How You can Implement Evidence-based Medicine into Practice

Presenter: Frank J. Domino, MD, Professor, Department of Family Medicine & Community Health, University of Massachusetts Medical School, Editor-in-Chief, 5 Minute Clinical Consult

Dr. Domino presented his top 10 practice changing concepts over the last 12 months and how evidence-based medicine can be employed and how to discuss the topics with patients. He explained that some of what he planned to discuss could even be implemented in a physician’s practice on Monday after the conference concludes. The information can truly make physicians reconsider the meaning of standard of care.

1. Obesity

Encourage your patients to 500 ml of drink water before a meal and they can eat all that they want.

A study found that there was a 44% greater weight loss for obese adults who drank water first compared to those who did not drink water. Domino said that pre-meal water can lead to a 4 lb greater loss versus following a regular diet.

In order to prevent obesity in children, Domino reviewed three habits that parents should consider:

1. Eat with the family
2. Have adequate sleep
3. Limit the amount of TV time

Studies found that children who were exposed to all three habits led to 14.3% obesity compare to 24.5% for those who were not exposed to the habits. It’s important that parents set limits for their children.

Obesity Drugs — Looking to 2011

Qnexa — 14% loss of body weight over 56 weeks. The researchers went for FDA approval, but because there was only one year’s worth of data, the application was turned down and were told to come back after two years. Domino thought that it should have received approval because this drug is probably the most effective of the three new ones.

Contrave — 5-7% loss of body weight over 24 weeks. Domino said that once researchers have longer data outcomes, it will be sustained and will probably be the first to receive FDA approval.

Locaserin — Approximately 3% loss of body weight after one year. Domino said that the drug is not impressive, but is novel and has few side effects. He said to watch for FDA approval because it’s likely this drug will make the biggest marketing splash—there is a lot of hype.

2. Drug Screening

According to the 2009 National Youth Risk Behavior Survey (measures what our adolescents are doing), the results showed that 1 in 5 high school students said they took prescription drugs without a prescription—the most common are Oxycontin, Perocet, Ritalin, Adderall, and Xanax. When looking at the data based on race, they learned the following: 23% of the students were white, 17% Hispanic, and 12% African-American.

When considering the various drugs that adolescents are exposed to, the below results are ranked by the number of adolescents who had taken drugs:

• Alcohol
• Marijuana
• Prescription — Domino was especially concerned about this because he believes doctors are responsible for this. There are now more students abusing prescription drugs than tobacco.
• Tobacco
• Cocaine
• Ecstasy
• Methamphetamine

They also found that 28% (1 in 3) of adolescents admitted to have ridden in a car where the driver was under the influence, and 46% (2 in 3) admitted to not using a condom the last time they had sex.

Approximately 400 patients answered yes when asked, “How many times in the past year have you used an illegal or prescription drug for non-medical reasons.

What is the source of the drugs? It is when lawfully prescribed medications are being used for illegal purposes. Domino cited that prescription opioids now cause more drug overdose deaths than cocaine and heroin combined. However, 40% of teen and an almost equal number of their parents actually think abusing prescription painkillers is safer than abusing “street” drugs. It was shocking to hear such a thing, but again, Domino tried to press the issue of prescription opioids saying, “This is our problem and we need to address it. Use caution when you prescribe.”

3. STI Screenings

The prevalence of STIs are extremely high among females between ages 14-19. Of the 838 females that were part of the National Health and Nutrition Survey in 2003-2004, 24% tested positive for at least one STI.

4. Diabetes

Results from the ACCORD trial found that lower A1C doesn’t necessarily mean it’s better; having blood pressure of 120 is no better than having 140 to prevent endpoints like CVA or CHD death; and using fibrates or statins did not help decrease lipids—in fact, there was an increase in adverse outcomes in women.

5. Gout

Domino stated that the clinical studies for 80% of new drugs that receive FDA approval and are released never get published. Even if a study is done, they can bring it to the FDA for review and that’s it. You have to wonder if there are politics involved with such instances, although 80% is a rather large number.

There are new trends in prescription drugs to treat gout; Domino used the term “prescriptions that reinvent.” He explained that the gout treatment, colchicine is as effective, if not more effective at a lower dose versus a higher does.

What Domino specifically focused on for gout was how much the drugs cost—generic and brand name:

Colchicine

Generic — 30 pills = $25

Colcrys — 30 pill = $170

Acetic acid/hydrocostisone otic

Generic — 15 ml = $8

Brand name — 15 ml = $210

Doxepin

Generic — 10 mg = $19/90

Brand — 3.6 mg = $18/30

Pill cutter = $2

6. Low back pain

Domino asked the audience a rhetorical question: “what predicts chronic lower back pain?” He went on to answer saying there are non-organic sings, mal-adaptive coping behavior, functional impairment, and even psychiatric attributes. Additionally, he explained that using opioids for a acute low back pain is counter-productive, and that as physicians “we are in charge of this, and we can do more harm than good.

7. Pain Relief

There is no difference between taking ibuprofen and using an ice or heat pack for 30 minutes. Domino said that if a physician was to ask a patient what his/her treatment approach for the next injury, 80% of the patients would use the same approach.

In France they have what’s called spa therapy for people with osteoarthritis in the knee. It is an 18-day program where patients will go and relax and have massage treatments to help ease the pain.

For children with fevers, Domino recommends that physicians prescribe the combination of acetaminophen and NSAIDS. If they are not used chronically, these treatments are safe to use together; combined they are more effective than alone. There is no increase in adverse events, and it’s safe, easy to use, and parents are already familiar with the treatments.

8. Food and Drugs

Domino told the audience that his favorite summer drink is the Seabreeze. He shared a story that one time he was drinking a seabreeze with some friends when one of them asked why he was drinking it since he takes a statin. It turns out that grapefruit juice inhibits intestinal C P-405, however Domino said that there is only one case report that shows a 40-year-old woman on 80mg of simvastatin who exercises daily, goes skydiving, and eats one grapefruit day had problems after two weeks of doing so. Immediately after she stopped eating the grapefruit she was fine. So although grapefruit juice might not be a good thing for people taking statins, Domino stressed that there was only one case!

Why use a statin?

Using statins is not associated with statistically significant reduction in all patients and may cause mortality. “This drug isn’t helping you. It may even be hurting you,” said Domino. Patients taking warfarin must consider the food they eat. Foods that have high vitamin K can actually reduce the effectiveness of warfarin. Patients can eat green vegetables a couple a times a week and have no treatment interference. The only vegetable that can cause an issue is kale.

9. AHRQ

Domino reviewed a number of sub-topics for AHRQ, but what he said about prostate cancer screening was extremely interesting, and possibly controversial.

Prostate cancer screening

Men who are screened for prostate cancer are 48 times more likely to be harmed than save nine years after diagnosed. In fact, Domino cited that screening actually doubles the risk of diagnosis, but does not significantly decrease a patient’s risk of dying. “A lot of aggressive care of this illness does not always lead to positive outcomes,” said Domino. “We don’t screen for a lot of cancers, and those that we do screen for are not done very well.”

Physicians, do you agree with what Dr. Domino said about cancer screenings?

10. All of the other stuff

Domino asked the audience, “How long is your average work day?” There is a study that shows if a person works 7-8 hours a day, he/she is ok, but if he/she works 10 hours, the risk of adverse events increase by 60%. Domino polled the audience (more than half raised their hands), and got a laugh upon saying, “Welcome to the dead zone.”

Unfortunately Domino was unable to find the data about life expectancy of female physicians in the US, but he did share data for male physicians:

White men = 73.0 years

Black men = 68.7 years

He then showed the life expectancy of lawyers, just for fun since he doesn’t like lawyers:

White men = 72.3 years

Black men = 60.0 years

Domino was glad to see that a lawyer’s life expectancy is less than a physician’s.

Summary of the 10 ten things Dr. Domino learned this year:

1. Obesity — drink water before meals

2. Screen for drug use; limit use

3. Screen for STI

4. Diabetic — A1C goal of 7.5 unless on co-morbidities

5. Gout — use colchrine

6. Acute low back pain — no narcotics

7. Pain relief

8. Statins/warfarin/diet

9. Breast cancer/prostate cancer screening

10. Work less than 10 hours per day