Primecuts – This Week In The Journals

September 24, 2012

By Gregory Katz, MD

Faculty Peer Reviewed

This week the presidential race continues to monopolize the news cycle with Mitt Romney’s leaked fundraiser footage dominating the headlines. But as Governor Romney attempts to distance himself from his comments about Americans who pay no federal income taxes and President Obama pounces on his gaffes, a report[i] from the Center for Public Integrity on changes to hospital billing practices that are costing Americans billions got lost in the shuffle. Analysis from Donald Berwick, former head of Centers for Medicare and Medicaid, suggests that most of these cost increases are from physicians better targeting vulnerabilities in Medicare’s payment system. This report piggybacks on a paper[ii] earlier this year from the Office of Inspector General suggesting that electronic medical records facilitate Medicare overbilling by health care providers.

In clinical news, two randomized controlled trials from the New England Journal of Medicine investigate the role sugar-sweetened beverages play in fueling obesity. The first trial[iii] enrolled adolescents in an intervention to reduce sugared beverage consumption by providing semiweekly home delivery of sugar free drinks. The study was composed of 224 boys and girls in grades 9 and 10 with a BMI at or above the 85th percentile for their age who reported consuming at least one sugary beverage – including fruit juice – every day. The intervention lasted for 12 months, and participants were followed for two years. Investigators found a statistically significant reduction in BMI at one year (−0.57, P=0.045), but this result disappeared at year two (−0.30, P=0.46).

The other study[iv] randomized a group of 641 normal weight children who consumed sugary beverages to an experimental group who were provided with one can daily of artificially sweetened, sugar-free beverages and to a control group who were provided with one can daily of sugar sweetened beverages. Compliance was the same in both groups, confirmed by testing urine in the experimental group for presence of sucralose. BMI adjusted for age increased 0.36 less in the sugar-free group than in the sugar group (P=0.001). Skinfold thickness measurements, waist-to-height ratio, and bioelectrical impedance all showed that the sugar free group gained significantly less body fat. This study showed that weight improvements are possible simply with a reduction in consumption of sugar-sweetened drinks, but the barriers to making better choices are high. Both trials show a reduction in BMI when participants are provided with alternatives to sugared beverages, but two-year data from the first trial indicate just how tenuous these improvements are.

While we struggle with how to prevent and treat obesity with lifestyle interventions, bariatric surgery continues to amass an impressive record in ameliorating the insulin resistance and its associated metabolic abnormalities that tends to occur in the obese. A new study[v] from JAMA followed patients who sought out Roux-en-Y gastric bypass for six years in an effort to determine how well both the body weight and metabolic improvements observed in bariatric surgery persist over the years. The authors compared 1156 severely obese patients from three separate groups: bariatric surgery (specifically roux-en-Y) patients, patients who sought out surgical consultation but ultimately decided against the procedure, and randomly selected obese adults. Vast differences were described for the groups: weight loss at 6 years was 27.7% of body weight in the bariatric group compared no weight loss in either control group. Diabetes remission rates were similarly impressive: 62% (95% CI, 49%-75%) in the bariatric surgery group, 8% (95% CI, 0%-16%) in control group 1, and 6% (95% CI, 0%-13%) in control group 2 (P < .001). These findings further emphasize both the importance of weight loss and the difficulty of achieving it without surgical intervention.

But not all of the research this week was about obesity. The Lancet has a new article[vi] about a subject that affects our lives every day: IV placement and removal. The authors investigated whether routine replacement of intravenous catheters at 3 days led to reduced risk of phlebitis than clinically indicated replacement. 3283 patients were randomized and mean time prior to replacement was 99 hours in the clinically indicated group and 70 hours in the control group. Adverse events occurred in 114 of 1593 (7%) of the experimental group and 114 of 1690 (7%) in the control group, leading to an absolute risk increase of 0.41% (95% CI −1.33 to 2.15%). These data suggest that routine IV replacement may not be an absolute necessity, which should be a relief to house staff caring for patients with vessels that are seemingly impossible to catheterize.

Finally, a few additional articles that garnered some attention this week:

1. Improving Patient Handovers From Hospital to Primary Care: A Systematic Review: http://annals.org/article.aspx?articleid=1359221

The Annals of Internal Medicine looks at the effectiveness of common methods of improving patient handoffs and reducing medical errors. The authors found that medication reconciliation, structured electronic tools to generate pre-specified patient information, discharge planning, and discharge notifications all serve as effective interventions.

2. Prospective, Observational Study of Pain and Analgesic Prescribing in Medical Oncology Outpatients With Breast, Colorectal, Lung, or Prostate Cancer: http://jco.ascopubs.org/content/early/2012/04/11/JCO.2011.39.2381.abstract

This paper in the Journal of Clinical Oncology found that minority patients with terminal cancer are twice as likely to receive inadequate pain control in an outpatient setting.

3. Prospective Study of Restless Legs Syndrome and Coronary Heart Disease Among Women: http://circ.ahajournals.org/content/early/2012/08/30/CIRCULATIONAHA.112.112698.abstract

Restless legs are more than just an annoyance at night. Women who have had with restless leg syndrome for more than 3 years have an increased risk of cardiovascular disease, providing us with another associated condition that may help better risk stratify women at risk for CAD.

4. Neighborhood Effects on the Long-Term Well-Being of Low-Income Adults: http://www.sciencemag.org/content/337/6101/1505.abstract

This paper in Science builds on earlier work showing that socioeconomic status is one of the best predictors of health outcomes. Here we see evidence that simply the neighborhood in which someone lives can have an important effect on subjective well-being.

And last, on a lighter, but authentically scientific note, this week marked the 22nd Ig Nobel Prize ceremony in Boston. Read the synopsis (http://www.improbable.com/ig/2012/) to learn about “achievements that first make people LAUGH then make them THINK” such as advice for the prevention of colonic explosions during colonoscopies, and the observation that chimpanzees can identify other chimpanzees individually from seeing photographs of their rear ends.

Dr. Gregory Katz 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:

[i] http://www.publicintegrity.org/2012/09/15/10810/how-doctors-and-hospitals-have-collected-billions-questionable-medicare-fees

[ii] https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

[iii] Cara B. Ebbeling, Ph.D., Henry A. Feldman, Ph.D., Virginia R. Chomitz, Ph.D., Tracy A. Antonelli, M.P.H., Steven L. Gortmaker, Ph.D., Stavroula K. Osganian, M.D., Sc.D., and David S. Ludwig, M.D., Ph.D. A Randomized Trial of Sugar-Sweetened Beverages and Adolescent Body Weight. NEJM 2012; 10.1056/NEJMoa1203388  http://www.nejm.org/doi/full/10.1056/NEJMoa1203388

[iv] Janne C. de Ruyter, M.Sc., Margreet R. Olthof, Ph.D., Jacob C. Seidell, Ph.D., and Martijn B. Katan, Ph.D. A Trial of Sugar-free or Sugar-Sweetened Beverages and Body Weight in Children. NEJM 2012; 10.1056/NEJMoa1203034  http://www.nejm.org/doi/full/10.1056/NEJMoa1203034

[v] Adams TD, Davidson LE, Litwin SE, et al. Health Benefits of Gastric Bypass Surgery After 6 Years. JAMA. 2012;308(11):1122-1131. http://jama.jamanetwork.com/article.aspx?articleid=1360861

[vi] Richard CM, Webster J, Wallis MC et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. The Lancet, Volume 380, Issue 9847, Pages 1066 – 1074

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