Faculty Peer Reviewed
This Labor Day weekend marked the unofficial end of summer, which meant the end of long lazy beach days and back to school for millions of American children. For many adults, and kids alike, this past weekend also marked the kickoff of the college football season. Whether a Buckeye, a Bulldog or a Bobcat (which is NYU’s mascot, although the university no longer has a football team), football season means alumni have the chance to show off their college pride, rooting for their alma mater, no matter how good or bad their beloved team may be. In other sports news this week, the US Open is in full swing in Flushing, Queens. This event brings tennis fans from around the world to The Big Apple to watch tennis superstars go head to head on the hard court. Now from the world of sports to that of medicine, there is equally exciting news to discuss…
As most practitioners are aware, rising healthcare costs are a pressing issue for many medical professionals. Providing efficient healthcare is crucial for controlling healthcare costs in the United States. A recent article out this month investigates a mechanism for reducing one type of medical inefficiency: redundant lab draws. Current guidelines about the frequency of lipid testing are dictated by the Adult Treatment Panel III, which suggests annual lipid panels in patients with coronary artery disease (CAD). This study, in the August 12/26, 2013 JAMA Internal Medicine, is a retrospective cohort study, in which the researchers identified 35,191 patients with CAD at the 7 VA Medical Centers in the Houston, Texas network. These patients were then stratified by the following categories: LDL level, if any future testing was performed on an annual basis, and if any treatment intensification occurred after testing. Treatment intensification was defined as an increase in a lipid-lowering medication dose or addition of another lipid-lowering medication to the patient’s medication regimen. The authors found that of this large group: 6290 patients had an LDL<100, did not receive any treatment intensification and no repeat lipid panel; 9200 patients also had their LDL<100, did not receive treatment intensification but had a repeat lipid panel performed; 12,457 were at an LDL<100 but received treatment intensification and 7244 were still at an LDL>100. This translates into 32.9% of patients (9200 patients) with LDL levels less than 100 receiving additional lipid testing without any treatment intensification or 12,686 lipid panels that did not need to be performed at $16.08 per test. Thus, the authors found $203,990 in excessive costs at only one institution. One could imagine how rethinking annual lipid panel guidelines might help save enormous medical costs if changes to these guidelines were implemented nationwide. 
In other news, a recent article in Circulation reaffirmed the effectiveness of intermittent pneumatic compression (IPC) in preventing venous thromboembolism in the lower extremities of hospitalized patients. The authors conducted a meta-analysis of 70 randomized controlled trials, which compared IPC to: TEDS, pharmacologic thromboprophylaxis, no prophylaxis and combined IPC/pharmacologic thromboprophylaxis. The authors found that IPC was more effective than no prophylaxis or TEDS, equally as effective as pharmacologic prophylaxis, but the combination of IPC and pharmacologic prophylaxis was most effective. This study should trigger clinicians to reconsider DVT prophylaxis for hospitalized patients, especially those who are at high-risk for thromboembolism. Such patients should ideally benefit from pharmacologic prophylaxis as well as ICP, although standard practice typically dictates choosing only one method of prophylaxis even in patients who can tolerate both types.
This week’s JAMA featured a timely article about how Accountable Care Organizations (ACOs) impact the cost and quality of healthcare. This quasi-experimental study compared Medicare patients enrolled in a commercial ACO in Massachusetts to Medicare beneficiaries in all other types of plans in the state. Utilizing difference-in-difference regression models, the authors found that Medicare beneficiaries receiving care via an ACO model saved 3.4% between year 1 and 2 of the study. The authors discovered that most of the savings were secondary to lower outpatient care costs, including less spending on procedures, imaging and lab tests. Of note, the authors also found that ACO-enrolled patients were more likely to have their LDL tested if they were diabetics or had cardiovascular disease, but the study did not otherwise show any significant difference regarding the quality of care. Although there was a limited impact on the quality of care, this study is proof that ACOs are an effective means of bending the healthcare cost curve, one of the central goals of the recently passed Affordable Care Act.
The New England Journal of Medicine featured a non-inferiority trial comparing apixaban (Brand Name: Eliquis), an oral twice-a-day factor Xa inhibitor, to subcutaneous enoxaparin bridged to warfarin, for the treatment of venous thromboembolism. The trial was a randomized double-blinded study funded by Pfizer and Bristol-Myers Squibb, the manufacturer of apixaban. The authors found that there was no significant difference in the percentage of recurrent venous thromboembolism, or death related to venous thromboembolism, between the apixaban group versus the conventional treatment group, but that there was a significant reduction in major bleeding risk with apixaban as compared to warfarin. These findings suggest that apixaban may be a safer method for anticoagulation in patients with venous thromboembolism than warfarin. However, it should be noted that apixaban has not yet been studied in patients with cancer or with impaired renal function, thus this study may only be generalizable to a narrow patient population and is likely to be far more expensive than conventional treatment with warfarin.
Other interesting reads this week…
1. Hong, Jin-Liern, Christoph R. Meier, Robert S. Sandler, Susan S. Jick, and Til Sturmer. “Risk of Colorectal Cancer after Initiation of Orlistat: Matched Cohort Study.” British Medical Journal 347:f5039 (2013): 27 Aug. 2013 http://www.bmj.com/content/347/bmj.f5039
Given recent animal studies, which showed that the top-selling anti-obesity medication orlistat (Brand Name: Alli) increased the risk of aberrant colonic crypt foci in rats, a team of epidemiologists at UNC School of Public Health conducted a retrospective matched cohort study utilizing data from the UK to assess the risk of colorectal cancer in patients using orlistat. The authors found that the incidence rate of colon cancer was not statistically significantly different between orlistat users and non-users. While these findings reassure the reader that orlistat is safe, it should be noted that the median follow up time in this study was just under 3 years, thus this study did not account for the possible long-term effects of orlistat use, which are still unknown.
2. Wharam, J. Frank, Fang Zhang, Bruce E. Landon, Stephen B. Soumerai, and Dennis Ross-Degnan. “Low-Socioeconomic-Status Enrollees In High-Deductible Plans Reduced High-Severity Emergency Care.” Health Affairs 32.8 (2013): 1398-406. Aug. 2013. http://content.healthaffairs.org/content/32/8/1398.full.pdf+html
With the Affordable Care Act in its implementation phase, one expected change is an increase in the number of people choosing high-deductible plans, or plans with low premiums, but higher out-of-pocket costs when one gets sick. The authors of this study utilized data from Massachusetts, which has had an individual mandate for many years, to study how high-deductible plans impact the behavior of individuals. The authors found that lower socioeconomic status (SES) individuals reduced high-severity ED visits by 25-30% after enrolling in a high-deductible plan, and that hospitalizations in the first year declined by 23%, but then increased in the subsequent year. From this, the authors implied that lower SES individuals did not seek necessary care because of high out-of-pocket costs, which led to subsequent higher costs as patients required more hospitalizations later on for poorly controlled morbidities. Of note, the high-deductible plans had no effect on the behavior of high SES individuals.
3. Erichsen, Rune, John A. Baron, Elena M. Stoffel, Soren Laurberg, Robert S. Sandler, and Henrik Toft Sorensen. “Characteristics and Survival of Interval and Sporadic Colorectal Cancer Patients: A Nationwide Population-Based Cohort Study.” The American Journal of Gastroenterology 108 (2013): 1332-340. Aug. 2013. http://www.nature.com/ajg/journal/v108/n8/pdf/ajg2013175a.pdf
In this study, Danish researchers utilized multivariate logistical regression models to compare interval colorectal cancers (defined as CRCs diagnosed within 1-5 years of a colonoscopy) to CRCs diagnosed greater than 10 years after colonoscopy to sporadic CRCs (defined as no prior colonoscopies). The authors found that interval CRCs were more common in older, female patients with comorbidities, and that the tumors were more likely to be proximal. However, interval CRCs were found at stages similar to sporadic CRCs. Based on these results, the authors concluded that interval CRCs are more likely due to missed lesions on colonoscopy, not more aggressive tumors.
Molly Somberg, MD, MPA is a first year internal medicine resident at NYU Langone Medical Center
Peer Reviewed by Brian Greet, MD, Associate Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497.
2. Virani, Salim S., LeChauncy D. Woodard, Degang Wang, Supicha S. Chitwood, Cassie R. Landrum, Tracy H. Urech, Kenneth Pietz, G. John Chen, Brian Hertz, Jeffrey Murawsky, Christie M. Ballantyne, and Lauren A. Petersen. “Correlates of Repeat Lipid Testing In Patients with Coronary Heart Diseae.” JAMA Internal Medicine 173.15 (2013): 1439-444. 12/26 Aug. 2013. http://archinte.jamanetwork.com/article.aspx?articleid=1726982
3. Ho, Kwok M., and Jen Aik Tan. “Stratified Meta-Analysis of Intermittent Pneumatic Compression of the Lower Limbs to Prevent Venous Thromboembolism in Hospitalized Patients.” Circulation 128 (2013): 1003-020. 28 Aug. 2013. http://circ.ahajournals.org/content/128/9/1003.abstract
4. McWilliams, J. Michael, Bruce E. Landon, and Michael E. Chernew. “Changes in Health Care Spending and Quality for Medicare Beneficiaries Associated With a Commercial ACO Contract.” JAMA: The Journal of the American Medical Association 310.8 (2013): 829-36. 28 Aug. 2013. http://jama.jamanetwork.com/article.aspx?articleid=1733718
5. Agnelli, Giancarlo, Harry R. Butler, Alexander Cohen, Madelyn Curto, Alexander S. Gallus, Margot Johnson, Urszula Masiukiewicz, Raphael Pak, John Thompson, Gary E. Raskob, and Jeffrey I. Weitz. “Oral Apixaban for the Treatment of Acute Venous Thromboembolism.” The New England Journal of Medicine 369.9 (2013): 799-808. 29 Aug. 2013. http://www.nejm.org/doi/full/10.1056/NEJMoa1302507