One thing I look forward to each day is looking through my medical feeds that keep me up to date with medical research. Most of this content ranges from bogus to unhelpful (in my opinion), but every once in a while, a truly game-changing article appears. Over the years, I have noticed that most of the game changing articles are debunking articles. They show that something that is commonly done in medicine actually has no value. I love these! Not only do they improve the medical care of my patients, they also make me more cost-effective. As I have said before, the main way to save money in Correctional Medicine is to eliminate (and stop paying for) medical practices that have no value—or even worse, are harmful to patients.
Association of Initiation of Basal Insulin Analogs vs Neutral Protamine Hagedorn Insulin With Hypoglycemia-Related Emergency Department Visits or Hospital Admissions and With Glycemic Control in Patients With Type 2 Diabetes, published in JAMA, June 23, 2018.
This article has a horrible title. You can read it without knowing what in the heck it is about. In fact, you could read it and fall asleep before you finished! The title should say: The new expensive analogue insulins are no better than the old, less expensive insulins in Type 2 diabetes. There is wide spread belief that the newer insulins, such as Lantus, Levemir, Humalog and Novalog (collectively called analogue insulins) are better than the older insulins they replaced, such as Humulin and NPH. This study compared the two types of insulin head to head in Type 2 diabetics looking specifically at hypoglycemic events, hospitalizations and A1C reduction. What did they find? Surprise! There was no advantage in using the analogue insulins. In fact, there was a statistical trend toward the analogues being worse! This is important since the analogue insulins have become insanely expensive. The bottom line according to the accompanying editorial is “NPH insulin is the front-line insulin option for most patients with type 2 diabetes.” (Revisiting NPH Insulin for Type 2 Diabetes. Is a Step Back the Path Forward?
JAMA, June 23, 2018)
Overdiagnosis of Penicillin Allergy Leads to Costly, Inappropriate Treatment, published in JAMA October 24, 2018.
This article points out that although patients commonly report an allergy to penicillin, less than 10% of them actually have a true penicillin allergy when tested. Because of this over-reporting of non-existent penicillin allergies, many of these patients receive what the article terms “suboptimal antibiotic therapy.” Often, the suboptimal therapy means bigger broad-spectrum antibiotics. The article points out that, because of this, patient reporting a penicillin allergy have an increased risk of developing MRSA, c. Difficile, and post-operative infections. The game changer part of this article is that it suggests that patients who report a penicillin allergy but are truly low risk based on their reported history can safely be given an oral challenge with one hour of observation after this. We can certainly do that in a correctional setting!
Misdiagnosis of asthma and COPD and underuse of spirometry in primary care unselected patients, published in Respiratory Medicine, September 2018. In this study, 300 patients who had been diagnosed with asthma or COPD by their primary care physicians were formally tested in a pulmonology lab. 30% of the patients diagnosed with asthma did NOT have asthma. And (get ready for this) 90% of the patients diagnosed with COPD did NOT have COPD per pulmonology testing. This follows on the heels of one of 2017’s great articles, which also showed that 1/3 of adults with the diagnosis of asthma actually do not have asthma (Reevaluation of Diagnosis in Adults with Physician-Diagnosed Asthma, published in JAMA January 17, 2017). These studies have huge potential implications for prison systems. Asthma medications are typically one of the top cost categories in medications expenditures. If 1/3 (or more) of these are simply not needed, that would be a big deal. The bottom line is that the diagnosis of asthma should be verified with spirometry whenever possible. Spirometry is just not that complicated or expensive to set up.
2018 Update on Medical Overuse, published in JAMA Internal Medicine February 1, 2018. These researchers reviewed 1446 articles and picked the ten “most influential” articles on common medical practices that have no medical utility. Here are three of the ten conclusions:
- Lipid monitoring in patients taking statins rarely affects care. So if a patient is already on a statin, you may stop ordering yearly lipid panels.
- Calcium and vitamin D supplementation does not reduce hip fractures (or any other fractures for that matter) in the elderly. Quote from the article: “Supplementation with calcium and vitamin D for community-dwelling adults should be discouraged.”
- Gabapentinoids (gabapentin and pregabalin) are ineffective for chronic back pain including sciatica. So don’t prescribe them.
What is your favorite recent research article? Please tell us in comments.
I always wonder about how to present this to our medical team. It sounds like really helpful and cost saving information, yet when I talk to my dad, a physician, he says not to bother as I will more than likely tick off a medical provider or medical director and could lose my job. I have asked my sister also a physician and she says it comes down to relationships but also advises against it as a lot of providers don’t want to be told better ways of doing things especially when it comes from nursing staff.
In my jail, we have mostly short-timers (30 days) who have no faith in our ability to control their BG—a BG near 80 or over 150 and they become irate, (despite their intake Hga1c’s of 10).
With the “no-peak” Levemir/lantus the pre-prandial BG levels are so stable and predictable in those first few days that their trust in us increases. In addition, It seems easier to see spikes and “one-offs” so we can help teach them diet tips. For the short-timers, the additional cost feels like it’s worth it.