Recent Papers that Shaped My Practice Alan Dow, MD, MSHA Virginia Commonwealth University

1. March 1st, 2013 Recent Papers thatShaped My PracticeAlan Dow, MD, MSHAVirginia Commonwealth University

2. 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.

3. Question For patients on dialysis, statin therapy decreases mortality by: • 0% • 15% • 33% • 50% • 75%

4. CKD & Statinvs 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.

5. Statin benefit: • ~20% for non-dialysis pts • No benefit for dialysis patients • Uncertain benefits for transplant patients Palmer SC et al. Ann Intern Med. 2012;157(4):263-275.

6. 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

7. Question For pregnant women with periodontal disease, using antimicrobial mouthwash cuts the risk of preterm birth by: • 0% • 10% • 33% • 50% • 75%

8. 6-20 weeks gestation • Periodontal disease • Refused mechanical dental care • Matched by smoking status, prior preterm birth (< 35 wks) 226 pregnant women 71 antimicrobial mouth rinse 155 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 p < 0.01 for all comparisons Jeffcoat M et al. Am J of OB and Gyn. 2011

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

10. 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 and objectives. 10. Advance the goals and objectives of Healthy People 2020. Advancing Oral Health in America. IOM. 2011

11. 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?

12. Question Compared 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? • No change • 10% decrease • 25% decrease • 50% decrease • 75% decrease

13. 3 question Partner Violence Screen • +  support video and resources 2708 women in primary care settings Computerized screening  video/ resource list Resource list; no screening No resources; no screening Quality of life, lost days of work and household activities, hospitalizations, ED visits, annual incidence of partner violence Klevens J et al. JAMA. 2012

14. 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

15. 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

16. 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? • Repeat course of PO vancomycin • A course of PO fidaxomicin • Duodenal infusion of donor feces • PO and IV metronidazole

17. 43 Patients with recurrent C. Diff • Failed 1 course of PO vancomycin or flagyl 17 pts: donor-feces infusion 13 pts: PO vancomycin and bowel lavage 13 pts: PO vancomycin Cure without relapse in 10 weeks van Nood E et al. NEJM. 2013. 368:407-15.

18. 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

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

20. Fidaxomicin and C. diff • Cure and recurrence 629 pts with C. diff Vancomycin 125 mg PO every 6 hours Fidaxomicin 200 mg PO every 12 hours Louie TJ et al. NEJM. 2011. 364(5):422-31.

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

22. 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: ???

23. 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 enchephalopathyprevention (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)

24. Question In order to decrease hospitalizations in high-risk Medicare patients, care coordination programs should: • Provide intense medication management • Focus on transitions of care • Act as a communication hub for all providers • Educate patients about their disease states • Provide all of the above services or the program will not be successful

25. 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) CMS Care Coordination Demonstration Projects: Decrease utilization in high-risk Medicare patients Four successful: 8-33% decrease in hospitalizations 11 unsuccessful: No change or increase in hospitalizations • 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.

26. PCP Hospitalist Patient Care Coordinator Pharmacist

27. 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?

28. Question How many additional adults would need to be covered by Medicaid to prevent 1 death per year? • 14 • 176 • 898 • 156,358 • Expanding Medicaid does not reduce mortality.

29. Adjusted comparisons five years before and after Medicaid expansion of CDC mortality data Sommers BD et al. NEJM. 2012;367:1025-1034

30. −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

31. 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

32. 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.

33. Question When Medicaid was expanded in Massachusetts in a fashion similar to the PPACA, which of the following was not observed? • For the first 3 years, only administrative positions were added to the healthcare workforce • The wait time for primary care almost doubled • Costs were as budgeted • Patient satisfaction improved

34. 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)

35. 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

36. Questions and Discussion awdow@vcu.edu @alan_dow