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March 17, 2015 Issue


Clinical Practice Points

Practice Based Learning and Improvement
Systems-based Practice
HVC

Cost-Effectiveness and Budget Impact of Hepatitis C Virus Treatment With Sofosbuvir and Ledipasvir in the United States

Cost-Effectiveness of Novel Regimens for the Treatment of Hepatitis C Virus

These studies each analyze the cost-effectiveness of new therapies for hepatitis C. While these novel drugs are very expensive, these analyses suggest that under certain conditions they are cost-effective.

Use these articles to:

  • Review the available treatment options for hepatitis C. Ask your learners what the costs of sofasbuvir and sofosbuvir–ledipasvir are. Find these costs in the introduction to the first article.
  • Use a concise review article to help you (and your learners) understand key concepts in the evaluation of cost-effectiveness. Ask your learners how it is possible that a drug can be so expensive yet found to be cost-effective. Ask how something that is itself relatively inexpensive (e.g., “routine screening” preoperative blood work) can be cost-ineffective and wasteful.
  • What is a quality-adjusted life-year? What is an incremental cost–benefit ratio? How is the threshold for value set?
  • As your learners how 2 analyses from different perspectives end up with different recommendations. One of these studies is performed from the perspective of a third-party payor, the other from a societal perspective. Ask why it matters. Invite an expert in cost-effectiveness analysis to help in a teaching session.


Patient Care
Practice Based Learning and Improvement
Medical Knowledge

Effect of a Culture-Based Screening Algorithm on Tuberculosis Incidence in Immigrants and Refugees Bound for the United States: A Population-Based Cross-sectional Study

This study assessed the efficacy of a culture-based screening program compared with the smear-based screening algorithm. The culture-based algorithm increased the number of tuberculosis (TB) cases detected in immigrants and refugees, leading the authors to suggest expansion of screening strategies to reduce the number of new TB cases in the United States.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your learners what the characteristics of a good screening test are. Review the definitions of sensitivity, specificity, and positive and negative predictive value and how the prevalence of a disease influences the choice of test. Use the material in the freely available High Value Care Curriculum —there is a teaching module on screening and prevention!
  • Review screening recommendations for TB in nonimmigrant populations in the United States. Use ACP Smart Medicine: Screening for Tuberculosis to help. What is the recommended management of latent TB? Which groups in the United States warrant special consideration regarding screening for TB?
  • Do your learners know how to place and interpret a Mantoux tuberculin skin test? Demonstrate this in a teaching session yourself, or invite someone from occupational health to remind your group how to place and interpret this test.


Medical Knowledge
Patient Care

Cervical Spine Clearance in Obtunded Patients After Blunt Traumatic Injury: A Systematic Review

Protocols for cervical spine clearance for unconscious patients after blunt traumatic injury and negative computed tomography findings are controversial. The potential emotional, psychological, and social burdens faced by these patients can lead physicians to prolong collar use as a defensive measure rather than one based on medical necessity. This study concludes that cervical spine clearance in obtunded adults after blunt traumatic injury with negative computed tomography results is probably safe and efficient.

Use this review to:

  • Invite an emergency physician or trauma surgeon to describe an evidence-based approach to unconscious trauma patients. What potential should be evaluated? What nonorthopedic injuries need to be excluded? What do internists need to know to help manage these patients?
  • Teach at the bedside: What should the neurologic exam of an unresponsive patient include?
  • Review the types of cervical collars and the indications for their use. If possible, let your learners try on various collars.

Clinical Guideline


Patient Care
HVC

Cardiac Screening With Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging: Advice for High-Value Care From the American College of Physicians

The High Value Care Task Force of the ACP recommends against using resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging to screen for cardiac disease in asymptomatic, low-risk adults. Clinicians should instead focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors and encouraging healthy levels of exercise.

Use this guideline to:

  • Ask your learners why the authors of this paper recommend against these screening tests in low-risk patients. Ask how to assess risk—use Table 3, and go to some of the links provided to cardiovascular risk calculators. Calculate the risks for cardiovascular disease of several of your team’s outpatients.
  • What forces promote the overuse of cardiac testing in asymptomatic adults? What are the potential harms of screening? Each of these questions is the title of a section in the paper. Use it to help review the answers.
  • Review how the predictive value of a test is affected by the prevalence of the disease in a population.
  • Log on and answer the CME questions accompanying this paper to earn credit for yourself!

A New Tool for Teaching!


search_iconNeed ideas for teaching? Need a paper relevant to a topic you want to cover, together with suggestions on how to use it for educating residents and medical students? Did you know that you can search the over 50 recent Annals for Educators Alerts for ideas on a specific topic? Go to the Annals Teaching Tools page and use the search engine provided to find material and ideas for educators!


Humanism and Professionalism


Professionalism
Interpersonal and Communication Skills

On Being a Doctor: White Flag

In their essay, Drs. Hirni and Carter describe the experience of telling their own grandmother and other family members that medical interventions were unlikely to be helpful and would likely cause suffering.

Use this essay to:

  • Listen to the recording of this essay, read by Dr. Michael LaCombe.
  • Ask your learners whether they have seen a “beautiful death?” What does that mean to them?
  • Have any of your learners been in a similar situation with family? How did they conduct themselves when playing the role of “doctor” with family? How was it different than at other times?
  • Discuss strategies to ensure that patients and families understand their options and how discussions should be framed with dying patients and their families.

Video Learning


Medical Knowledge
Consult Guys logo

The Consult Guys: Anticoagulation? Antiplatelet? What’s the Score?

Watch this episode of the consultative medicine talk show. Geno and Howard (The Consult Guys) work their way through a challenging, yet common, scenario. How long does a patient need antiplatelet therapy? How many agents? What about anticoagulation? How does the CHA2DS 2-VASc score work? What does it tell you? Answer these and the provided CME questions—and earn some credit yourself.


mksap16

A 23-year-old man undergoes preliminary evaluation. He has just been admitted to a detoxification center because of injection drug use.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 125/75 mm Hg, pulse rate is 90/min, and respiration rate is 18/min. Findings of physical examination demonstrate evidence of injection drug use on the bilateral upper extremities but are otherwise normal.

Tuberculin skin testing induces 6 mm of induration. The patient has not had previous tuberculin skin tests. Results of a serologic test for HIV infection are negative.

Which of the following is the most appropriate next step in the management of this patient?

A. Chest radiograph
B. Isoniazid
C. Isoniazid, rifampin, pyrazinamide, and ethambutol
D. No additional therapy or evaluation

Correct Answer
D. No additional therapy or evaluation

Key Point
A tuberculin skin test reaction of less than 10 mm in a person who uses injection drugs requires no additional evaluation or treatment.

Educational Objective
Interpret a tuberculin skin test reaction in a patient who uses injection drugs.

No additional evaluation or treatment is indicated for a person who uses injection drugs and has a tuberculin skin test reaction of less than 10 mm of induration.

Certain high-risk groups require a chest radiograph to exclude active tuberculosis when their tuberculin skin test reaction is greater than or equal to 5 mm. These groups include recent contacts of patients with active tuberculosis, patients with HIV infection, persons with fibrotic changes on prior chest radiographs consistent with old healed tuberculosis, and organ transplant recipients and patients with other immunocompromising conditions. High-risk persons who require a chest radiograph when their tuberculin skin test reaction is greater than or equal to 10 mm include injection drug users; persons from countries with a high prevalence of tuberculosis who immigrated to the United States less than 5 years ago; employees or residents of high-risk congregate settings such as prisons, nursing homes, hospitals, or homeless shelters; mycobacteriology laboratory workers; patients with clinical conditions that put them at increased risk for active tuberculosis (for example, chronic kidney disease; diabetes mellitus; silicosis; lymphoproliferative disorders; cancer of the neck, head, or lung; gastrectomy or jejunoileal bypass and weight loss of ≥10% from ideal body weight); children who are younger than 4 years of age; and adolescents, children, and infants who are exposed to adults in high-risk categories. Asymptomatic persons in either of these two groups who have a chest radiograph that is normal or is inconsistent with active tuberculosis should receive treatment for latent tuberculosis infection because they are at increased risk for tuberculosis. Treatment will substantially reduce the risk that latent tuberculosis will progress to active disease. Treatment of latent tuberculosis typically consists of isoniazid for 9 months unless there is strong suspicion of infection with isoniazid-resistant mycobacteria (for example, exposure to a person with known isoniazid-resistant tuberculosis). In this situation, rifampin for 4 months is a reasonable alternative. Recently, the Centers for Disease Control and Prevention also included 3 months of directly observed, once-weekly rifapentine and isoniazid combination therapy for treatment of latent tuberculosis.

Four-drug therapy with isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat active tuberculosis. There is no evidence that the asymptomatic person described here has active tuberculosis.

Bibliography
American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Recomm Rep. 2000;49(RR-6):1-51. PMID: 10881762

This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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