Sunday, December 29, 2013

Telephone coaching doesn't work for diabetes

A noble effort by the good folks at the General Practice and Primary Health Care Academic Centre at the University of Melbourne to demonstrate the effectiveness of telephone coaching by trained nurses in type 2 diabetes ended in disappointment.

As reported in the British Medical Journal, they randomized 59 primary care practices with 473 adults with A1C above 7.5%. The nurses in the  intervention practices were trained to make structured calls to their patients, engaging them in dealing with their chronic problems, managing stress, improving their lifestyle, self-monitoring their disease, and doing some other good things. The program included seven telephone coaching sessions over 10 months, a face to face coaching session at 12 months, and a final telephone session at 15 months. The nurses were paid to do the calls, overcoming an important barrier in many settings. In other words, this was a well-designed, fairly high-intensity intervention. And, the evaluation is very rigorous and well-designed with little room for random error or bias. These investigators are pros and it shows.

Unfortunately, it didn't work. After 18 months, the A1C in the intervention group was the same as the control group (P=.84). On the plus side, fewer intervention patients were overweight or obese (P=.03). However, some outcomes actually got worse: HDL-cholesterol (P=.05) and systolic blood pressure (P=.07). Given the very large number of secondary outcomes reported, and the lack of any big trends across the outcomes as a group, these apparent effects are probably random error due to multiple comparisons. All in all, there is no evidence that this intervention had important effects on the patients or the health care system.

This isn't the only evidence that high-intensity phone interventions don't work in this setting. Even if they were to generate some improvement, they are so expensive that they can only be used for the sickest patients. So for now, we are left with the proven beneficial effects of less intensive patient engagement techniques that seek to keep patients connected with the practice and activate them when they need to be, rather than educate and prepare them ahead of time. It looks like the "teachable moment" may be more valuable than all the that coaching and preparation.

Blackberry ID, Furler JS, Best JD, Chondros P, Vale M, Walker C, Dunning T, Segal L, Dunbar J, Audehm R, Liew D, Young D. Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement and Coaching for Health (PEACH) pragmatic cluster randomised controlled trial. BMJ. 2013 Sep 18;347:f5272. doi: 10.1136/bmj.f5272.

Monday, December 23, 2013

Missing the diagnosis of CKD

The good folks at the Oregon Rural Practice Based Research Network looked through their database of lab results and found 865 patients with laboratory evidence of chronic kidney disease (CKD). Of these, 52% had no documentation of the diagnosis in the chart. CKD in women was missed more often than in men. Importantly, the care of high blood pressure was better in those CKD patients where the provider had documented the diagnosis.
What's going on? Is this just a documentation issue?  Probably not. We've seen the same phenomenon in several other clinical settings. It's related to the difficulty of interpreting serum creatinine levels, the complexity and relative newness of the diagnostic criteria for CKD, the permanent brain cramp for all things kidney that medical school renal physiology courses induce, and the presence of the creatinine test in larger panels that are used when kidney disease is not top of mind. So, like the Oregonians, we also found that the number of known CKD cases goes up by 80-100% when the creatinine is systematically looked at (in the form of the estimated GFR value).
You can't engage patients in the care of their kidney problems and prevent end-stage renal disease if you don't even recognize that the patient has kidney disease in the first place! Happily, there are systems to help, and they are effective, easy and inexpensive. Let me know if you want to know more.

Sunday, December 22, 2013

Does CKD increase the risk for prostate cancer?

Here's one more reason to aggressively identify, manage, and stay connected to patients with chronic kidney disease (CKD): Prostate cancer. 

A recent study from Korea analyzed a group of men with elevated prostate-specific antigen levels (PSA 4-10 ng/ml). They were all biopsied, but those with stage 3-5 CKD (eGFR < 60) were more likely to have a cancer detected.

Although I'm not sure that PSA screening is a good idea in this population (or any others, for that matter), these findings are certainly disturbing. What isn't clear is whether our strategies for slowing the progression of renal insufficiency (especially blood pressure control and angiotensin inhibition) can prevent the development of prostate cancer.

Cho SYPark SLee SBSon HJeong HDifferences in prostate cancer detection rates according to the level of glomerular filtration rate in patients with prostate specific antigen levels of 4.0-10.0 ng/ml.  2013 Jun;67(6):552-7. doi: 10.1111/j.1742-1241.2012.03014.x.

Sunday, December 15, 2013

"By the way...": The pros and cons of incidental findings

Melissa Healy wrote a very interesting story for the LA Times last week on what happens when a medical test reports something unexpected.You're looking for pneumonia and the chest x-ray shows a cancer in the spine, but you don't know where it came from. A head CT to rule out subdural hematoma after a head injury shows an aneurysm...that might or might not cause trouble one day. These "incidental findings" are disturbingly common.

High tech imaging tests like CT scans and MRIs are particularly prone to this because they are not very specific in their field of view and provide a huge amount of information. If you get a CT of the abdomen to look at the liver, you're going to get all sorts of information about the gallbladder, stomach, intestines, kidneys, pancreas, etc. even if you don't want it. In my experience, lungs and brains are particularly full of findings of "uncertain significance" that are time consuming, costly and difficult to evaluate. They certainly induce a huge amount of anxiety in the patient.Whole genome studies are going to be even worse. The vast majority of genetic information in a person is not interpretable with anything like the accuracy required for clinical decision making.

The new that stimulated Healy's article was that the Presidential Committee for the Study of Bioethical Issues said professional organizations need to start writing guidelines for how to deal with these incidental results. In other words, we should stop treating them like they are not anticipated - we know we are going to get them even if we don't ask for them, so we better make a plan.

I'm all for coming up with guidance on this tricky issue, especially in cases where the consequences of over-diagnosis and unnecessary work-ups are high and the benefits are low. 

The unintended uses of diagnostic tests have a few other upsides to keep in mind, though. They can be used for public health surveillance to help develop strategies for the whole population of patients. This is done routinely with infectious disease tests, for instance, to alert us to new outbreaks.  More recently, we have been systematically scanning commonly done blood and urine chemistry tests to identify patients with undiagnosed diabetes and kidney disease. In the case of chronic kidney damage especially, even the doctors don't always recognize the condition as present. By using an automated system to monitor laboratory results, we can identify patients who need extra attention, reach out to them, connect them to the resources they need and prevent emergencies and other complications.

If you have thoughts on this issue, do leave a comment!