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Annals of Internal Medicine Tip Sheet
October 10, 2017


Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.


1. A substantial number of opioid-dosage combinations have no prescribing restrictions under Medicare formulary

Formularies offer underused opportunity to restrict opioid prescribing

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1823

Medicare Part D formularies allowed unrestrictive coverage for many opioids over the past decade, especially at high doses, including for drugs commonly associated with overdose. Because formulary coverage directly affects prescribing, these findings suggest that formularies present on underused opportunity to restrict opioid prescribing. A brief research report is published in Annals of Internal Medicine.

Restricting formulary coverage for prescription drugs is one strategy to decrease opioid prescribing. A private insurer showed that implementing prior authorization, quantity limits, and provider-patient agreements was associated with a 15 percent decrease in opioid prescribing. The extent to which opioids are covered and/or restricted among Medicare formularies is unknown.

A team of researchers led by Yale University sought to characterize the extent to which utilization management strategies have been used to restrict access to prescription opioids among Medicare Part D formularies from 2006 to 2015. Using data from the Centers for Medicare & Medicaid Services (CMS), the researchers compared coverage for all available doses of commonly used short- and long-acting opioid medications except for methadone. They found that more than two thirds of drug-dosage combinations had no opioid prescribing restrictions in 2006 and 2011 and approximately one third had no restrictions in 2015. While quantity limits and prior authorization to restrict daily allowable prescribed dosing increased over the years, unrestrictive coverage persisted for many opioids.

The researchers suggest greater use of formularies to restrict opioid prescribing. Limiting prescribed morphine milligram equivalents (MME) per day or requiring prior authorization or step therapy for high-dose opioids may facilitate better adherence to Center for Disease Control and Prevention (CDC) prescribing recommendations.

2. Evidence suggests that patient navigators and provider reminders may improve follow-up after positive fecal blood test

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1361

Interventions, such as patient navigators and provider reminders, may improve follow-up colonoscopy rates after a positive fecal blood test. Follow-up is an important step in effective screening for colorectal cancer. Findings from a systematic evidence review are published in Annals of Internal Medicine.

Colorectal cancer, the second leading cause of cancer death in the United States, is largely preventable with screening. Fecal immunochemical testing has become the most commonly used method for colorectal cancer screening worldwide and is increasingly used in the United States to improve population-level screening rates. However, the proportion of test-positive patients having a timely colonoscopy after a positive test is generally low, suggesting a need to identify proven interventions that can be implemented in practice to improve follow-up colonoscopy rates.

A team of investigators led by Kaiser Permanente Division of Research, reviewed published studies to identify interventions that have been evaluated for improving rates of follow-up colonoscopy after positive fecal test results in asymptomatic adults. The researchers identified 23 studies that met their inclusion criteria. While most of the research was low quality, particularly with regard to system-level interventions, the team found moderate evidence to support the implementation of patient- and provider-level interventions. The evidence suggests that the use of patient navigators, or individuals who work with patients to counsel and guide them through the barriers associated with cancer care, can increase rates of follow-up colonoscopy. Provider-level interventions that utilize electronic reminders to alert physicians of patients who have not taken adequate action after a positive test result were shown to improve colonoscopy completion from 9 to 25 percentage points.

The researchers note that these findings are important because until now, research on follow up of positive fecal blood tests in colorectal cancer screening has been hard to find. Since most of the research is low-quality, more research is needed to provide good, quality evidence for effective interventions.

3. Multistep tool is effective for discontinuing inappropriate medication use in the nursing home setting

Abstract: http://annals.org/aim/article/doi/10.7326/M16-2729
Editorial: http://annals.org/aim/article/doi/10.7326/M17-2268

A Multidisciplinary Multistep Medication Review (3MR) tool used in the nursing home setting is effective for discontinuing inappropriate medication in frail elderly patients without a decline in their well-being. Given that many nursing home patients take several long-term medications, this tool could provide practical guidance on how to operationalize deprescribing. The findings of a cluster randomized controlled trial are published in Annals of Internal Medicine.

Polypharmacy, or the coincident prescribing of at least five long-term medications, is associated with increased risk for inappropriate prescribing. Up to 40 percent of nursing home residents may receive one or more inappropriate drugs, the use of which has been associated with adverse events and hospitalizations. Deprescribing is the discontinuation of inappropriate medication use to manage polypharmacy. While the clinical problem is well-known, few interventions have focused on reducing inappropriate medication use.

Researchers from the University of Groningen and University Medical Center Groningen (The Netherlands) randomly assigned 426 nursing home residents recruited from 59 Dutch nursing home wards to an intervention to reduce inappropriate medication use or to usual care. The intervention, 3MR, consisted of an assessment of the patient perspective, medical history, analysis of medications, a meeting between the treating physician and the pharmacist, and implementation of medication changes. The intervention was performed once, with an evaluation 4 months later. The goal was to discontinue inappropriate medication during the study period and to examine the effects on nursing home residents’ well-being.

The researchers found that a greater proportion of patients in the intervention group than in the control group successfully discontinued at least one drug without a decline in their well-being. Clinicians practicing in the nursing home should note that improvements in medication use can be facilitated by working in a multidisciplinary team with a pharmacist. The 3MR approach could be an efficient and effective tool for use in the nursing home setting.

Also in this issue:

Novel Metrics for Improving Professional Fulfillment

Yumi T. DiAngi, MD; Tzielan C. Lee, MD; Christine A. Sinsky, MD; Bryan D. Bohman, MD; Christopher D. Sharp, MD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M17-0658

The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension

Jenifer M. Brown, MD; Cassianne Robinson-Cohen, PhD; Miguel Angel Luque-Fernandez, MSc, MPH, PhD; Matthew A. Allison, MD, MPH; Rene Baudrand, MD; Joachim H. Ix, MD, MS; Bryan Kestenbaum, MD, MS; Ian H. de Boer, MD, MS; and Anand Vaidya, MD, MMSc
Original Research
Abstract: http://annals.org/aim/article/doi/10.7326/M17-0882

Lipoprotein Apheresis for Sitosterolemia

Nagahiko Sakuma, MD, PhD; Hayato Tada, MD, PhD; Hiroshi Mabuchi, MD, PhD; Takeshi Hibino, MD, PhD; Hirotake Kasuga, MD
Brief Case Report
Abstract: http://annals.org/aim/article/doi/10.7326/L17-0502

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