disease management

Managing Opioid Use Disorder in Primary Care: PEER Simplified Guide

Bethie Seay — Mon, 13 Sep 2021 05:00:00 +0000

Date Added:

September 13, 2021

Type:

Meta-analyses, Reviews, and Guidelines

PMID (1):

31088869

MeSH

decision making

disease management

Humans

Opiate Substitution Treatment

opioid-related disorders

primary health care

A easy-to-use, primary care-oriented opioid use disorder management guideline from the College of Family Physicians of Canada.

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Objective: To use the best available evidence and principles of shared, informed decision making to develop a clinical practice guideline for a simplified approach to managing opioid use disorder (OUD) in primary care.

Methods: Eleven health care and allied health professionals representing various practice settings, professions, and locations created a list of key questions relevant to the management of OUD in primary care. These questions related to the treatment setting, diagnosis, treatment, and management of comorbidities in OUD. The questions were researched by a team with expertise in evidence evaluation using a series of systematic reviews of randomized controlled trials. The Guideline Committee used the systematic reviews to create recommendations.

Recommendations: Recommendations outline the role of primary care in treating patients with OUD, as well as pharmacologic and psychotherapy treatments and various prescribing practices (eg, urine drug testing and contracts). Specific recommendations could not be made for management of comorbidities in patients with OUD owing to limited evidence.

Conclusion: The recommendations will help simplify the complex management of patients with OUD in primary care. They will aid clinicians and patients in making informed decisions regarding their care.

Author/s:

Korownyk, C., Perry, D, Kolber, M. R., Garrision, S., Thomas, B., Allan, G. M., Bateman, C., de Queiroz, R., Kennedy, D., Lamba, W., Marlinga, J., Mogus, T., Nickonchuk, T., Orrantia, E., Reich, K., Wong, N., Dugré, N., Lindblad, A. J.

Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care

Bethie Seay — Tue, 25 May 2021 05:00:00 +0000

Date Added:

May 25, 2021

Type:

Notifications and Opportunities

MeSH

Humans

United States

Information Technology

Adaptation, physiological

Quality of Health Care

This is a summary of recommendations from a National Academy of Medicine panel on Implementing High Quality Primary Care.

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High-quality primary care is the foundation of a high-functioning health care system. When it is high-quality, primary care provides continuous, personcentered, relationship-based care that considers the needs and preferences of individuals, families, and communities. Without access to high-quality primary care, minor health problems can spiral into chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventive care lags, and health care spending soars to unsustainable levels.

Unequal access to primary care remains a concern, and the COVID-19 pandemic amplified pervasive economic, mental health, and social health disparities that ubiquitous, high-quality primary care might have reduced. Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes. For this reason, primary care is a common good, which makes the strength and quality of the country’s primary care services a public concern.

The National Academies of Sciences, Engineering, and Medicine formed the Committee on Implementing High-Quality Primary Care in 2019. Building on the recommendations of the 1996 Institute of Medicine report Primary Care: America’s Health in a New Era, the committee was tasked to develop an implementation plan for high-quality primary care in the United States.

The committee’s definition of high-quality primary care (see Box 1) describes what it should be, not what most people in the United States experience today. To rebuild a strong foundation for the U.S. health care system, the committee’s implementation plan includes objectives and actions targeting primary care stakeholders and balancing national needs for scalable solutions while allowing for adaptations to meet local needs.

The committee set five implementation objectives to make high-quality primary care available to all people living in the United States:

1. Pay for primary care teams to care for people, not doctors to deliver services.

2.Ensure that high-quality primary care is available to every individual and family in every community.

3.Train primary care teams where people live and work.

4.Design information technology that serves the patient, family, and the interprofessional care team.

5.Ensure that high-quality primary care is implemented in the United States.

Author/s:

The National Academy of Sciences

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Brian Desmarais — Tue, 18 Feb 2020 17:15:18 +0000

Date Added:

February 18, 2020

Journal/Publication:

Annals of Internal Medicine

Publication Date:

February 18, 2020

URL:

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.7326/M19-3575

Keywords

evaluation

sleep apnea

chronic insomnia

MeSH

sleep initiation and maintenance disorders

This is a guideline for evaluation and management of obstructive sleep apnea and chronic insomnia developed by the VA and DoD. The recommendations are concise and useful. James W. Mold, MD, MPH

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Abstract

Description:

In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions.

Methods:

In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Recommendations:

This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

The National Institutes of Health has estimated that insomnia and obstructive sleep apnea (OSA) are 2 of the most common sleep disorders in the general U.S. population and in the military and veteran populations (1). Insomnia symptoms are the most common sleep symptoms among U.S. adults, occurring in approximately 20% to 30% of adults, and the prevalence of chronic insomnia disorder ranges from 6% to 10% (2–6). The prevalence of OSA ranges from 9% to 38% and is associated with older age, higher body mass index, male sex, and menopause.

Sleep disorders are more prevalent in the populations served by the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) than in the general civilian population. In the RAND report “Sleep in the Military: Promoting Healthy Sleep Among U.S. Servicemembers,” 48.6% of military personnel surveyed had poor sleep quality (Pittsburgh Sleep Quality Index score >5) (7). The prevalence of insomnia symptoms has been reported to be as high as 41% in service members deployed to combat and 25% in noncombatants (8). In a large cohort of soldiers preparing for deployment, 19.9% met criteria for insomnia according to the Insomnia Severity Index (ISI) (8). A more recent study evaluated the incidence of insomnia and OSA in the entire population of U.S. Army soldiers from 1997 to 2011 (9) and showed unprecedented increases in the incidence of both conditions (652% and 600%, respectively) during this period. In military personnel referred for sleep evaluations, sleep-disordered breathing is the most frequently diagnosed disorder, and some studies have found that military personnel have high rates of comorbid insomnia and OSA (10, 11). Further, military personnel with sleep disorders often also have posttraumatic stress disorder (PTSD), symptoms of anxiety and depression, and traumatic brain injury, which can complicate diagnosis and management (11–13).

Sleep disturbances are also common in veterans (14–16). Similar to findings from active-duty service members, the National Veteran Sleep Disorder Study found that the number of veterans diagnosed with sleep disorders increased nearly 6-fold from 2000 to 2010. In this study, 4.5% of veterans were diagnosed with sleep-disordered breathing, and 2.5% were diagnosed with insomnia. However, the actual prevalence of insomnia disorder among veterans is likely to be considerably higher (17) because it is often not documented in the medical record (18, 19). Comorbid PTSD was associated with a 7.6-fold greater risk for OSA and a 6.3-fold greater risk for insomnia (15). Because veterans have high rates of cardiovascular disease and PTSD, and because OSA is more prevalent in patients with these disorders (20), there is likely a large percentage of veterans who have not yet been diagnosed with OSA (21).

Author/s:

Mysliwiec, V., Martin, J.L., Ulmer, J.S., Chowdhuri, S., Brock, M.S., Spevak, C.

Association of Pharmacological Treatments With Long-term Pain Control in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis

Brian Desmarais — Thu, 09 Jan 2020 19:15:00 +0000

Date Added:

January 9, 2020

Journal/Publication:

Journal of the American Medical Association

Publication Date:

December 25, 2019

Issue:

Volume:

320

URL:

Association of Pharmacological Treatments With Long-term Pain Control in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2018.19319

MeSH

disease management

pain

Osteochondrodysplasias

Spondylometaphyseal dysplasia, Sedaghatian type

Information Storage and Retrieval

Network Meta-Analysis

follow-up studies

Bayes Theorem

osteoarthritis, knee

In this systematic review and meta-analysis of knee osteoarthritis RCTs with at least one year of follow-up, the only pharmacological intervention associated with long term benefits was glucosamine. James W. Mold, MD, MPH

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IMPORTANCE:

Even though osteoarthritis is a chronic and progressive disease, pharmacological agents are mainly studied over short-term periods, resulting in unclear recommendations for long-term disease management.

OBJECTIVE:

To search, review, and analyze long-term (≥12 months) outcomes (symptoms, joint structure) from randomized clinical trials (RCTs) of medications for knee osteoarthritis.

DATA SOURCES AND STUDY SELECTION:

The databases of MEDLINE, Scopus, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were searched until June 30, 2018 (MEDLINE alerts through August 31, 2018) for RCTs of patients with knee osteoarthritis that had treatment and follow-up lasting 1 year or longer.

DATA EXTRACTION AND SYNTHESIS:

Data at baseline and at the longest available treatment and follow-up of 12 months' duration or longer (or the change from baseline) were extracted. A Bayesian random-effects network meta-analysis was performed.

MAIN OUTCOMES AND MEASURES:

The primary outcome was the mean change from baseline in knee pain. Secondary outcomes were physical function and joint structure (the latter was measured radiologically as joint space narrowing). Standardized mean differences (SMDs) and mean differences with 95% credibility intervals (95% CrIs) were calculated. Findings were interpreted as associations when the 95% CrIs excluded the null value.

RESULTS:

Forty-seven RCTs (22 037 patients; mean age range, mostly 55-70 years; and a higher mean proportion of women than men, around 70%) included the following medication categories: analgesics; antioxidants; bone-acting agents such as bisphosphonates and strontium ranelate; nonsteroidal anti-inflammatory drugs; intra-articular injection medications such as hyaluronic acid and corticosteroids; symptomatic slow-acting drugs in osteoarthritis such as glucosamine and chondroitin sulfate; and putative disease-modifying agents such as cindunistat and sprifermin. Thirty-one interventions were studied for pain, 13 for physical function, and 16 for joint structure. Trial duration ranged from 1 to 4 years. Associations with decreases in pain were found for the nonsteroidal anti-inflammatory drug celecoxib (SMD, -0.18 [95% CrI, -0.35 to -0.01]) and the symptomatic slow-acting drug in osteoarthritis glucosamine sulfate (SMD, -0.29 [95% CrI, -0.49 to -0.09]), but there was large uncertainty for all estimates vs placebo. The association with pain improvement remained significant only for glucosamine sulfate when data were analyzed using the mean difference on a scale from 0 to 100 and when trials at high risk of bias were excluded. Associations with improvement in joint space narrowing were found for glucosamine sulfate (SMD, -0.42 [95% CrI, -0.65 to -0.19]), chondroitin sulfate (SMD, -0.20 [95% CrI, -0.31 to -0.07]), and strontium ranelate (SMD, -0.20 [95% CrI, -0.36 to -0.05]).

CONCLUSIONS AND RELEVANCE:

In this systematic review and network meta-analysis of studies of patients with knee osteoarthritis and at least 12 months of follow-up, there was uncertainty around the estimates of effect size for change in pain for all comparisons with placebo. Larger RCTs are needed to resolve the uncertainty around efficacy of medications for knee osteoarthritis.

Author/s:

Gregori, D., Giacovelli, G., Minto, C., Barbetta, B., Gualtieri, F., Azzolina, D., Vaghi, P.

COPD: All You Need to Know in 20 Minutes

Tracy Ashby — Mon, 29 Apr 2019 05:00:00 +0000

Date Added:

April 29, 2019

Publication Date:

February 26, 2019

URL:

COPD: All You Need to Know in 20 Minutes

Type:

Meta-analyses, Reviews, and Guidelines

Keywords

chronic obstructive pulmonary disease

MeSH

pulmonary disease, chronic obstructive

disease management

This is a 20 min audio review of the dx and tx of COPD. James W. Mold, MD, MPH

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COPD is common enough that it is responsible for 3% of all clinic visits in the United States. Clinicians will undoubtedly deal with this disease in their practice. How to diagnose and manage it is reviewed by Frank C. Sciurba, MD, a professor of medicine from the University of Pittsburgh, Pennsylvania.

Author/s:

Sciurba, Frank C.