Clinical Health Updates

Asking “Is there something else?” decreases patients’ unmet concerns

Clinical Question:
Can specific wording make a difference in addressing patients’ unmet concerns?

Bottom Line:
After eliciting a patient’s chief concern, asking “Is there something else you want to address in the visit today?” decreases the likelihood of them leaving with unmet concerns. Asking this variation of the more typical, “Is there anything else you want to address in the visit today?” did not increase the average visit duration. The authors did not study whether patient satisfaction was improved.

Reference:
Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients’ unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007;22(10):1429-1433.

Study Design:
Cross-sectional

Synopsis:
In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed. The investigators test an intervention to reduce patients’ unmet concerns. They did a cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys. Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania were included. A volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition. After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition). Patients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys. Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.

NT-BNP reduces cost and rehospitalization rates in dyspneic patients.

Clinical Question:
Does the use of B-natriuretic peptide testing improve clinical and economic outcomes in patients hospitalized with dyspnea?

Bottom Line:
The use of the N-terminal B natriuretic peptide (NT-BNP) reduces the cost of care, the length of the emergency department (ED) visit, and the likelihood of rehospitalization when used in the evaluation of patients presenting to the ED with dyspnea. However, it does not reduce mortality or hospital length of stay.

Reference:
Moe GW, Howlett J, Januzzi JL, Zowall H; Canadian Multicenter Improved Management of Patients With Congestive Heart Failure (IMPROVE-CHF) Study Investigators. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian Prospective Randomized Multicenter IMPROVE-CHF study. Circulation 2007;115(24):3103-3110.

Study Design:
Randomized controlled trial (single-blinded)

Synopsis:
Sometimes new tests are just, well, more tests. Ultimately, we should not only ask whether a new test is accurate (disease-oriented evidence), but also ask whether the use of the test improves clinical outcomes. This is one of the few studies to do just that. The authors of this study, sponsored by the test manufacturer, identified 534 adults presenting to a Canadian ED with dyspnea. Patients with advanced renal disease, acute myocardial infarction, malignancy, and dyspnea due to “clinically overt” origins, such as pneumothorax or chest trauma, were excluded, leaving 500 patients for the final study. The ED physician was asked to commit to a diagnosis of heart failure or no heart failure without knowledge of NT-BNP. Patients were then randomized to receive care guided by NT-BNP or care without knowledge of that test result. The results of the test were given to the ED physician and all physicians involved in the patient’s care, and the test was repeated 72 hours later in hospitalized patients. The final diagnosis of heart failure (present in 46% of patients) was made by 2 cardiologists who were given all of the clinical data except the NT-BNP result (having knowledge of the NT-BNP result as part of the reference standard would bias the study and inflate the accuracy of the test).

Patients were followed up at 60 days for clinical and economic outcomes. Groups were balanced at the start of the study, and analysis was by intention to treat. Patients in the group whose care was informed by the NT-BNP result had a shorter ED visit (5.6 vs 6.3 hours; P = .03), lower total direct cost (CAN $5180 vs $6129; P = .02), and fewer rehospitalizations (13% vs 20%; P = .046). There was also a nonsignificant trend toward less use of outpatient diagnostic testing, but no difference in hospital length of stay or mortality rates. Benefits were greater in patients with an intermediate clinical probability of heart failure; that is, those for whom the diagnosis was in question. The researchers also looked at the accuracy of clinical judgment alone versus judgment supplemented by the NT-BNP result, and found that the test increased the accuracy of diagnosis (area under the receiver operating characteristic curve 0.90 vs 0.83, where 1.0 = a perfect test and 0.5 = a worthless test).

Second-line antibiotics more effective than first-line in AECB

Clinical Question:
Are second-line antibiotics more effective for the treatment of acute exacerbation of chronic bronchitis than first-line antibiotics?

Bottom Line:
Compared to first-line antibiotics, second-line antibiotics are more effective, but not less safe, when administered to patients with AECB. The available data did not allow for stratified analyses according to the presence of risk factors for poor outcome, such as increased age, impaired lung function, airway obstruction, and frequency of exacerbations; this fact should be taken into consideration when interpreting the findings of this metaanalysis.

Reference:
Dimopoulos G, Siempos II, Korbila IP, Manta KG, Falagas ME. Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a meta-analysis of randomized controlled trials. Chest 2007;132:447-55.

Study Design:
Meta-analysis (randomized controlled trials)

Synopsis:
Although first-line antibiotics are still recommended by most guidelines as the treatment of choice for patients with AECB, increasing resistance to these antibiotics has prompted many clinicians to reconsider that choice. The authors identified 12 randomized controlled trials with 2261 adults that compared first-line antibiotics (amoxicillin, ampicillin, pivampicillin, trimethoprim sulfamethoxazole, and doxycycline) with broad-spectrum antibiotics (amoxicillin/clavulanic acid, cefaclor, macrolides, and quinolones). Nine studies were double-blinded and 3 were single-blinded; the study quality was judged as good for for all but 2 studies. However, only 2 studies reported data on the basis of intention to treat. Also, many studies included both inpatients and outpatients, which might cloud the analysis. The mean age of patients was approximately 60 years for most studies. The primary outcome was treatment success; only 5 studies reported mortality data, and there were too few deaths for useful analysis (7 – 10 in each group). First-line antibiotics were less likely to result in treatment success than broad-spectrum antibiotics (odds ratio = 0.51; 95% CI, 0.34 – 0.75). The authors performed subgroup analyses and found similar results when they included only double-blinded studies, only studies after 1991, and only studies rated as “good quality.” They did not find an advantage to second-line antibiotics when the analysis was limited to older studies.

Once-weekly tai chi decreases rate of falls in the elderly

Clinical Question:
Does once-weekly tai chi prevent falls in the elderly?

Bottom Line:
One hour of tai chi a week for 16 weeks modestly decreases the rate of falls in community-dwelling elderly patients.

Reference:
Voukelatos A, Cumming RG, Lord SR, Rissel C. A randomized, controlled trial of tai chi for the prevention of falls: the Central Sydney tai chi Trial. J Am Geriatr Soc 2007;55:1185-1191.

Study Design:
Randomized controlled trial (nonblinded)

Synopsis:
Prior studies have found that twice-weekly tai chi prevents falls in community-dwelling elders. In this study, the researchers evaluated a 16-week program of tai chi. The sessions lasted 1 hour and were led by instructors with at least 5 years’ experience or who completed an accredited trainer’s course. The patients had to be at least 60 years of age and living in the community.The patients were recruited via newspaper adds and randomized to the intervention group (n=353) or to the control group (n=349). The control patients were able to participate in the tai chi program at the conclusion of the study. The researchers excluded anyone with degenerative neurological conditions (such as Parkinson?s disease), dementia, a severely debilitating stroke, severe arthritis, marked vision impairment, if they had done tai chi during the previous year, or if they were unable to walk across a room unaided. Approximately 85% of the patients in both groups rated themselves as generally healthy and the mean age was 69 years (considered young elderly). The participants and control patients were followed up for 8 weeks after completing the program to see how many falls occurred by the end of the program and 8 weeks later. At the end of the study, only 18 patients dropped out (6 from the intervention group, 12 from the control group). At the end of the 16-week program, there was no difference in the rate of falls; however, 8 weeks after completing the program, the rate of falls in the intervention group was 33% lower than in the control group (P=.02). Although the number of patients with multiple falls was quite small, tai chi was most effective in preventing these types of falls.

No long-term harm from medical abortion

Clinical Question:
What are the long-term health consequences of medical abortion?

Bottom Line:
Subsequent pregnancy outcomes are similar after medical abortion using prostaglandins to the outcomes after surgical abortion.

Reference:
Virk J, Zhang J, Olsen J. Medical abortion and the risk of subsequent adverse pregnancy outcomes. N Engl J Med 2007;357:648-653.

Study Design:
Cohort (prospective)

Synopsis:
The long-term safety of surgical abortion in the first trimester is well established. Despite the increasing use of medical abortion (abortion by means of medication), limited information is available regarding the effects of this procedure on subsequent pregnancies. The authors identified all women living in Denmark who had undergone an abortion for nonmedical reasons between 1999 and 2004 and obtained information regarding subsequent pregnancies from national registries. Risks of ectopic pregnancy, spontaneous abortion, preterm birth (at <37 weeks of gestation), and low birth weight (<2500 g) in the first subsequent pregnancy in women who had had a first-trimester medical abortion were compared with risks in women who had had a first-trimester surgical abortion. Among 11,814 pregnancies in women who had had a previous first-trimester medical abortion (2710 women) or surgical abortion (9104 women), there were 274 ectopic pregnancies (respective incidence rates, 2.4% and 2.3%), 1426 spontaneous abortions (12.2% and 12.7%), 552 preterm births (5.4% and 6.7%), and 478 births with low birth weight (4.0% and 5.1%). After adjustment for maternal age, interval between pregnancies, gestational age at abortion, parity, cohabitation status, and urban or nonurban residence, medical abortion was not associated with a significantly increased risk of ectopic pregnancy (relative risk, 1.04; 95% confidence interval [CI], 0.76 to 1.41), spontaneous abortion (relative risk, 0.87; 95% CI, 0.72 to 1.05), preterm birth (relative risk, 0.88; 95% CI, 0.66 to 1.18), or low birth weight (relative risk, 0.82; 95% CI, 0.61 to 1.11). Gestational age at medical abortion was not significantly associated with any of these adverse outcomes.

Improving first impressions on patients is easy

Clinical Question:
How do patients expect to be greeted by their physician?

Bottom Line:
According to this telephone survey, patients prefer physicians who greet them with a simple handshake, who address them by their first name or first and last names, and who introduce themselves as “Dr Smith” or “Sara Smith,” but not as “Sara.”

Reference:
Makoul G, Zick A, Green M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med 2007;167:1172-1176.

Study Design:
Cross-sectional

Synopsis:
Widely used models for teaching and assessing communication skills highlight the importance of greeting patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting. To obtain data on patient expectations for greetings, the authors asked closed-ended questions about preferences for shaking hands, use of patient names, and use of physician names in a computer-assisted telephone survey of adults in the 48 contiguous United States. They also analyzed an existing sample of 123 videotaped new patient visits to characterize patterns of greeting behavior in everyday clinical practice. Most (78.1%) of the 415 survey respondents reported that they want the physician to shake their hand, 50.4% want their first name to be used when physicians greet them, and 56.4% want physicians to introduce themselves using their first and last names; these expectations vary somewhat with patient sex, age, and race. Videotapes revealed that physicians and patients shook hands in 82.9% of visits. In 50.4% of the initial encounters, physicians did not mention the patient’s name at all. Physicians tended to use their first and last names when introducing themselves.

For severe secondary peritonitis, on-demand relaparotomy > planned relaparotomy

Clinical Question:
In patients with secondary peritonitis who undergo initial emergent laparotomy, does planned relaparotomy reduce morbidity, mortality, and costs over on-demand relaparotomy?

Bottom Line:
Mortality rates did not differ between the 2 approaches, but on-demand laparotomy resulted in reduced intensive care unit (ICU) length of stay, reduced overall hospital length of stay, and decreased costs.

Reference:
van Ruler O, Mahler CW, Boer KR, et al, for the Dutch Peritonitis Study Group. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis. JAMA 2007;298:865-873.

Study Design:
Randomized controlled trial (nonblinded)

Synopsis:
In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparotomy:
1. planned relaparotomy
2. relaparotomy

Only when the patient’s condition demands it (“on-demand”). The on-demand strategy may reduce mortality, morbidity, health care utilization, and costs. However, randomized trials have not been performed.

The investigators compared
1. patient outcome
2. health care utilization
3. costs of on-demand and planned relaparotomy.

They did a randomized, nonblinded clinical trial of patients who had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater
1. 2 academic teaching hospitals in the Netherlands from November 2001 through February 2005
2. 5 regional teaching hospitals in the Netherlands from November 2001 through February 2005

End Points are.
1. The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period.
2. Secondary end points included health care utilization and costs.

A total of 232 patients (116 on-demand and 116 planned) were randomized. One patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis and 3 in each group withdrew or were lost to follow-up. There was no significant difference in primary end point (57% on-demand [n = 64] vs 65% planned [n = 73]; P = .25) or in mortality alone (29% on-demand [n = 32] vs 36% planned [n = 41]; P = .22) or morbidity alone (40% on-demand [n = 32] vs 44% planned [n = 32]; P = .58). A total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group. A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned group (P <.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P = .001) and shorter median hospital stays (27 vs 35 days; P = .008). Direct medical costs per patient were reduced by 23% using the on-demand strategy.

Dressing choice unimportant for leg ulcers

Clinical Question:
Which dressing is best when used under a pressure bandage for venous leg ulcers?

Bottom Line:
The type of dressing applied beneath compression was not shown to affect ulcer healing. The results of the meta-analysis showed that applying hydrocolloid dressings beneath compression produced no benefit in terms of ulcer healing compared with applying simple low adherent dressings. No conclusive recommendations can be made as to which type of dressing is most cost effective. Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practitioner or patient.

Reference:
Palfreyman S, Nelson EA, Michaels JA. Dressings for venous leg ulcers: systematic review and meta-analysis. BMJ 2007;335:244.

Study Design:
Meta-analysis (randomized controlled trials)

Synopsis:
The authors reviewed the evidence of effectiveness of dressings applied to venous leg ulcers. They did a systematic review and meta-analysis of hand searches of journals and searches of electronic databases, conference proceedings, and bibliographies up to April 2006; contacts with dressing manufacturers for unpublished studies. The authors reviewed all randomised controlled trials that evaluated dressings applied to venous leg ulcers were eligible for inclusion. Data from eligible studies were extracted and summarised independently by two reviewers using a data extraction sheet. Methodological quality was assessed independently by two reviewers. The search strategy identified 254 studies; 42 of these fulfilled the inclusion criteria. Hydrocolloids were no more effective than simple low adherent dressings used beneath compression (eight trials; relative risk for healing with hydrocolloid 1.02, 95% confidence interval 0.83 to 1.28). For other comparisons, insufficient evidence was available to allow firm conclusions to be drawn. None of the dressing comparisons showed evidence that a particular class of dressing healed more ulcers. Some differences existed between dressings in terms of subjective outcome measures and ulcer healing rates. The results were not affected by the size or quality of trials or the unit of randomisation. Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of different dressings.

Cognitive functioning improved by correcting anemia in young women

Clinical Question:
Does treatment improve cognitive abilities in young women with iron deficiency anemia?

Bottom Line:
Women with iron deficiency anemia, on average, perform worse on cognitive tests than women who have sufficient iron stores. Treatment over 4 months improved measures of cognitive performance (accuracy), as well as the speed of performing the tasks.

Reference:
Murray-Kolb LE, Beard JL. Iron treatment normalizes cognitive functioning in young women. Am J Clin Nutr 2007;85:778-787.

Study Design:
Randomized controlled trial (double-blinded)

Synopsis:
Evidence suggests that brain iron deficiency at any time in life may disrupt metabolic processes and subsequently change cognitive and behavioral functioning. Women of reproductive age are among those most vulnerable to iron deficiency and may be at high risk for cognitive alterations due to iron deficiency. The authors examined the relation between iron status and cognitive abilities in young women. A blinded, placebo-controlled, stratified intervention study was conducted in women aged 18-35 y of varied iron status who were randomly assigned to receive iron supplements or a placebo. Cognition was assessed by using 8 cognitive performance tasks (from Detterman’s Cognitive Abilities Test) at baseline (n = 149) and after 16 wk of treatment (n = 113). At baseline, the iron-sufficient women (n = 42) performed better on cognitive tasks (P = 0.011) and completed them faster (P = 0.038) than did the women with iron deficiency anemia (n = 34). Factors representing performance accuracy and the time needed to complete the tasks by the iron-deficient but nonanemic women (n = 73) were intermediate between the 2 extremes of iron status. After treatment, a significant improvement in serum ferritin was associated with a 5-7-fold improvement in cognitive performance, whereas a significant improvement in hemoglobin was related to improved speed in completing the cognitive tasks.

Bariatric surgery reduces all-cause mortality in morbidly obese

Clinical Question:
Does bariatric surgery reduce all-cause mortality?

Bottom Line:
This nonrandomized controlled trial showed that bariatric surgery results in sustained weight loss of 14% to 25% after 10 years and also reduces all-cause mortality.

Reference:
Sjostrom L, Narbro K, Sjostrom CD, et al, for the Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741-752.

Study Design:
Non-randomized controlled trial

Synopsis:
Obesity is associated with increased mortality. Weight loss improves cardiovascular risk factors, but no prospective interventional studies have reported whether weight loss decreases overall mortality. In fact, many observational studies suggest that weight reduction is associated with increased mortality. They did a prospective, controlled Swedish Obese Subjects study involved 4047 obese subjects. Of these subjects, 2010 underwent bariatric surgery (surgery group) and 2037 received conventional treatment (matched control group). We report on overall mortality during an average of 10.9 years of follow-up. At the time of the analysis (November 1, 2005), vital status was known for all but three subjects (follow-up rate, 99.9%). The average weight change in control subjects was less than +/-2% during the period of up to 15 years during which weights were recorded. Maximum weight losses in the surgical subgroups were observed after 1 to 2 years: gastric bypass, 32%; vertical-banded gastroplasty, 25%; and banding, 20%. After 10 years, the weight losses from baseline were stabilized at 25%, 16%, and 14%, respectively. There were 129 deaths in the control group and 101 deaths in the surgery group. The unadjusted overall hazard ratio was 0.76 in the surgery group (P=0.04), as compared with the control group, and the hazard ratio adjusted for sex, age, and risk factors was 0.71 (P=0.01). The most common causes of death were myocardial infarction (control group, 25 subjects; surgery group, 13 subjects) and cancer (control group, 47; surgery group, 29).