Primecuts – This Week In The Journals

January 17, 2012

By Matt Neimat, MD

Faculty Peer Reviewed

With the upcoming elections, a hot topic of debate is healthcare reform and it appears as though even the government is making New Year’s resolutions. A recent article in the Boston Globe detailed an interesting new healthcare intuitive: beginning on January 1 2012, 32 hospitals and doctor groups, including five in Massachusetts, launched a new healthcare model called Accountable Care Organizations (ACOs) aimed at improving care incentives while lowering healthcare costs [1]. ACOs contract with healthcare payers such as Medicare and Medicaid and are paid according to 33 quality measures. Seven of these measures will be based on patient surveys and include questions about access to appointments and specialists. Ideally, this system will create incentive for better care by awarding doctors with bonus payments for better outcomes and penalty fees for overspending and adverse outcomes. If physicians overspend healthcare dollars, they could be stuck with covering the cost themselves. Traditionally, doctors were only paid for face-to-face encounters, specific tests or treatments. With the new model, doctors will be compensated for consultations over the phone or via secure email when appropriate. In this system, physicians will be awarded for saving patients and the system money by keeping patients healthy and out of the hospital. Physicians will supposedly get to keep a portion of the money that they save Medicare patients, the remainder of the money saved is kept by the government. Officials predict that this program will save 1.1 billion over 5 years.

This system is an interesting shift in the incentive structure of the healthcare system, which is a traditionally for profit industry that has often been criticized for putting patients’ interests last. The exact nature of this proposal’s quality measures are not detailed in the article and are likely subject to change. As with any outcome-based incentive system, it will be very interesting to see how this structured agreement will deal with the risk of physicians selectively treating low-risk patients with a higher probability of good outcomes and avoiding patients with a high risk of adverse outcomes. The system will need to be structured in a way that incentivizes the treatment of chronically ill patients who are likely to decline and whos intervention only determines the rate of decline. This shift in the payment structure of healthcare will no doubt seed many heated debates in the near future and could have a large impact on the way we practice medicine but has good intentions towards keeping patients healthy and out of the hospital while lowering costs.

In a recent study with implications for keeping patients out of the hospital, the anticoagulant dabigatran has been associated with higher risk of MI in a paper published in The Archives of Internal Medicine [2]. This recent meta-analysis pooled randomized controlled trials of dabigatran that reported MI or ACS as a secondary outcome. The fixed-effects Mantel-Haenszel (M-H) test was then used to evaluate the effect of dabigatran on ACS or MI. Seven trials were selected with a total N = 30514. Control arms for these studies included warfarin, enoxaparin, or placebo administration. Dabigatran showed significantly higher incidence of ACS and MI than the control agents used (1.19% vs 0.79% OR = 1.33, P = 0.03). This study suggests that the use of dabigatran may be associated with some adverse outcomes but the mechanism is still unclear. Physicians should evaluate the risk and comorbidities before electing to use dabigatran until more is understood about this correlation.

In another study of oral anticoagulants, everyone’s favorite anti-platelet drug, aspirin, was evaluated for its role in preventing adverse outcomes in a paper also published in The Archives of Internal Medicine [3]. In this meta-analysis, 9 randomized placebo-controlled clinical trials were included, each with no fewer than 1000 participants for an N greater than 100,000 and included data on cardiovascular disease, nonvascular outcomes, and death. The authors abstracted data and odds ratios and combined them using random-effects meta-analysis. Risks vs. benefits were evaluated by comparing CVD risk reductions with increases in bleeding. This meta-analysis showed that during a mean (SD) follow-up of 6.0 years (2.1), aspirin treatment reduced total CVD events by 10% (OR, 0.90; 95% CI, 0.85-0.96; number needed to treat, 120), driven primarily by reduction in nonfatal MI (OR, 0.80; 95% CI, 0.67-0.96; number needed to treat, 162). There was no significant reduction in CVD death (OR, 0.99; 95% CI, 0.85-1.15) or cancer mortality (OR, 0.93; 95% CI, 0.84-1.03), and there was increased risk of nontrivial bleeding events (OR, 1.31; 95% CI, 1.14-1.50; number needed to harm, 73). Significant heterogeneity was observed for coronary heart disease and bleeding outcomes, which could not be accounted for by major demographic or participant characteristics.

This suggests that aspirin, although commonly used for prophylaxis of adverse endovascular events, is useful in preventing primary events but may not be useful in preventing death due to underlying CVD or other chronic endovascular illness. Given the risk of adverse bleeding events, the use of aspirin as prophylaxis is questionable in people with low risk for MI. Those without prior history or significant risk factors may not be good candidates for daily 81mg prophylaxis. Pt risk factors should be carefully evaluated and weighed against the risk of bleeding.

And lastly, for all those who promised themselves to be more active in the new year, a recent retrospective study, published in Medicine and Science in Sports and Exercise, compared the injury rates of middle and long-distance college runners and examined their footstrike habits, including the incidence and rate of specific injuries, the severity of each injury, and the rate of mild, moderate, and severe injuries per mile run [4]. Of the 52 runners studied, 36 (59%) primarily used a rearfoot strike (heel to toe) and 16 (31%) primarily used a forefoot strike. Approximately 74% of runners experienced a moderate or severe injury each year, but those who habitually rearfoot strike had approximately twice the rate of repetitive stress injuries than individuals who habitually forefoot strike. Traumatic injury rates were not significantly different between the two groups. A generalized linear model showed that strike type correlates significantly (p<0.01) with repetitive injury rates. The authors noted that one hypothesis, which requires further research, is that the absence of a marked impact peak during forefoot strike compared to a rearfoot strike may contribute to lower rates of injuries in habitual forefoot strikers.

This study may suggest that for the competitive college runner, rearfoot strike may have significantly higher rates of repetitive stress injury but can this be applied to a slightly older and less active population of former runners such as medical students and, more so, medical residents? It may be true that any amount of repetitive stress whether forefoot, midfoot, or rearfoot may cause significant stress injury in this older, less-conditioned population. In addition, this study does address the growing variety of running footwear, such as the minimalist movement. This new theory in running uses less to no material and has already made significant claims as to the prevention of running injuries by the distribution of forces across naturally interacting bones and in the foot. Many endorsing this movement have suggested that padded shoes have created a relatively shortened achilles tendon with a large heel cushion. This, it is theorized, could cause a more natural midfoot strike when running barefoot due to a shortened plantar flexion. This could account for the anecdotal decrease in injury seen with these minimalist shoes. More research is warranted to better understand proper running for injury reduction.

Early in this New Year we have already had the promise of many new developments in the field of medicine. There is a significant election approaching in which issues central to our vocation and practice are a focus. There is the opportunity for significant change, which may allow us to practice in a system that supports the best interest of our patients as we do. Much of what we are doing by reading articles and furthering our understanding is in an effort to optimize care. The prospect of practicing in a system that shares these same goals, while somehow managing the monetary implications, seems idealistic. Yet it is the optimism of this New Year that allows us to imagine the possibilities and contribute to the process.

Dr. Matt Neimat is a 1st year resident at NYU Langone Medical Center

Peer reviewed by Barbara Porter, MD, section editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References:

1. Conaboy, Chelsea. Understanding Accountable Health Care organizations. The Boston Globe, January 9, 2012. http://www.bostonglobe.com/lifestyle/health-wellness/2012/01/09/understanding-accountable-health-care-organizations/nuQjojrpZiOkzk1kwD79LO/story.html

2. Uchino K, Hernandez AV. Dabigatran Association With Higher Risk of Acute Coronary Events: Meta-analysis of Noninferiority Randomized Controlled Trials. Arch Intern Med. Published online January 9, 2012. doi:10.1001/archinternmed.2011.1666 http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.1666

3. Seshasai SRK, Wijesuriya S, Sivakumaran R, Nethercott S, Erqou S, Sattar N, Ray KK. Effect of Aspirin on Vascular and Nonvascular Outcomes: Meta-analysis of Randomized Controlled Trials. Arch Intern Med. 2012;0(2012):20116281-8.  http://www.ncbi.nlm.nih.gov/pubmed/22231610

4. Daoud AI, Geissler GJ, Wang F, Saretsky J, Daoud YA, Lieberman DE. Foot Strike and Injury Rates in Endurance Runners: a retrospective study. Med Sci Sports Exerc. 2012 Jan 3. http://www.ncbi.nlm.nih.gov/pubmed/22217561

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