PrimeCuts: This Week in the Journals

March 9, 2009

big_sur.jpgCommentary by Sarah Moore MD, PGY-2 

Faculty Peer Reviewed

It has been a difficult week for the stock market and perhaps for some physicians. Most doctors can describe a handful of frustrating patient encounters that prompt eye-rolling and exacerbated sighs. The characteristics of these “difficult patients” are well described in the literature but in last week’s Archives of Internal Medicine Dr. Perry An, took a closer look at those providers identified as having a high frequency of difficult patient encounters. A survey of 422 primary care physicians across 5 community based practices nationwide revealed that physicians with a perceived higher burden of difficult patient encounters were more likely to be female and younger (mean age 41 compared to 43 and 46 in the medium and low cluster respectively). There was no significant difference in race, ethnicity, or full time vs. part time status amongst the groups. Furthermore, those physicians with high numbers of difficult patient encounters were more likely to experience burn-out and to report suboptimal care. They were also more likely to anticipate that they would make an error in the future which begs the question: which came first, the difficult patient encounter or the burned out physician?

Maybe the answer to this dilemma comes in the form of a study from this week’s Annals of Internal Medicine that examines the relationship between patient-physician “connectedness” and performance outcomes. The authors examined patients who were part of the Massachusetts General Hospital adult primary care network, which includes 181 PCPs across 13 practice settings. Using a previously tested algorithm (developed in part by asking physicians to identify “their patients” from a network generated list of assigned patients), the authors compared 93,315 physician-connected patients to 53,669 patients who were merely “practice-connected”. Overall those who were connected to a specific physician were more likely to receive age appropriate cancer screening and timely measures of HgbA1c and LDL when indicated, compared to those who were not connected, regardless of number of visits. Actually connectedness or lack thereof resulted in a bigger disparity in outcomes than did race or ethnicity.

Perhaps those difficult patients had tooth aches that weren’t being addressed. Not to worry, primary care doctors in Maine, where there is 1 dentist for every 2,300 patients, are being trained to drain oral abscess and pull rotting teeth according to a New York Times article as part of an ongoing program to fill the needs of patients in rural areas. It probably isn’t usually a nagging toothache because insistence on a particular prescription drug was the most often sited characteristic of the “difficult patient.” With that in mind, pharmaceuticals were center stage this week in articles detailing drug interactions, novel therapies for asthma, and ethical quandaries for Harvard.

The Annals of Internal Medicine included a randomized, placebo controlled, multicenter trial looking at the use of oral vitamin K in patients with supratherapeutic INRs (4.5-10) on coumadin. The investigators hypothesized that the reduction in INR due to vitamin K should also reflect a reduction in clinical bleeding events. On the contrary, the study found no difference in bleeding rates between those patients receiving a single dose of oral 1.25mg vitamin K vs. placebo at 90 days. Bleeding events included not only major or fatal bleeding, but also trivial bleeding such as recurrent epistaxis which did not require medical evaluation. Though the study was not adequately powered to assess small differences in the rates of major bleeding, it shows that simple coumadin withdrawal is an appropriate strategy for those patients with INRs 4.5-10 who are not actively bleeding.

A retrospective cohort study in JAMA of over eight thousand patients hospitalized for ACS in the VA system looked at outcomes of those taking a PPI with clopidogrel vs clopidogrel without PPI after discharge. The primary outcome was a combined endpoint of all cause mortality and re-hospitalization for ACS. Multivariable analysis showed an increased risk of adverse outcomes in the combined therapy group as compared to those taking clopidogrel without PPI (adjusted odds ratio, 1.25). Prior studies have proposed mechanisms by which PPIs may interfere with clopidogrel’s platelet inhibitory effect, and this study supports a growing body of evidence suggesting an association with dual therapy and adverse clinical outcomes.

The New England Journal of Medicine highlighted two small trials that used mepolizumab, an anti-interleukin-5 monoclonal antibody for the treatment of eosinophilic asthma in an attempt to broadly clarify the role of eosinophils in some severe asthmatics. The first by Haldar et al. randomized 61 patients with refractory eosinophilic asthma (partly defined by sputum eosinophil percentage over 3% despite high dose steroids) to metpolizumab or placebo. Overall metpolizumab reduced the number of severe exacerbations compared to placebo, but there were no differences between the groups regarding other symptoms or FEV1 measurements after bronchodilator use. An original article by Nair et al. which included only 20 patients showed that metpolizumab may be beneficial as a steroid sparing agent in patients with eosinophilic asthma.

Finally, over 200 Harvard medical students have started a movement to better expose the industry ties and limit the influence of pharmaceutical companies on their professors and classes as reported this week in the New York Times. This comes in the wake of an F grade from the American Medical School Association which rates how well schools curtail the influence of drug industry money. This may be hard for Harvard to fight as drug industry funding is filling the gaps left due to a shrinking endowment and waning philanthropy in this economic downturn.

Reviewed by Neil Shapiro MD, Editor-in-Chief, Clinical Correlations