleeding between groups. All-cause mortality during the 18-month randomization period was 2% in patients with extended DAPT vs. 1.5% with placebo (p = 0.05). Increased risk of stent thrombosis and myocardial infarction were observed for the first 3 months after thienopyridine discontinuation, regardless of treatment duration.
This trial suggests that increasing the duration of DAPT to 30 months after implantation of a drug-eluting stent decreases the risk of stent thrombosis as well as major cardiovascular and cerebrovascular events. Extended DAPT therapy was associated with a small increase in all-cause mortality, but this finding was driven by an increase in cancer-related deaths in patients with a cancer diagnosis before randomization. The difference in all-cause mortality between groups was no longer significant if patients with cancer diagnoses before randomization were excluded from analysis. Concerns have previously been raised about whether prasugrel promotes the development or progression of cancer (Arch Intern Med 2010 Jun 28;170(12):1078). Overall, there appears to be a cardiovascular benefit with extended treatment, but patients with pre-existing cancer may not see an overall benefit.
For more information, see the Antiplatelet and anticoagulant drugs for coronary artery disease topic in DynaMed.
Schouten HJ, Geersing GJ, Oudega R, et al. Accuracy of the Wells Clinical Prediction Rule for Pulmonary Embolism in Older Ambulatory Adults. J Am Geriatr Soc. 2014 Nov 3. doi: 10.1111/jgs.13080. (Original) PMID: 25366538
OBJECTIVES: To determine whether the Wells clinical prediction rule for pulmonary embolism (PE), which produces a point score based on clinical features and the likelihood of diagnoses other than PE, combined with normal D-dimer testing can be used to exclude PE in older unhospitalized adults.
DESIGN: Prospective cohort study. SETTING: Primary care and nursing homes.
PARTICIPANTS: Adults >/=60 clinically suspected of having a PE (N = 294, mean age 76, 44% residing in nursing home).
MEASUREMENTS: The presence of PE was confirmed using a composite reference standard including computed tomography and 3-month follow-up. The proportion of individuals with an unlikely risk of PE was calculated according to the Wells rule (
RESULTS: Pulmonary embolism occurred in 83 participants (28%). Eighty-five participants had an unlikely risk according to the Wells rule and a normal D-dimer test (efficiency 29%), five of whom experienced a nonfatal PE during 3 months of follow-up (failure rate = 5.9%, 95% confidence interval (CI) = 2.5-13%). According to a refitted diagnostic strategy for older adults, 69 had a low risk of PE (24%), two of whom had PE (failure rate = 2.9%, 95% CI = 0.8-10%).
CONCLUSION: The use of the well-known and widely used Wells rule (original or refitted) does not guarantee safe exclusion of PE in older unhospitalized adults with suspected PE. This may lead to discussion among professionals as to whether the original or revised Wells rule is useful for elderly outpatients.
In patients with obstructive sleep apnea, is continuous positive airway pressure or nocturnal oxygen therapy better for reducing blood pressure than usual care alone?
The use of continuous positive airway pressure (CPAP) in addition to education on sleep hygiene and healthy lifestyle led to lower mean arterial blood pressures in patients with obstructive sleep apnea (OSA) after 12 weeks as compared with either education alone or nocturnal oxygen therapy plus education, even in patients with well-controlled blood pressure at baseline. The absolute reduction was modest (~ 2.5 mmHg), but observational studies associate this level of reduction with a significant reduction in the likelihood of cardiovascular events. This study, however, was not powered to detect any change in patient-oriented outcomes. (LOE = 1b)
Gottlieb D, Punjabi N, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014;370(24):2276-2285.
|Study Design Randomized controlled trial (nonblinded)||Funding Government|
|Setting Outpatient (specialty)||Allocation Concealed|
Patients at 4 cardiology clinics with established cardiovascular disease (CVD) or CVD risk factors were screened for OSA with the Berlin questionnaire (which assesses the presence of snoring and cessation of breathing, daytime sleepiness, and obesity or hypertension), the Epworth Sleepiness Scale (which measures daytime sleepiness), and home sleep testing. The researchers randomized 318 patients with moderate to severe OSA to receive education on sleep hygiene and healthy lifestyle, education and CPAP treatment, or education and nocturnal oxygen therapy. Eligible patients were aged between 45 years and 75 years, scored positively on at least 2 of 3 domains on the Berlin questionnaire, and experienced 15 to 50 events per hour on the apnea-hypopnea index. The primary outcome was 24-hour mean arterial blood pressure. After excluding patients who did not complete blood pressure measurement at baseline and at 12 weeks, 281 (88%) participants were eligible for analysis. Baseline patient characteristics were similar across all 3 groups, save for the ratings of daytime sleepiness and the proportion of patients using alpha-adrenergic blockers. Half the participants had established CVD, 88% had hypertension, and the average 24-hour blood pressure was 124/71. After 12 weeks, both the CPAP and supplemental oxygen groups demonstrated greater than 60% reductions in the frequency of desaturation events. Mean duration of oxygen therapy use was significantly greater than CPAP use (4.8 ± 2.4 versus 3.5 ± 2.7 hours). The mean arterial blood pressure at 12 weeks was significantly lower in the CPAP group than in the education-only group (?2.4 mmHg; 95% CI, ?4.7 to ?0.1) and the supplemental oxygen group (?2.8 mmHg; ?5.1 to ?0.5). The authors suggest that this study offers no support for the largely untested clinical practice of salvage oxygen therapy in OSA patients.
Please attribute the authorship of this POEM to Lauren S. Hughes, MD, MPH, Robert Wood Johnson Foundation Clinical Scholar, Department of Family Medicine, University of Michigan, Ann Arbor, MI.
The following are excerpts from the remarks by Naval Adm. William H. McRaven, ninth commander of U.S. Special Operations Command, at the May 17th, 2014 Commencement at The University of Texas:
If you want to change the world,
- Start off by making your bed.
- Find someone to help you paddle.
- Measure a person by the size of their heart, not the size of their flippers.
- Get over being a sugar cookie and keep moving forward.
- Don’t be afraid of the circuses.
- Sometimes you have to slide down the obstacle head first.
- Don’t back down from the sharks.
- You must be your very best in the darkest moment.
- Start singing when you’re up to your neck in mud.
- Don’t ever, ever ring the bell.
Start each day with a task completed.
Find someone to help you through life.
Know that life is not fair and that you will fail often, but if take you take some risks, step up when the times are toughest, face down the bullies, lift up the downtrodden and never, ever give up—if you do these things, then next generation and the generations that follow will live in a world far better than the one we have today and—what started here will indeed have changed the world—for the better.
The 2013 Merritt Hawkins survey of inpatient and outpatient revenue generated for hospitals by different specialties contained some pleasant surprises for family docs.
Check out this YouTube clip for a short video of the data: http://youtu.be/Y38JYZvK-9Q
We don’t make the Top 5 in salary:
But look at the top 5 revenue generators:
And the Top 5 specialties by return on investment (dollars in revenue generated per dollar spent on salary):
Ob / Gyn
As it turns out, we spend more time multitasking than we ever have before, but studies show that 98% of us aren’t actually very good at it. Dozens of studies agree that both kids and adults are far less effective as learners, communicators and problem solvers when they’re distracted.
The reason it feels effortless to jump between hypertext links on Wikipedia or Twitter hashtags while we’re transcribing lecture notes or finishing up assignments is because we actually are expending less effort and, as a result, we’re also learning less. It’s much more productive to focus on one task at a time.
The graphic below breaks down the costs multitasking takes on the quality of the “study hours” we wile away doing just about everything but studying:
I am finally warming up to ICD 10. That’s good since it is coming next fall whether I like it or not. My clinic and hospital are in the midst of a top to down audit to find every process we need to change to be compliant. The answer is almost everything. It is difficult to underestimate how extensive this conversion will be. While I am not a big fan of ICD9 with its archaic and vague terminology, the breadth of this change made me reluctant to embrace the new system.
Learning more about ICD 10 has gradually changed my attitude. While the musculoskeletal and procedure codes will be more numerous and complex, the common chronic disease codes I use often will change little. The description is often the same while the number will change to a letter and number combination. Now I agree with the author below. It is time to accept this change and move forward.
ICD-9 vs. ICD-10: What’s the difference?
Brooke Andrus Friday, October 11, 2013
If you’re a proponent of the old “if it ain’t broke, don’t fix it” mentality, you might be a little reluctant to buy into all of this ICD-10 business. After all, you use ICD-9 now, and that seems to be working just fine. So why rock the boat?
Well, there’s another old saying that goes something like, “You don’t know what you’re missing until you reach out and touch it.” In this case, those still clinging to ICD-9 are completely overlooking the benefits of the new code set — things like improved interoperability , data-sharing, outcomes, and ultimately improved healthcare.
There’s no shortage of drawbacks to ICD-9. Chief among them: It’s 34 years old. Take a moment and think about the healthcare landscape 34 years ago. (Hint: People could still smoke in hospitals. Not a good sign.)
In addition to being old and outdated, ICD-9:
- Isn’t detailed enough to describe patient diagnoses and modern medical services and procedures
- Uses antiquated terminology
- Produces incorrect, limited patient data (cue the auditors)
So, what about ICD-10 makes it so much better than ICD-9? For starters, it has way more diagnosis codes — about 68,000 to ICD-9’s 13,000 — and in this case, more is definitely better. Why? Because with more codes, medical providers can more accurately document clinical information, including patient diagnoses.
And, as CMS points out , that leads to:
- Greater opportunity for evidence-based practice
- Better insight for optimizing grouping and reimbursement processes
- Less burden on clinicians to provide detailed supporting documentation
ICD-10 also provides much-needed updates to medical terminology and disease classification, as well as codes that allow for comparison of mortality and morbidity data. In case you haven’t noticed, “better data” is pretty much the battle cry of ICD-10, and justifiably so.
In addition to the data benefits I’ve already covered, the uberspecific code set will allow medical professionals to better:
- Evaluate patient care
- Support research initiatives
- Construct payment systems
- Process claims
- Make clinical decisions
- Observe public health trends
- Uncover fraud
Sure, the transition will be tough. No one’s arguing with that. But, to continue with the quotable cliché theme of this post, “No pain, no gain.” It’s our responsibility to propel the healthcare industry forward, and ICD-10 is a very important step in that process. So, stop clinging to ICD-9 — it belongs in the past, along with eight-tracks and leisure suits — and start embracing the future.
Check out this video for good basic information on the Affordable Care Act (Obamacare) :http://link.brightcove.com/services/player/bcpid601344150001?bckey=AQ%7E%7E%2CAAAAAG_HivY%7E%2CsgDjaI7wvss5F_Ibvao19TzWdI7m89OV&bctid=2549622229001
You can also go to this website for unbiased information. It is run by the Kaiser Family Foundation: http://kff.org/health-reform/
On Tuesday October 1st, one of the major parts of the Affordable Care Act takes effect. Many friends and patients have questions about what this means for them. This handout from the American Academy of Family Physicians summarizes the Health Insurance Marketplaces (Exchanges) which open on the 1st.
What is the Affordable Care Act?
The Affordable Care Act (ACA) became law on March 23, 2010, and it helps patients in many ways. Some of the benefits include:
- Free preventive health care appointments
- Health insurance coverage for you and/or your children, even if you have pre-existing conditions
- Coverage for people 26 years of age or younger, even for those who do not live with parents and are not students
- Maintenance of health insurance coverage, even if you get sick or become seriously ill
- No lifetime financial limits on benefits. This means that your health insurance plan is required to offer you the same benefits, even if you have a long or expensive illness.
- Creation of Health Insurance Marketplaces, which will open for enrollment on October 1, 2013.
What is a Health Insurance Marketplace?
Health Insurance Marketplaces can help you find the best health insurance plan for your needs and budget. All plans in Marketplaces will offer comprehensive coverage, and you will be able to compare available options, prices, and plans by filling out just one application. After you apply, you will learn whether you qualify for free or low-cost health care, such as Medicaid or the Children’s Health Insurance Program.
All health insurance plans in the Marketplaces are offered by private companies. Texas has allowed the United States Department of Health and Human Services to host the marketplace in our state. Access the Marketplace in your state.
Open enrollment in the Health Insurance Marketplaces will begin October 1, 2013, and health insurance coverage will begin as soon as January 1, 2014.
What are the different types of plans being offered?
All plans offered are required to include “essential health benefits.” These benefits will include:
- Emergency services
- Lab work coverage
- Maternity and newborn care
- Mental health care
- Outpatient services (health care you receive without being admitted to the hospital)
- Pediatric services
- Prescription drug coverage
- Preventive health services
- Rehabilitative services (services that help you regain physical and occupational skills after you have been injured or sick)
These are the basic services that all plans are required to offer you. However, you can also choose a plan that offers additional services. When the Marketplaces open, you will be able to compare different health insurance plans. Plans will be placed into four different categories based on how much you want to pay for your monthly premium. These levels are Bronze, Silver, Gold, and Platinum. The Platinum plan will have the highest monthly premium, and the Bronze plan will have the lowest monthly premium. Remember to keep in mind that the higher the monthly premium you pay, the lower your out-of-pocket costs will be for things like office visits or other medical services.
You will be able to view and compare specific plans when the Marketplaces open on October 1, 2013.
What if I have a pre-existing condition?
You cannot be denied health insurance coverage if you have a pre-existing health condition. A health insurance company also cannot charge you more or refuse to pay for treatments related to a pre-existing condition. Also, women will not have to pay higher costs than men for the same health insurance plan.
What if I can’t afford health insurance?
You may qualify for lower monthly premiums or lower out-of-pocket costs based on your income and your family size. If you qualify for lower premiums or out-of-pocket costs, those lower prices will be reflected when you review your insurance plan options. The application process will determine whether you qualify for lower costs or for free or low-cost care, such as Medicaid or the Children’s Health Insurance Program.
How do I get enrolled?
Once enrollment begins in October, you can go to the Marketplace application web page, create a personal account, fill out the application form, and be presented with various plans that meet your needs.
Before the Marketplaces open, you can create your personal account and find a checklist of information that you will need in order to complete your application, including information about your income, family size, and any health insurance coverage that you currently have.
What if I already have health insurance? Can I still use a Marketplace?
If you have health insurance through your employer, you can choose to keep your insurance or shop for a different plan in your state Marketplace. However, it is important to remember that your employer most likely pays part of your health insurance premiums, and if you decide to cancel your job-based health insurance, your employer is not required to help pay your premiums for a new plan that you pick through the Marketplaces.
What if I don’t get health insurance?
If you don’t have health insurance, and you choose not to select a plan through the Marketplaces, you will be responsible for all your medical costs, including office visits, immunizations, prescription medicines, and major medical services such as surgery and hospitalization. Also, starting in 2014, you will have to pay a fee for not having health insurance.
Where can I get more information about Health Insurance Marketplaces?
The following resources can help you learn more about the Marketplaces and your health insurance options.
. Healthcare.gov. Accessed July 15, 2013
. Enroll America. Accessed July 15, 2013
. Get Covered America. Accessed July 15, 2013
Written by familydoctor.org editorial staff