Friday, February 17, 2012

The Tiniest Three Year Sinusitis Trial

Yet again, another article that saturated the lay press due to its publication in JAMA - this time regarding amoxicillin for acute sinusitis.

The problem is, I agree with the fundamental point the authors are making - according to the introduction, antibiotics for sinusitis account for 1 in 5 antibiotic prescriptions in the United States and they're typically unnecessary, especially in an era where better antibiotic stewardship is needed.  However, I cannot imagine how a multicenter study of ten community clinics in St. Louis over three years only managed to enroll 166 adults into this study over the course of three years.  Their recruitment diagram states only 244 patients were assessed for eligibility - which seems like it ought to be a a couple months worth of URI presentations in an outpatient setting.

If you read the newspaper, you already know the main results - "no difference between 10 days of amoxicillin and placebo."  But 11 of 85 intervention group patients discontinued treatment, as well of 12 of 81 placebo patients.  Due to lost data, 4 of 85 intervention patients were excluded from analysis, as well as 7 of 81 placebo patients.  Then, 32% of patients in the intervention group were non-compliant with the intervention - so, while this is valid in a real-world effectiveness sense, they're increasingly no longer relevant to the actual efficacy of the intervention.  These are big holes in a small study.

And, bizarrely, the baseline characteristics they use to describe the two groups include more social characteristics than clinical characteristics - healthcare insurance, family income, etc.  Children living in the home, children in day care, etc., is an interesting demographic criteria, suggesting unique infectious exposure - 9% more intervention group patients had children at home, but this isn't statistically significant because the sample sizes are so tiny.  Then, the clinical characteristics they chose only seem to partially reflect issues relevant to antibiotic efficacy - "usual health excellent or good" isn't a very useful descriptor of whether they have impaired baseline immune function that places them at increased risk of significant bacterial superinfection.  For what it's worth, the control group was significantly "healthier", but also had significantly more smoking history.

Getting back to the main results - yes, the average SNOT-16 scores were equal at day 0, 3 and 10, but favored the intervention at day 7 - leading to their final conclusion that amoxicillin was of no benefit.  But, at the individual patient level, the control group patients were impaired from their usual activities almost 50% longer - 1.67 days vs. 1.15 days, and there was a 12% absolute difference in satisfaction with treatment favoring the intervention - 53% vs. 41 %.  But, due to the tiny sample size, none of these differences reached statistical significance.

In the end, it's a fair real-world trial and addition to the literature, but it's far too small and flawed a trial to stand on to as evidence.

Oddly, one of the authors receives royalties for the SNOT-16 scale.

"Amoxicillin for Acute Rhinosinusitis: A Randomized Controlled Trial"
http://jama.ama-assn.org/content/307/7/685

Thursday, February 16, 2012

Bunnahabhain, Highland Park, Ardbeg

I had a request for a Scotch posting again - and, it has been about six months since I made a Scotch post - so, here's what's left on my shelf at the moment.



 - Bunnahabhain 28-year Signatory Collection.  This was a gift Scotch that is, essentially, my major celebration Scotch.  Cardinals won the World Series, bought a house, got a grant, etc.  Smooth and tastes like caramel.
 - Highland Park 18.  Has won several sort of "Scotch of the Year" type awards.  It's not as complex as other Scotches I've had, but it's sort of a sweet, smooth Scotch that will likely appeal to a wide variety of drinkers.
 - Ardbeg Alligator.  In contrast, this will not appeal to a wide variety of drinkers.  It is a peaty, burning, smoky/charcoal Scotch that has a very distinct taste acquired from being aged in charred barrels.  It's not for everyone, and it takes a little bit of water to soften up, but the uniqueness outweighs the harshness.

I'm lucky enough to live, literally, within walking distance of the world's largest liquor store, so typically when I'm shopping for Scotch, I have plenty to choose from.  I've also given the Octomore 3.1/152 as a gift, which was the fourth edition in their super-phenolic distillations, and it makes for a very uniquely peaty, nose-filling sensation that lasts forever.  Hard to find, but absolutely well worth it.  Comes in a kind of silly black matte bottle, however:

Patients: More Satisfied, More Dead?

Another article pulled out of the mainstream media - and one that highlights an issue many are familiar with: patient satisfaction.  There isn't an ED out there whose medical director doesn't know their patient satisfaction scores, whether Press-Ganey or their own evaluations, and many EPs compensation (or employment) is tied to their patient satisfaction.  And, we've argued time and time again that patient satisfaction has nothing to do with high-quality care, and that it's insulting to degrade medical practice to customer service.

Now, this prospective cohort study of 36,428 patients from Archives demonstrates an association between patient satisfaction with their primary care physician and worse health outcomes.  They used the "Consumer Assessment of Health Plans Survey", which included four items of interest to the authors: whether the physician listened carefully, explained things well, showed respect, and spent enough time with the patient.  There was also a fifth overall item of general health care rating for all their physician visits from the past year.

For a huge data set with a lot of granularity, the authors, unfortunately, don't report the unadjusted mortality - which seems like it would be appropriate, when the major selling point is that mortality difference.  But, in any event, a few of the interesting adjusted associations:
 - Black race was more likely to be satisfied with their physicians. (1.17)
 - College graduates were less likely to be satisfied with their physicians. (0.78)
 - Public insurance was more likely to be satisfied with their physicians. (1.14)
 - Those in poor health were more likely to be satisfied with their physicians. (1.33)

That last item - the poor health - could potentially explain all the mortality difference.  They report unadjusted percentages for the rest of their measures, in addition to the adjusted OR, and then their main results come out: more satisfied patients are less likely to show up in the ED, more likely to be admitted, consumed slightly more healthcare dollars, and had slightly more prescription drug expenditures.  And, then, finally, the 1.26 increased hazard ratio for mortality.  Interestingly enough, when patients who have self-reported poor health and more than three chronic diseases are removed, the hazard ratio increases to 1.44.

So, satisfied patients in fairly good health, on whom more healthcare dollars are being expended, have significantly worse outcomes?  There must be more to this story than just patient satisfaction - which, unfortunately, seems to be all the lay press focuses on.

"The Cost of Satisfaction"

Tuesday, February 14, 2012

Automagical Problem Lists

This is a nice informatics paper that deals mostly with problem lists.  These are meticulously maintained (in theory) by inpatient and ambulatory physicians to accurately reflect a patient's current medical issues.  Then, when they arrive in the ED, you do your quick chart biopsy from the EMR, and you can rapidly learn about your patient.  However, these lists are invariably inaccurate - studies show they'll appropriately be updated with breast cancer 78% of the time, but as low as 4% of the time for renal insufficiency.  This is bad because, supposedly, accurate problem lists lead to higher-quality care - more CHF patients receiving ACE or ARBs if it was on their diagnosis list, etc.

These authors created a natural language processing engine, as well as a set of inference rules based on medications, lab results, and billing codes for 17 diagnoses, and implemented an alert prompt to encourage clinicians to update the problem list as necessary.  Overall, 17,043 alerts were fired during the study period, and clinicians accepted the recommendations of 41% - which could be better, but it's really quite good for an alert.  As you might expect, the study group with the alerts generated 3 times greater additions to the patient problem lists.  These authors think this is a good thing - although, I have seen some incredible problem list bloat.

What's interesting is that a follow-up audit of alerts to evaluate their accuracy based on clinical reading of the patient's chart estimated the alerts were 91% accurate - which means all those ignored alerts were actually mostly correct.  So, there's clearly still a lot of important work that needs to go into finding better ways to integrate this sort of clinical feedback into the workflow.

So, in theory, better problem lists, better outcomes.  However, updating your wife's problem list can probably wait until after Valentine's Day.

"Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial."
www.ncbi.nlm.nih.gov/pubmed/22215056

Sunday, February 12, 2012

Eat Your Vegetables!

This may be a candidate for an IgNobel Prize, published as a research letter in JAMA: how to get schoolchildren to eat their vegetables!

Control group: normal lunch trays.  Intervention group: lunch trays with compartments specifically labeled with photographs of green beans and carrots.  Results: success!  Green bean choice went from 6.3% of children to 14.8% of children, and carrot choice went from 11.6% to 36.8%.  Amount of green bean and carrot consumption was stable on an individual basis, resulting in an overal net consumption of both green beans and carrots by their cohort.

Of course, this was only a single day intervention - my guess is the effect would fatigue - but, at least, for one day, children ate more vegetables.

This has far-reaching implications for Emergency Medicine.

"Photographs in Lunch Tray Compartments and Vegetable Consumption Among Children in Elementary School Cafeterias"
http://jama.ama-assn.org/content/early/2012/01/31/jama.2012.170.full