Annals for Educators - 17 January 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives17 January 2017Annals for Educators - 17 January 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201701170 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAssociation Between Patient-Centered Medical Homes and Adherence to Chronic Disease Medications. A Cohort StudyBecause poor medication adherence is strongly associated with worse patient outcomes and high health care spending, it is viewed as a key measure of quality of care by major organizations. However, it has not been evaluated in primary care practices that meet recognition criteria for patient-centered medical homes. In this cohort study, the authors assess the association between medication adherence and medical homes in a national patient and provider population.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners if they know the difference between medication adherence (filling or refilling a prescription on time) and medication compliance (taking a medication as prescribed).Do your learners ask their patients whether, and how, they take each of their medications? If they do not, does someone else in their practice ask? What exactly is asked? Does that really establish adherence?What is a patient-centered medical home? The authors discuss this in the study's introduction, as does the editorial that accompanies the article.Is your practice a patient-centered medical home? In what ways does your practice meet or not meet the definition noted above?How would our learners propose to study how well your practice does in meeting one (or more) of the requirements for a medical home?Video LearningAnnals Consult Guys - Measuring Lipids: To Fast or Not to Fast?In this episode of the Annals Consult Guys video series, Howard and Geno tackle the question of whether patients need to fast before measuring serum lipid levels.Use this video to:Ask your learners how LDL is calculated from measured lipid values.Ask what effect eating has on the measured lipid levels, and whether your learners think it is important that their patients fast before having their blood drawn.Then, watch the brief video with your team. What's the answer?What will your learners do in the future when measuring lipids in their patients?Do they know the answer to the multiple-choice question provided with the video? Be sure to log-in and enter your answer to earn CME credit for yourself.History of MedicineHistorical Perspective on the Rise and Fall and Rise of Antibiotics and Human Weight GainThis article discusses the effect of antibiotics on many aspects of human growth and health, which has garnered intense interest for more than 60 years.Use this paper to:Ask your learners why antibiotics might promote weight gain.Might antibiotics be helpful for the treatment of malnutrition? What theories regarding changes in the microbiome have been used to suggest “treatments” to alter the host flora and help people lose weight?Are these hypotheses well-founded? How do your learners respond when their patients inquire about what they have read about in the lay press?Our Health Care SystemThe Demise of the Affordable Care Act? Not So FastMany expect the newly consolidated Republican government to follow through on campaign commitments to repeal and replace the Patient Protection and Affordable Care Act (ACA). What kind of viable replacement will be proposed, how such talk will disrupt the insurance industry, and whether the 20 million newly insured Americans will be able to retain their coverage remain to be seen.Use this paper to:Ask your learners whether they think that “ObamaCare” has been a good thing? What provisions are good? Bad? Need fixing?Do your learners have concerns with the potential repeal of the ACA? What might be the direct impact on some of their patients? In what ways would your learners be directly impacted themselves?Do your learners feel that they should get involved in the debate regarding the future of the ACA? If so, what should they do and how? Is there anything they would like to do as a group?Humanism and ProfessionalismDear Plagiarist: A Letter to a Peer Reviewer Who Stole and Published Our Manuscript as His OwnScientific Misconduct HurtsRecently, Annals of Internal Medicine experienced an egregious case of scientific misconduct. In this commentary, a researcher whose work was plagiarized outlines the harm that intellectual theft causes both the plagiarist and those whose work has been stolen. Plagiarism and other forms of intellectual theft are far more common in science than one would like to think.Use these papers to:Ask your learners how plagiarism such as what occurred here might harm the scientific community.Why might someone plagiarize another person's work? Although not excusable, what pressures might contribute to the occurrence of such behavior? What, if anything, can be done about it?Do your learners think that all authors of the paper plagiarized from others' work are equally responsible for the act? How should those who plagiarize others' work be punished?On Being a Doctor: Blanket SignsIn Uganda, a patient's personal belongings can be indicative of her family's ability or inability to pay for medical care. In her essay, Dr. Ma ponders how despite the ability of U.S. hospitals to provide all patients with the same clean beds and linens, social differences may be accentuated by small gestures—and that they may signal a difference in how we care for patients.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners if your hospital treats wealthy individuals differently than those without material wealth. In what ways?Does your hospital have special rooms for those who can pay more for certain amenities? Are there rooms that are reserved for “VIPs?” Do your learners find such things objectionable? Would they ask for such arrangements for their loved ones in the hospital?Are the people in these rooms treated differently? Do they receive better care? Might being labeled a “VIP” lead to avoidance of certain hospital routines that are important for patient safety and the receipt of optimal care?MKSAP 17 QuestionA 67-year-old man is evaluated following a recent diagnosis of type 2 diabetes mellitus. He is sedentary but is without cardiopulmonary symptoms. Family history is significant for myocardial infarction in his father at age 50 years and stroke in his mother at age 54 years. He takes no medications.On physical examination, the patient is afebrile, and blood pressure is 144/96 mm Hg. BMI is 40. Other than obesity, his physical examination is normal.Laboratory studies:Alanine aminotransferase31 U/LTotal cholesterol203 mg/dL (5.26 mmol/L)LDL cholesterol123 mg/dL (3.19 mmol/L)HDL cholesterol40 mg/dL (1.04 mmol/L)Serum creatinine0.75 mg/dL (66.3 µmol/L)Glucose194 mg/dL (10.8 mmol/L)Triglycerides201 mg/dL (2.27 mmol/L)Hemoglobin A1c6.7% Electrocardiogram is normal.His 10-year atherosclerotic cardiovascular disease risk based on the Pooled Cohort Equations is 25%.The patient is counseled on lifestyle changes to reduce cardiovascular risk, and management of his diabetes and hypertension is initiated with metformin and ramipril.Which of the following is the most appropriate treatment of this patient's hyperlipidemia?A. GemfibrozilB. High-intensity atorvastatinC. Moderate-intensity simvastatinD. No additional treatmentCorrect AnswerB. High-intensity atorvastatinEducational ObjectiveTreat hyperlipidemia in a patient with diabetes mellitus and elevated cardiovascular risk.CritiqueThe most appropriate treatment for this patient is high-intensity statin therapy, such as with atorvastatin. Strong evidence indicates that statins are effective in both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). According to the American College of Cardiology/American Heart Association guidelines, this patient with diabetes and no clinical ASCVD meets the criteria for one of four patient groups that have been shown to benefit from the treatment of hyperlipidemia with statin therapy. For patients 40 to 75 years of age with diabetes mellitus and an LDL cholesterol level of 70 to 189 mg/dL (1.8-4.90 mmol/L), intensity of statin therapy is dictated by the estimated 10-year risk for ASCVD as determined by the Pooled Cohort Equations. High-intensity statin therapy (for example, atorvastatin, 40-80 mg/d, or rosuvastatin, 20-40 mg/d) is recommended for all patients with a 10-year ASCVD risk of 7.5% or higher, and moderate-intensity therapy is indicated for patients with a risk of less than 7.5%. This patient's 10-year ASCVD risk exceeds 7.5%; therefore, high-intensity therapy is recommended.Significant reductions in cardiovascular events have not been clearly demonstrated with fibrate monotherapy, rendering gemfibrozil an inferior choice for this patient with elevated risk for clinical ASCVD. Fibrates are indicated for patients with triglyceride levels greater than 500 mg/dL (5.65 mmol/L), patients with hypertriglyceridemia-induced pancreatitis, and patients who have an inadequate response to statin therapy.Moderate-intensity statin therapy (for example, simvastatin, 20-40 mg/d; atorvastatin, 10-20 mg/d; or rosuvastatin, 5-10 mg/d) is not appropriate for this patient with diabetes, elevated 10-year risk for ASCVD, other cardiovascular risk factors (family history of premature cardiovascular disease), and no contraindications to high-intensity therapy. Moderate-intensity statin therapy is an acceptable alternative to high-intensity therapy in patients who tolerate statins poorly or have risk factors for statin-associated adverse effects (impaired kidney or liver function, history of muscle disorders, use of drugs affecting statin metabolism [calcium channel blockers, fibrates, protease inhibitors, amiodarone, macrolide antibiotics], and age greater than 75 years). Because none of these factors are present in this patient, high-intensity statin therapy would be the optimal therapeutic approach given his risk profile.Therapeutic lifestyle changes are a cornerstone of treatment for hyperlipidemia and should be encouraged in all patients; however, additional treatment with statins is indicated in this patient with an elevated 10-year risk of ASCVD and diabetes.Key PointIn adults 40 to 75 years of age with diabetes mellitus, an LDL cholesterol level of 70 to 189 mg/dL (1.8-4.90 mmol/L), and an estimated 10-year atherosclerotic cardiovascular disease risk of 7.5% or higher, high-intensity statin therapy is recommended.BibliographyStone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 24;129(25 Suppl 2):S1-45. Erratum in: Circulation. 2014 Jun 24;129(25 Suppl 2):S46-8.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 17 January 2017Volume 166, Issue 2Page: ED2KeywordsAntibioticsAtherosclerotic cardiovascular diseaseCardiovascular disease riskHeartHyperlipidemiaLipidsLow density lipoproteinPatient Protection and Affordable Care ActStatinsTreatment guidelines ePublished: 17 January 2017 Issue Published: 17 January 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. 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