Thursday, April 17, 2014

Winning the war against kidney failure

Ed Gregg, the master of diabetes epidemiology, and his team from the CDC, just published their latest report on the state of the nation's epidemic of diabetes. The good news is that the rates of diabetic complications - heart attacks, amputations, kidney failure, fatal hyperglycemic crisis, stroke - have fallen quite a bit since 1990. This is almost certainly do to the widespread application of practice guidelines by specialists and especially primary care providers. Monitoring and managing A1C, blood pressure, lipids and early renal damage is paying off at the national scale.

What about adults without diabetes?
"Trends in the population of adults without diabetes were generally not as promising as those in the population with diabetes, with smaller reductions in the rate of acute myocardial infarction, no significant change in rates of stroke and lower-extremity amputation, and an increase in the rate of end-stage renal disease."
An increase in end-stage renal disease? At the same time that we were making significant inroads against renal failure in diabetes (-28% drop in the rate), we see a swelling of the rates in non-diabetic adults by a whopping 65%. Why is this?

First, early stage chronic kidney disease is often un-noticed by providers who may not understand the implications of apparently small increases in serum creatinine. Second, proteinuria, the hallmark of treatable early renal damage, may not even be sought. Third, blood pressure is hard to reduce, often requiring multiple medications and persistent, frequent monitoring. You can't prevent the progression of early chronic kidney disease with once-a-year visits.

These problems in the quality of care are very much like those that beset diabetes 20 years ago, but we have made great strides by becoming aware of the problem, deciding as a profession that we should and shall do something about it, and marshalling all our resources - guidelines, educators, non-physician providers, reminders, lifestyle changes, new medications - and building them into our ongoing processes of care. In many practices, the optimal care of diabetes is a stated goal and the office uses standing orders, automated reminders and all the tricks of modern systems management to reliably deliver state-of-the-art care for diabetes. It's time to do that for early kidney disease.

Changes in Diabetes-Related Complications in the United States, 1990–2010
Edward W. Gregg, Ph.D., Yanfeng Li, M.D., Jing Wang, M.D., Nilka Rios Burrows, M.P.H., Mohammed K. Ali, M.B., Ch.B., Deborah Rolka, M.S., Desmond E. Williams, M.D., Ph.D., and Linda Geiss, M.A.
N Engl J Med 2014; 370:1514-1523 April 17, 2014 DOI: 10.1056/NEJMoa1310799

Thursday, April 10, 2014

Patient Engagement for Suicide Prevention

You can't manage what you can't measure is a truism in quality improvement. In mental health, it goes even further: You can't manage what you won't even talk about. Although lots of barriers have fallen in the realm of acceptable topics for conversation between doctors and patients - we no longer avoid saying "cancer" like the word itself was the disease - suicide is still a particularly difficult topic for providers to broach. No doubt training the doctors to deal with this sticky area head on can help, but it takes two to tango, and physicians hate to initiate a difficult discussion as much as anyone else.

So, Ruby Shah, Richard Kravitz and the good folks at UC Davis went at the problem from the other end. They used patient engagement techniques - a tailored interactive media program shown in the waiting room - to activate the patient to discuss their symptoms (both emotional and physical) including thoughts of self-harm, and the possibility that those symptoms were due to depression. Among patients with mild depression, there was little impact, perhaps because there was little need. But among patients with moderate to severe depression, the probability that suicide would at least be discussed went from 40% to 58%. 

Is this enough to make a difference? Talking about the issue is only the first step. Did it result in appropriate action? Kravitz and company already reported in JAMA that the engagement approach increased treatment (or referral for treatment) from 16% to 26%. So, the intervention works in the sense that it sometimes stimulates the necessary discussion and appropriate treatment. However, the depression scores 12 weeks later were not better in the engagement group and were even a bit worse. Increased prescribing for non-depressed patients raises the possibility that the engagement program actually made things worse for some patients.

This study was excellent science, but not a clear cut success for patient care. The tailored messaging had an impact on behavior and resulted in treatment changes. However, some of those treatment changes could have made things worse, not better. Twelve weeks later, there was little evidence that the patients felt better - probably because depression is hard to treat, especially with medications.

Shah R, Franks P, Jerant A, Feldman M, Duberstein P, Y Garcia EF, Hinton L,
Strohecker L, Kravitz RL. The Effect of Targeted and Tailored Patient Depression 
Engagement Interventions on Patient-Physician Discussion of Suicidal Thoughts: A 
Randomized Control Trial. J Gen Intern Med. 2014 Apr 8. [Epub ahead of print]
PubMed PMID: 24710994.

Kravitz RL, Franks P, Feldman MD, et al. Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care: A Randomized Trial. JAMA. 2013;310(17):1818-1828. doi:10.1001/jama.2013.280038