CHA Family Medicine Residency

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UberDiagnosis – Chapter 5: the NNT and NNH

You’ve heard about the “Number Needed to Treat” and the “Number Needed to Harm.” This statistic guesstimates how many people we need to screen in the clinic/hospital before we find a benefit or harm from a treatment.

Has your family or friends ever heard of the NNT? Have your patients ever asked: “what’s the NNH for this?

 

Well, this is an exciting year for biostatistics because NNT and NNH have hit pop culture and the mainstream media in a big way!

 

First, it started in October 2014 in the Wired Magazine. Then, PBS spread the word in December 2014.
Next, it hit the NY Times two months ago:How to Measure a Medical Treatment’s Potential for Harm

 

Then the AFP decided to get in on the action in this month’s AAFP: Introducing Medicine by the Numbers: A Collaboration of The NNT Group and AFP

This new series will appear in the online-only edition of AFP. Each month, medical editors from AFP and TheNNT.com will select a topic to feature. We will use TheNNT.com’s color-coding to quickly convey the relative merits of an intervention, and present the numbers for benefit and harm in a summary box. A discussion outlines the background evidence and the rationale for the rating, accompanied by key supporting references.

 

 

If you’ve worked with me, you might have heard me quoting things like “1 out of 8 to 9 people who are treated for AOM or sinusitis with antibiotics with GI upset and diarrhea.”

Where did I get these facts? How do I know them off the top of my head?

From the great website theNNT.com! In addition to facts on treatment, they also have launched a new section on diagnosis (and most relevantly here, on harms associated with overdiagnosis.)

 

Here are some of the relevant links to check out below. How often have you asked yourself a question about these clinical issues in the past month?

Primary Care: Diagnosis

 

Primary Care: Treatment

 

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UberDx Chapter 4

So now you know about Overdiagnosis Bias. The answer to Question 1 in Chapter 3 is “False”. In this scenario, screening does not diagnose more cancers, but the numerator and denominator are inflated because of all the false positives and “pseudodisease” screening creates. So it looks like the 10 year survival is better. Have you had to deal with this recently, as CHA has embarked on screening smokers for lung cancer? I certainly have. I really try to engage patients in shared decision-making about that and I basically try to talk them out of it. We know how to prevent lung cancer.

Ok, so take a look at this:

Cancer incidence

 

Can you think if some cancers that fit the A graph: we pick up more aggressive cancers by screening? How about the B graph: we seem to diagnose more, but there is no corresponding increase in number of people dying from the diagnosis? In B we are: 1. Picking up more benign cancers, 2. Simultaneously improving treatment while picking up more cancers, 3. Diagnosing more, maybe earlier, but having no effect on survival.

There aren’t too many good examples of “A”, at least for cancer. Alzheimer’s disease fits the graph pretty well, though. Cervical cancer is actually a good example, but the death rate begins to fall off after time, because we have good interventions.

There are a lot of examples that fit “B”. Prostate cancer. Thyroid cancer. Can you think of any others?


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UberDx Chapter 3

Did you read http://en.wikipedia.org/wiki/Overdiagnosis? (See emails below)

If not, proceed no further. Even if you think you know everything, you still have to read it.

If you have, then this graphic should look familiar:

Overdiagnosis bias

Overdiagnosis Bias: The over-inflation of survival statistic by “early diagnosis”.

So, now think about these questions:

  1. More lung cancers are detected in screened populations than in unscreened populations. True or false?
  2. What are some examples of “pseudodisease” in the case of lung cancer screening? (“the small solitary pulmonary nodule”)
  3. What reactions have your patients had from a CT scan that requires follow up to rule out cancer?


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The Natural History of Benign Thyroid Nodules

Friday, we discussed the UBER sexy topic of thyroid nodules:

Durante et al, “The Natural History of Benign Thyroid Nodules,” JAMA. 2015; 313(9):926-935

Why do we care?

We all have “that patient” who has to get repeat thyroid ultrasounds and aspirations for either a nodule or multinodular disease. More than 90% of detected nodules are clinically insignificant benign lesions, but we are picking up more thyroid nodules everyday with our non-evidence-based annual physicals and incidentalomas on CT/MRI.

Currently, established guidelines for initial biopsy include:

– nodule size: > 1 cm

– sonographic characteristics: hypoechogenicity, irregular margins, taller-than-wide shape, intranodular vascular spots, microcalcifications

Furthermore, current guidelines recommend serial ultrasound exams for benign thyroid nodules and repeat needle biopsy if a nodule grows by 20%. The problem is that not much is known about the correlation between nodule growth and actual cancer.

This was a prospective study that followed some middle-aged Italian folks over five years with benign nodules, confirmed via laboratory testing and needle aspiration at the baseline evaluation. They received serial ultrasounds and a needle aspiration if they experienced nodule growth of 20% or if the ultrasound met the above-mentioned criteria for biopsy.

P: About a thousand Italian people, with a mean age of 52 years, 82% of whom were female. After loss to follow up and people who no longer met criteria (developed thyroid dysfunction), they were left with 992 patients.

I: This study wasn’t really about an “intervention,” rather it followed growth of nodules over time, so the groups were split into those who experienced growth vs…

C: Those who experienced no growth.

O: In 69% of patients, the thyroid nodules remained stable. 18% shrank spontaneously. In 2%, the nodules *disappeared.* 15% grew, most of which were in patients who had multiple nodules at baseline. 9% developed new nodules. “Over the course of the 5 years, 37% met re-aspiration criteria (growth or concerning features on ultrasound).” (growth or concerning features on ultrasound). Of these, 98.9% confirmed the baseline benign diagnosis.  Thyroid cancer was detected in 0.3% of the 1567 original nodules. 

Limitations:

– 1k patients in the grand scheme of things isn’t a whole lot, but it helps that this study underlines what we already suspected about thyroid nodules

– This doesn’t help us with younger people, in whom thyroid cancer is more prevalent

– 5 years of follow up is a drop in the bucket compared to the usual length of time our patients get follow up (eons) — additional studies should have a longer follow up time

– This was the most boring article EVER. Seriously. OMG.

Bottom Line: Don’t freak out about thyroid nodules! And the guidelines should probably space out ultrasounds because most of them won’t grow, anyway.


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Early Imaging for Back Pain

Today we discussed early imaging in back pain.

Jarvik JG et al. “Association of Early Imaging for Back Pain with Clinical Outcomes in Older Adults.” JAMA 2015; 313 (11): 1143-1153.

Population: 5k patients who are, according to the #’s, mostly white, over 65, with a high school or higher education, but with a smattering of other races and educational levels thrown in. Drawn from Harvard Vanguard, Kaiser Permanente of NoCA, and Henry Ford health systems.
Excluded: people with cancer or back surgery

Intervention: early back imaging < 6 weeks from “index visit”

Control: propensity-matched controls that did NOT undergo imaging

Outcome: Patient self-reported pain/function/depression at different intervals, mainly 3-, 6-, and 12-month intervals. Basically, 1300-1500 dollars more usage per patient in those who undergo early imaging. The short version is: early imaging largely results in same outcomes with more health care costs. Proportion of cancer diagnoses were not statistically different between the two groups!

Limitations of study: patient-reported data and a morass of CPT, ICD9, and RVU data pulled from medical records. How to account for osteoporotic patients?

Short version: you can safely avoid getting early (< 6 weeks) imaging in older folks who present with your basic back pain visit without worrying about “missing something.”

Why did this study matter? Most back pain literature is based on younger < 65 year old peeps.

Questions? Concerns? Comments?
-Danielle


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Match Day 2015!

March 20, 2015

MATCH DAY is an exciting day for all residency programs in the US and for thousands of soon-to-be doctors who learn their “match” for which residency program they will be joining.

We are thrilled to welcome Danielle, Faiz, Jennifer, Matthew, Kanthi, Devorah, Ian and Meera into our Tufts FMR @ CHA family!! (see attached Tufts FMR Interns 2015 pdf or the sidebar of our main page in the media section) This is a diverse and dynamic group of individuals that I’m confident will help us continue to grow as a program and discipline and will be leaders in the “primary care revolution” a flame that we are aggressively fanning.

Cambridge Health Alliance is the last public hospital system in Massachusetts and has a deep social justice mission to meet the needs of our diverse underserved patient population. We know that “nonwhite physicians provide a disproportionate share of care to underserved populations. Hence, increasing the racial and ethnic diversity of the physician workforce may be key to meeting national goals to eliminate health disparities.”For this reason, this year our program adopted a new strategic approach to our recruiting and interview season with a goal of recruiting a higher portion minority residents with diverse racial and ethnic origin. Practicing in Malden, a school district with the most diversity in Massachusetts, we hoped to recruit an intern class with broader diversity that better mirrors the populations we serve. We were wildly successful on this front with five of our eight new interns being underrepresented minorities and bringing language skills in 12 . . . yes, I said 12 languages other than English!

Our clinic has undergone a major expansion in the last year as we aim to double our capacity from 13,000 to 26,000 patients that we care for. The success of the “Massachusetts Healthcare Experiment” has shown us that when people get insured (and 98.2% of Massachusetts is now insured!), they want to use it and get seen, so we’re busier than ever (Monday we had 763 phone calls to our clinic – a new record). With our new cohort of additional faculty, PA’s, nurses, front desk, medical assistants, complex care managers, planned care coordinators and integrated mental health team, our team-based care model is maturing and performing better than ever. It’s thrilling to watch a medical assistant light up and take pride in her ownership for proactively increasing our cancer screening rates through outreach and patient engagement. To make primary care sustainable and successful, it HAS to be a team sport and it’s trilling to watch that transformation take place her at the CHA Malden Family Medicine Center.

Congratulations to us, to our new class, and to all newly matched residents and residency program. It’s a very exciting time of year for all of us, and I can’t wait to get to know and work with our new amazing group of young physicians that will be joining our family at TuftsFMR@CHA!

Onward,
~g

Gregory Sawin MD MPH
Program Director
Tufts University Family Medicine Residency
at Cambridge Health Alliance
www.tuftsfmr.org
Assistant Professor of Family Medicine
Tufts University School of Medicine
Clinical Instructor of Population Medicine
Harvard Medical School


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GI diet diary challenge!

We played a game on Tuesday as a part of the R2 conference on Dyspepsia and Changes in Bowel Habits.

  • A 36 year old Italian-American woman presents to you with a history of GERD for follow up. She brings in a diet diary with the following foods.
    • Which foods aggravate her symptoms?
    • Which foods alleviates her symptoms?

Here’s the answers we assembled.
_________________________________________________

 

 

aIMG_1279a

aIMG_1278

 

 

 

________________________________

Now, the harder challenge:

  • She returns with a new diagnosis of IBS that she self-diagnosed. She brings in (another!) diet diary with the following foods.
    • Which foods aggravate her symptoms?
    • Which foods alleviates her symptoms?

aIMG_1276

aIMG_1277

Can you think of any tasty recipes you would recommend to this woman with GERD and IBS?