Publications

Following a comprehensive review of the College’s training programmes, a spokesperson said it was now necessary to have a knowledge-based assessment as part of its BST General Internal Medicine programme to preserve the international standing of the BST Certificate of Completion, and to ensure that all trainees attained the necessary knowledge and clinical skills on completion.

This meant the MRCPI was now the examination on which the awarding of a Certificate of Completion was based, along with existing BST requirements, such as clinical training in supervised posts and attendance at professional development courses, the College explained.

Knowledge-based examinations, the RCPI added, were already an essential component of comparable BST programmes worldwide. Dr Geoff Chadwick, RCPI Associate Dean of BST, said this was a “positive and pragmatic development”.

“We recognise there is a need for formal assessment of biomedical knowledge and clinical skill as part of the BST curriculum. We recognise that this assessment already exists in the MRCPI examination and we have, therefore, moved formally to link BST with MRCPI,” he commented.

In recent years, the BST curriculum had been updated to reflect more closely the syllabus for the MRCPI examination, and following the addition of the exam to the list of requirements for BST, the MRCPI examination itself would now undergo some changes to bring it more into line with the BST curriculum, the RCPI indicated.

The College, however, agreed that from July 2011, doctors would be able to apply to sit Part 1 of the exam 12 months after obtaining their primary medical degree, i.e. as soon as they entered BST.

According to the College, this would increase the number of times trainees could sit the MRCPI examinations while on the BST programme.
Previously, all applicants had to have obtained their medical degree at least 18 months beforehand. The College said the first Part 1 examination would take place next September.

 

Screening for Ovarian Cancer: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement

Description: Reaffirmation of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for ovarian cancer.

Methods: A 2008 review of the literature commissioned by the USPSTF revealed no new evidence about the benefits of screening for ovarian cancer but provided some new data about observed harms of screening. A bridge search to 2011 focused on evidence from randomized, controlled trials.

Population: This recommendation applies to asymptomatic women. It does not apply to women with known genetic mutations that increase their risk for ovarian cancer (for example, BRCA mutations).

Recommendation: The USPSTF recommends against screening for ovarian cancer in women (D recommendation).

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

 

Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review

 

Meera Viswanathan, PhD; Carol E. Golin, MD; Christine D. Jones, MD, MS; Mahima Ashok, PhD; Susan J. Blalock, MPH, PhD; Roberta C.M. Wines, MPH; Emmanuel J.L. Coker-Schwimmer, MPH; David L. Rosen, MD, PhD; Priyanka Sista, BA; and Kathleen N. Lohr, PhD

 

Abstract

Background: Suboptimum medication adherence is common in the United States and leads to serious negative health consequences but may respond to intervention.

Purpose: To assess the comparative effectiveness of patient, provider, systems, and policy interventions that aim to improve medication adherence for chronic health conditions in the United States.

Data Sources: Eligible peer-reviewed publications from MEDLINE and the Cochrane Library indexed through 4 June 2016 and additional studies from reference lists and technical experts.

Study Selection: Randomized, controlled trials of patient, provider, or systems interventions to improve adherence to long-term medications and nonrandomized studies of policy interventions to improve medication adherence.

Data Extraction: Two investigators independently selected, extracted data from, and rated the risk of bias of relevant studies.

Data Synthesis: The evidence was synthesized separately for each clinical condition; within each condition, the type of intervention was synthesized. Two reviewers graded the strength of evidence by using established criteria. From 4124 eligible abstracts, 62 trials of patient-, provider-, or systems-level interventions evaluated 18 types of interventions; another 4 observational studies and 1 trial of policy interventions evaluated the effect of reduced medication copayments or improved prescription drug coverage. Clinical conditions amenable to multiple approaches to improving adherence include hypertension, heart failure, depression, and asthma. Interventions that improve adherence across multiple clinical conditions include policy interventions to reduce copayments or improve prescription drug coverage, systems interventions to offer case management, and patient-level educational interventions with behavioral support.

Limitations: Studies were limited to adults with chronic conditions (excluding HIV, AIDS, severe mental illness, and substance abuse) in the United States. Clinical and methodological heterogeneity hindered quantitative data pooling.

Conclusion: Reduced out-of-pocket expenses, case management, and patient education with behavioral support all improved medication adherence for more than 1 condition. Evidence is limited on whether these approaches are broadly applicable or affect long-term medication adherence and health outcomes.

Primary Funding Source: Agency for Healthcare Research and Quality.

Although many efficacious medical treatments exist, a recent Institute of Medicine report identified a gap between current treatment success rates and those believed to be achievable . This gap has been attributed partly to lack of patient adherence to recommended treatment . Poor medication adherence is common . Studies have consistently shown that 20% to 30% of medication prescriptions are never filled and that approximately 50% of medications for chronic disease are not taken as prescribed .

This lack of adherence has dramatic effects on health . In the United States, it is estimated to cause approximately 125 000 deaths, at least 10% of hospitalizations , and a substantial increase in morbidity and mortality . Nonadherence has been estimated to cost the U.S. health care system between $100 billion and $289 billion annually .

This review is part of a larger initiative, Closing the Quality Gap: Revisiting the State of the Science, and builds on an earlier Agency for Healthcare Research and Quality (AHRQ) collection of publications, Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. This new series focuses on selected settings, interventions, and clinical conditions for quality improvement. Our report addresses the comparative effectiveness of interventions to improve medication adherence.

Methods

 This article focuses on 2 of our key questions. First, among patients with chronic diseases with self-administered medication prescribed by a provider for secondary or tertiary prevention, what is the comparative effectiveness of interventions aimed at patients, providers, or systems in improving medication adherence? Is improved medication adherence associated with improved patient outcomes? Second, what is the comparative effectiveness of policy interventions for improving medication adherence? Is improved medication adherence associated with improved patient outcomes?

Study Eligibility

We assessed medication adherence effectiveness for studies conducted in outpatient primary and specialty care, as well as community-based and home-based settings (Appendix Table 1). We excluded studies in institutional settings because medications are generally not self-administered there, interventions to improve antiretroviral adherence because comprehensive reviews of such interventions were only recently completed , interventions for adherence to medications for patients with severe mental illness (schizophrenia, other psychoses, and bipolar disorder) and substance abuse because the complex cognitive features of adherence for such conditions require specific interventions that are not applicable to patients with other conditions, acute conditions because adherence for such disease differs from that for chronic illness , studies published before 1994 because of a large systematic review that included studies up to 1994 , and non–English-language and non-U.S. studies to ensure greater applicability of our findings to the unique health care setting of the United States. Other systematic reviews also note that adherence studies from non–U.S.-based health care systems are inherently different from those in the United States because of variations in the ways that patients procure, pay for, and monitor medications .

Appendix Table 1.  

Inclusion and Exclusion Criteria

Adherence is a complex multifactorial behavior that is influenced by social and economic factors (for example, age, race, sex, and socioeconomic status), patient-related factors (for example, knowledge, attitude, and beliefs), condition- and treatment-related factors (for example, severity of the symptoms and disease, complexity of the medical regimen, duration of treatment, and adverse effects), provider characteristics (for example, communication skills, training, and resources), and setting (for example, drug coverage, cost sharing of medications, and access to medication and clinical care) . Such factors interact to influence adherence behavior. For instance, the setting may influence patient and provider behavior through appointments that are too short to discuss adherence, fee structures that do not support reimbursement for patient counseling and education, poor continuity of care that disrupts the patient–provider relationship, and systems that impede information sharing between providers and pharmacists on prescription refills .

Hence, patient adherence behaviors in countries or settings without the systemic characteristics of the United States are markedly different. Residents of the United States have been found to be 2 to 3 times more likely to report cost-related nonadherence than Canadian residents , even when the results were stratified by insurance status. Publicly or privately insured patients in the United States were more than twice as likely to report cost-related nonadherence than the reference group of patients who were seniors receiving social assistance in Ontario, Canada . Of note, in our review of 61 excluded non-U.S. studies, 7 were set in developing countries , 1 was a multicenter trial that included developing countries , and the remaining 53 were set in 15 advanced economies with universal coverage of various types . Of these, more than half were set in the United Kingdom (17 studies)  and Canada (10 studies) .

As suggested by Norris and colleagues , we conducted a preliminary assessment of the availability of evidence from randomized, controlled trials (RCTs) and the likelihood of selection bias and confounding from observational studies and accordingly focused on RCTs for patient, provider, and systems interventions. We expanded the scope to include observational studies for policy interventions because these studies allowed us to assess the effectiveness of policy innovations in practice settings that are not usually tested in trials.

Data Sources and Searches

To identify relevant articles, we conducted separate targeted literature searches for patient, provider, systems, and policy interventions by using MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials from 1994 through 4 June 2016. We reviewed our search strategy with a panel of technical experts and supplemented it as needed according to their recommendations. To avoid retrieval bias, we manually searched the reference lists of pertinent reviews to identify relevant citations that our searches missed.

Study Selection

Two trained researchers independently reviewed each title and abstract. All titles selected by at least 1 reviewer went on to full-text review by 2 independent reviewers. Reviewers resolved conflicts by discussion and consensus or consultation with a third reviewer as needed.

Data Extraction and Quality Assessment

For studies meeting the inclusion criteria, a trained reviewer abstracted data into structured evidence tables that were then reviewed by a second trained reviewer for completeness and accuracy.

Two independent reviewers assessed risk of bias for each study by using predefined criteria based on those developed by AHRQ  and specified in the RTI Item Bank . We resolved disagreements between reviewers by consulting a senior member of the team.

Data Analysis and Synthesis

To make the findings as clinically useful as possible, we analyzed results for each key question by both clinical condition and intervention type. We specified a priori the data to be collected for all outcomes except biomarkers and morbidity. On the basis of the recommendations of the technical expert panel, we elected to collect a comprehensive set of biomarkers and morbidity outcomes, rather than judge which to collect in advance. We determined quantitative analysis to be inappropriate because of clinical or methodological heterogeneity, low numbers of similar studies, and insufficiency or in outcome reporting, so we synthesized data qualitatively. We grouped interventions into categories that reflected key intervention components.

We graded the strength of evidence for medication adherence, biomarkers (for example, systolic blood pressure and hemoglobin A1c), morbidity (for example, depressive symptoms and asthma symptoms), mortality, and other health outcomes. These grades incorporate 4 key considerations when the strength of a stated effect is being evaluated: risk of bias (including study design and aggregate quality), consistency, directness, and precision (see Appendix Table 2 for definitions of strength-of-evidence grades). We excluded studies with high risk of bias and found no variation in directness. As a result, consistency and precision were key drivers of the strength-of-evidence grades in this body of studies with medium and low risk of bias.

Appendix Table 2.  

Definitions of Grades of Overall Strength of Evidence

Role of the Funding Source

The AHRQ funded the systematic review. The key questions, protocol, and draft report were reviewed by the funder, the peer reviewers, the technical expert panel members, and the public. Approval from AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for its content and the decision to submit it for publication.

Results

First, we present the results from our literature search and a summary of the characteristics of our included studies. We then present our results for patient, provider, and systems interventions by clinical condition and intervention type. Supplement 1 and Appendix Table 3 summarize our findings and give the strength-of-evidence grade for each intervention. Although we present our results separately by clinical condition and intervention type, the close correlation between these 2 factors requires that results synthesized by clinical condition specify intervention type. Similarly, results synthesized by intervention type specify clinical condition. Finally, we present results for policy interventions and summarize the findings in Appendix Table 4. We generally highlight evidence of moderate or low strength.

 

Trauma Informed Care for Primary Care: The Lessons of War

 

Robert J. Ursano, MD; David M. Benedek, MD; and Charles C. Engel, MD, MPH

 

Over 2 million Americans have deployed to the wars in Iraq and Afghanistan over the past decade. For these individuals, anticipated and actual exposure to life-threatening events were a routine part of daily life. Similarly, natural disasters, such as Katrina, the recent natural and man-made consequences of the Japan earthquake and tsunami, the massive South East Asia tsunami of 2005, and tornadoes tearing through the Southeast United States, have placed in graphic relief the traumatic events that affect many millions of lives every year. Even in our everyday life (and medical practice), trauma is ever-present: sexual assault, domestic violence, gang shootings, and accidents. In the United States, over 10 million motor vehicle accidents result in more than 35 000 deaths each year . If we told our hospitals that 34% of everyone in the intensive care unit had a staphylococcal infection, they would immediately institute screening, treatment, and observation. Yet we know that approximately that rate of posttraumatic stress disorder (PTSD) occurs in patients presenting to hospital trauma units after serious motor vehicle accidents. Regardless, assessment for PTSD and other trauma-related disorders is not a standard of care in emergency departments, nor in outpatient settings where many patients affected by trauma present.

Posttraumatic stress disorder manifests as intrusive thoughts and memories of traumatic events; attempts to avoid reminders of the event; and startle, arousal, and sleep problems. We often talk of PTSD as being associated with memory problems; however, it can also be considered a disorder of impaired capacity to “forget.” The adaptive aspects of forgetting are seldom recognized, perhaps in part because of psychoanalytic perspectives that focus on the importance of remembering (and do not recognize that the goal of remembering is often to be able to forget) and because of our attention to the aging population and dementia, such as Alzheimer disease. But forgetting is probably a much more important function for our brains than remembering. We are constantly taking in information and if we could not “forget,” our brains would rapidly go on overload. So is PTSD a disorder of impaired forgetting?

Posttraumatic stress disorder is certainly a “brain injury” in that an environmental event (although not necessarily a blow or bullet) has altered the brain. We know this from imaging studies that show changes in the hippocampus, amygdale, and prefrontal cortex—the primary regions associated with PTSD . Posttraumatic stress disorder is not the only mental disorder associated with traumatic events: depression, panic attacks, and substance abuse are also common. Depression and substance abuse are common comorbid conditions of PTSD. There are abundant data that everyone is at risk for PTSD, given a sufficiently traumatic event. Many if not most people have nightmares, avoidance, numbing, negative thoughts, and arousal after common trauma. Most also recover over a few months. Thus, PTSD, similar to other diseases in medicine, can be like a common cold that resolves without treatment or can progress to pneumonia with severe morbidity . Too often we and the public speak of all psychiatric illnesses as if they were cancer. But psychiatric illness, like most medical illnesses, may be in the form of a bruise or a broken bone—not always cancer.

In addition to PTSD, recent attention has focused on the increased rates of suicide in the U.S. Army during the conflicts in Iraq and Afghanistan. In World War II, rates of suicide were lower than in peacetime. But now, rates of suicide in the U.S Army have nearly doubled over the past decade. Before the wars in Iraq and Afghanistan, rates of suicide in soldiers were about half that of age- and sex-matched general populations; that is, being in the Army predicted a lower risk for suicide. Now the rates are about the same as age- and gender-matched populations (about 20 to 22/100,000 per year) . Although it is tempting to focus solely on the suicide rate of combat veterans, suicide remains a leading cause of death among youth and working-age U.S. men. In the general population, suicide is nearly as common as vehicular death. Suicidal ideation is predicted by depression, so detecting depression is an important step in preventing suicide whether the patient is a combat veteran with war-related PTSD or a civilian who has less visible trauma. Specifically inquiring about suicidal risk is critical.

There are brief assessment tools for PTSD and depression that are useful in primary care settings . Obtaining mental health care is often challenging and dependent on health insurance options and state or county programs. Recent changes to Medicare support reimbursement for depression screening . Two questions during patient assessment in a variety of settings can help to determine the need to assess for PTSD or suicidality: “Have you ever been in a setting where your life was in danger?” and “Have you had any thoughts of wanting to hurt yourself (or someone else)?” The first question, which asks about life-threat exposure, is equivalent to an exposure to a “toxin” and an affirmative answer should lead to further assessment. Similarly, thoughts of wishing to hurt one's self are of serious concern. Depression, even without suicidality, has significant effects on health and alters family function and parental care giving. Suicidal thoughts or plans warrant further evaluation and assessment.

The challenges experienced by military members returning from combat deployment remind us of the toll that exposure to traumatic events may exact on well-being. Concern for the welfare of those returning from war has historically led to better characterization of, and development of treatments for, trauma-related distress and dysfunction as well as for physical injury, infectious diseases, and toxin exposures. War has taught us much about these processes. But traumatic exposure and trauma-related distress and illness are not military-specific phenomena. Accidents, violence, and natural and man-made disasters occur in times of peace and war. A new focus on national health care provides an opportunity to address national health issues. Trauma-informed care—recognizing and planning for detecting and treating the disorders that result after traumatic events—will benefit not only military personnel but all patients. Posttraumatic stress disorder and depression are perhaps the most common disorders related to traumatic events . We have good treatments for both and should identify patients in need of these interventions.

 

The Resurgence of West Nile Virus

Catherine M. Brown, DVM, MSc, MPH; and Alfred DeMaria, MD

 

Over the past several decades, public health officials have worked to alert the public to the threat of emerging infections, and the idea has captured the imagination of the American public; consider The Andromeda Strain, Outbreak, and Contagion. However, these theatrical portrayals—in which a scary, mysterious disease emerges but is investigated and controlled by the time the credits roll—fail to reveal the true drama, the ecological complexity of the world where real and deadly diseases occur. Over the years, public health professionals and the public alike have gotten excited about such pathogens as hantavirus, H5N1 avian influenza, the severe acute respiratory syndrome (SARS), monkeypox, and West Nile virus (WNV). Whereas H5N1, SARS, and monkeypox are only vague memories for most Americans because the ecosystem that fostered disease transmission exists overseas and not in our own backyards, WNV and hantavirus are different. While the public and professionals may have become somewhat complacent about both diseases, 2016 is reminding us that perhaps we shouldn't have.

West Nile virus has become endemic in North America. It is here to stay because we have the right combination of birds and mosquitoes. But this very endemicity has been driving complacency. After all, up to 80% of infected persons have few or no symptoms. However, WNV still causes life-threatening encephalitis and meningoencephalitis in some patients, and we are learning more about long-term sequelae , including flaccid paralysis . Although no vaccine or effective treatment is available, clinicians must maintain clinical suspicion of infection under the right circumstances of season and mosquito exposure to arrive at the correct diagnosis in a presenting patient. In addition, WNV remains a significant concern for blood collection organizations and transfusion services, requiring screening of donors, either individually or in pooled samples, on the basis of virus activity indicators.

Cases of WNV infection in 2016 in the United States have already exceeded that of any other year—with 1590 cases, 65 deaths, and 303 viremic blood donors as of 28 August 2016 —including the earliest years after the introduction of WNV in 1999 when the U.S. population, both bird and human, was immunologically naive to the virus. The problem this year is so dramatic that cities, such as Dallas , have resorted to aerial pesticide application to kill adult mosquitoes (adulticiding) for the first time in 45 years. Texas, South Dakota, Mississippi, Oklahoma, Louisiana, and Michigan have been particularly hard hit. Could this be a new strain of the virus, a reintroduction, or a mutation? Is a long-term temporal cycle of WNV infection emerging? Or, and perhaps most likely, is this year's experience related to unusual weather patterns? Temperature does have a role in WNV amplification.

This year we have been hearing from local health departments, wildlife rehabilitators, and other observers about an increase in dead bird sightings compared with recent years, which is similar to what had been seen earlier in the WNV experience. This might suggest a new WNV strain, either by natural selection or introduction. A new strain could also account for a change in human epidemiology. Alternatively, the reservoir of infection in birds might be substantial—some species experienced considerable mortality when the virus first arrived, but studies indicate that most populations have at least stabilized, if not recovered . But we cannot discount the possibility of increased numbers of the Culex species of mosquitoes that are the prime vectors. C. pipiens, C. restuans, and C. tarsalis are abundant and ubiquitous puddle- and container-breeding mosquitoes broadly distributed geographically in overlapping ranges in urban, suburban, and rural settings. These mosquitoes thrive and reproduce in stagnant, dirty, putrid collections of water in puddles and containers, sewers, storm drains, and catch basins, all of which are part of our residential infrastructure. The drought that has gripped much of the country this year has caused contraction of water sources, creating excellent breeding conditions for these mosquitoes. The record-breaking heat is known to speed up both the reproductive rate of mosquitoes and the rate of virus development within them. The interplay of heat, drought, human habitats, increased mosquito populations, and enhanced viral development all act in concert to increase the force of transmission. At least, that's the theory. The truth of what lies behind the resurgence of WNV activity this year will take time to uncover.

A frequently cited publication states that three quarters of emerging infections are zoonotic, that is, shared in nature by humans and animals . West Nile virus is first and foremost a bird virus. But it is spread within the avian reservoir by mosquitoes. And humans live in the same ecosystem as both birds and mosquitoes. So, to truly understand WNV and its manifestations, including the causes of increased incidence, we need to understand the virus and its cycle in nature, including the reservoir and the vector, and how the human-built environment contributes. Similar questions about hantavirus may eventually help explain the concerns about that disease that have also arisen this year . This integration of environmental science and veterinary medicine with human medicine is the essence of the One Health initiative, an international effort toward inclusive collaboration across disciplines. Fully understanding a disease like WNV, with its strong environmental component, will require work on all 3 fronts.

In the meantime, mosquito-prevention messages must be unrelenting, directed at personal protective behaviors (avoidance, repellents, and clothing) and reduction of breeding sites. The public must be constantly prodded, with a balance of sensible precautions and serious awareness of the possibility for severe disease. Reduction of mosquitoes requires an integrated pest-management approach, and we must come to grips with the sometimes controversial issue of pesticide application to kill adult mosquitoes, when benefit outweighs risk, and objectively determine efficacy under various conditions. For the long term, perhaps modifying the way we create our own environment will be an important part of reducing the impact of the disease.