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Clinical Practice Assessments

Dean's Evidence Based Medicine (EBM) Committee has developed clinical practice assessment summaries for the convenience of our providers. Choose the assessment area from the list to view summaries and additional documentation.

AAA Screen
AC Bridging
Atypical Antipsychotics and Dementia
Bariatric Surgery
Bisphosphonate Drug Holidays
Effect of Calcium Intake on CV Events
Clopidogrel and PPI
Coronary Artery Calcium (CAC) Score
Delayed vs. Immediate Treatment for TIA
Does CPM after Total Knee Arthroplasty Improve Outcomes?
DVT and SimpiRED D-dimer
Effect of PPI’s on fracture Risk
Epidural Steroid Injections
Fecal Occult Blood Testing (FOBT) for Colorectal Cancer
Fecal Transplantation Treatment for C Difficile
GFR Equation Alternatives
HBV Reactivation during Immunosuppression Therapy with Biologics
HCV Screening by Birth
Hip Fracture and Zoledronate
Hepatitis B Vaccination in DM
Intensive Glucose Control
Lung Cancer Screening
Lung CA Screening with Low Dose CD
Mammography Between Ages 40 and 49
Monitoring Lipids in the Elderly
Niacin as Secondary Prevention of Coronary Heart Disease
Osteoporosis Screening & Management
Primary Prevention of Heart Disease
Procalcitonin Testing for Acute Respiratory Illness
PSA Screening
Pulmonary Embolism and SimpliRED D-dimer
Robotic Surgery
Screening for Colorectal Cancer
Screening for Vitamin-D Deficiency
Target LDL in Patients with Ischemic Vascular Disease
Testosterone Therapy CVD risk
Treating Barrett’s with Radiofrequency Ablation
Treating Urinary Incontinence with PTNS
Tuberculosis Testing
Use of Troponin to Rule Out a Myocardial Infarction

Archived Evidence-based Medicine Documents


Abdominal Aortic Aneurysm (AAA) Screen

AAA Screen

Clinical Question
Does screening for AAA in men ages 65-74 decrease morbidity and/or mortality?

Bottom Line
Limiting screening for AAA to men ages 65-74 who have ever smoked or with a significant family history will maximize the benefits of screening, and minimize the harms.

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Anticoagulation (AC) Bridging

Clinical Decision Support Tool
(this should be viewed as a powerpoint slideshow.)

Clinical Question
What are the current guidelines for managing patients on anticoagulants who undergo an invasive procedure?

Bottom Line
See Clinical Decision Support Tool.

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Atypical Antipsychotic use in Alzheimer's disease

Atypical Antipsychotic use in Alzheimer's disease

Clinical Question
In patients with Alzheimer's disease who are psychotic, aggressive, or agitated, how effective and safe is the use of atypical antipsychotic medications?

Bottom Line
For elderly Alzheimer’s patients with psychosis, aggression, or agitation, there appears to be no significant clinical benefit from atypical antipsychotic medications as compared with placebo.

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Bariatric Surgery

Bariatric Surgery

Clinical Question
In patients with obesity, do those who undergo a bariatric surgery procedure, compared to those managed medically, have better outcomes?

Bottom Line

Surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared to non-surgical interventions. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.

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Bisphosphonate Drug Holidays

Bisphosphonate Drug Holidays

Clinical Question
Is there a role for a drug holiday following Bisphosphonate therapy?

Bottom Line

Patients with the highest risk of osteoporotic fracture appear to have the greatest benefit from continued bisphosphonate therapy. Risk calculators (e.g. FRAX) can help identify these patients.

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Calcium Intake, Effect on CV Events

Effect of Calcium Intake on CV Events

Clinical Question
Does calcium supplementation with or without vitamin D increase the risk of cardiovascular events in post menopausal women?

Bottom Line
Meta-analysis suggests an increased risk of all-cause mortality and myocardial infarction in women on calcium supplements of > 500mg/day (either as Calcium Citrate or Calcium Carbonate) with or without the addition of vitamin D. Those with a high (greater than 1400mg/day) dietary calcium intake also exhibited comparable risk. Other studies suggest vitamin D supplementation has beneficial effects (see Vitamin D Clinical Practice Assessment).

The USPSTF does not recommend supplementation with calcium and vitamin D for primary prevention of osteoporosis.

The IOM recommends a daily total of 1000-1200mg of elemental calcium with 600-800IU of vitamin D for adults.

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Clopidogrel and PPI

Clopidogrel and PPI

Clinical Question
Does the combination of omeprazole (Prilosec) and clopidogrel (Plavix) result in increased cardiovascular events compared with clopidogrel alone?

Bottom Line
Some observational studies suggest an increase in cardiovascular events in patients on the combination (1, 2, 3) but others do not (4, 5).  The only randomized, placebo-controlled trial (6) did not demonstrate reduced clopidogrel efficacy. The decision to prescribe this combination should be made following a thoughtful discussion between prescriber and patient weighing the risks, benefits and alternatives.  This discussion should be well-documented in the chart.

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Coronary Artery Calcium (CAC) Score

CAC Score

Clinical Question
Does the use of the coronary artery calcium score (CACS) to screen asymptomatic individuals for coronary heart disease (CHD) lead to more clinical benefit than harm?

Bottom Line
There have been no large-scale prospective trials demonstrating more benefit than harm when the CACS is used to systematically screen asymptomatic individuals.

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Delayed vs. Immediate Treatment for TIA

Delayed vs. Immediate Treatment for TIA

Clinical Question
For patients with acute TIA symptoms or minor stroke, does immediate versus delayed treatment result in improved patient outcomes?

Bottom Line

The EXPRESS study found a significant decrease in recurrent stroke within 90 days for immediate (median 1 day) treatment with specific (antiplatelet, anticoagulation, dyslipidemia and HTN) therapies versus delayed (median 20 days) treatment (ARR= 8.2%, NNT= 12).

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Does CPM after Total Knee Arthroplasty Improve Outcomes?

CPM following TKR

Clinical Question
Does the use of Continuous Passive Motion (CPM) following total knee arthroplasty improve outcomes?

Bottom Line

The effects of continuous passive motion on active and passive knee range of motion following total knee arthroplasty are too small to be clinically relevant.

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DVT and SimpiRED D-dimer

DVT and SimpiRED D-dimer
Wells Criteria for DVT Probability

Clinical Question
In outpatients who present with a low pretest probability for deep venous thrombosis (DVT), can a normal result from the rapid SimpliRED D-dimer test be used to withhold anticoagulation or further testing?

Bottom Line

The combination of a low clinical probability for deep venous thrombosis (DVT), and a normal result from the SimpliRED D-dimer test can be used to safely withhold anticoagulation therapy or further testing.

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Effect of PPI’s on Fracture Risk

Effect of PPI’s on fracture Risk

Clinical Question
Do patients who use proton pump inhibitor’s (PPI’s) for more than a year have an increased fragility fracture risk?

Bottom Line

Yes, multiple large case control studies show a weak association with prolonged PPI use (more than 1 year) and an increased rate of fragility fractures warranting the judicious administration of long term PPIs. When prescribing PPI’s to manage symptoms, intermittent PPI use or use of H2 blockers with less profound acid suppression may be both effective and of less potential long term fracture risk.

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Epidural Steroid Injections

Epidural Steroid Injections

Clinical Question
In patients with chronic low back pain (LBP), do epidural steroid injections (ESI’s), single or multiple, provide better pain control and reduce the need for subsequent surgery compared to traditional conservative therapy?

Bottom Line

ESI’s provide limited short term symptom relief but do not provide long term (>6 weeks) improvement in patients with sciatica or neurogenic claudication due to spinal stenosis. There are no Level 1 or 2 studies that support a multiple injection strategy for long-term symptom relief or a reduction in the rate of subsequent back surgery.

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Fecal Occult Blood Testing (FOBT) for Colorectal Cancer (CRC) Screening

FOBT

Clinical Question
Does immune-based fecal occult blood testing provide better patient-oriented outcomes compared to guaiac-based tests?

Bottom Line
In terms of the patient-oriented outcome, death from colorectal cancer, there is no direct evidence that one test is better than the other. In terms of the disease-oriented outcome, detection of clinically significant colorectal neoplasia, immune-based fecal occult blood testing is clearly superior.

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Fecal Transplantation Treatment for C Difficile

Fecal Transplantation Treatment for C Difficile

Clinical Question
In patients with recurrent Clostridium difficile infection is fecal transplantation effective therapy?

Bottom Line
Yes, fecal transplantation is associated with a high cure rate. One small 10 week controlled open-labeled randomized study shows an 81% cure with one infusion and in the non-responders a 94% cure rate with a second infusion.

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GRF Equation Alternatives

GFR Equation Alternatives

Clinical Question
Is the alternative CKD EPI equation for estimating GFR better at predicting patient outcomes?

Bottom Line
Estimation of GFR using the CKD EPI equation correlates better with risk assessment and patient outcomes compared to using the MDRD equation.

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HBV Reactivation during Immunosuppression Therapy with Biologics

HBV IS CPA
HBV Flowsheet

Clinical Question
In patients with Chronic HBV starting immunosuppressive therapy with biologics is preemptive therapy of HBV helpful at preventing reactivation?

Bottom Line
Depending on the patients HBV serology, therapy or monitoring for HBV DNA is indicated.

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HCV Screening by Birth Cohort

HCV Screening by Birth Cohort

Clinical Question
Does birth cohort testing for Hepatitis C infection result in improved patient outcomes?

Bottom Line
Based on CDC expert opinion, birth cohort testing for hepatitis C virus infection should result in fewer people progressing to cirrhosis, developing hepatocellular carcinoma, requiring liver transplant, and dying due to HCV-related illnesses.

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Hepatitis B Vaccination in DM

Hepatitis B Vaccination in DM

Clinical Question
Should all patients with diabetes mellitus be vaccinated for Hepatitis B?

Bottom Line

Persons with diabetes (but without the usual HBV related risk behaviors) have an increased risk of developing acute HBV infection compared with those persons without diabetes (Annual incidence in DM = 1.8/100,000). Evidence that vaccination improves patient outcomes is limited therefore the strength of the recommendation for vaccination in all persons with diabetes age 19-65 is a B (SORT taxonomy).

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Hip Fracture and Zoledronate

Zoledronic Acid & Hip Fracture

Clinical Question
Does intravenous bisphosphonate therapy with zoledronic acid administered after osteoporotic hip fractures reduce the frequency of subsequent fractures or mortality?

Bottom Line

Once-yearly IV zoledronic acid administered initially within 90 days of an osteoporotic hip fracture resulted in a significant reduction in subsequent fractures (ARR 5.3%; NNT 19) and mortality (ARR 3.7%; NNT 27) over 2 years.

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Intensive Blood Glucose Control in Type 2 Diabetes

Intensive Blood Glucose Control

Clinical Question
In patients with type 2 diabetes does intensive therapy (goal: A1c < 7) compared to conventional therapy (goal: A1c < 8) result in improved patient-oriented outcomes?

Bottom Line

Not necessarily. Intensive therapy to lower A1c below 7 can have benefits (decreased retinal laser treatments) but can also have risks (weight gain, severe hypoglycemia, increased hospitalization and even death in one study).

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Lung Cancer Screening

Lung Cancer Screening

Clinical Question
Does low dose CT (LDCT) screening for lung cancer reduce mortality in high-risk individuals?


Bottom Line
Annual LDCT screening for 3 years reduces mortality from lung cancer in high-risk individuals. The high cost (>$100,000/WALY) and high number of false positive examples (96.4%) limits the usefulness of this technique.

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Lung CA Screening with Low Dose CT

Lung CA Screening with Low Dose CT

Clinical Question
Does annual low dose CT screening for 3 years reduce mortality in high risk individuals?


Bottom Line
Annual low dose CT screening for 3 years reduces mortality from lung cancer (R.R.R. 20%; A.R.R. 0.4%) in high-risk individuals. The high cost (>$100,000/QALY) and high number of false positive exams (96.4%) limits the usefulness of this technique.

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Mammography Between Ages 40 and 49

Mammography Between Ages 40 and 49

Shared Decision Making materials

Clinical Question
Does mammography screening in women ages 40 to 49 significantly reduce mortality and/or morbidity?

Bottom Line

The two randomized trials designed to evaluate breast cancer screening in women 40 to 50 years old both reported no statistically significant effects on breast cancer mortality or on total mortality.

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Monitoring Lipids in the Elderly

Monitoring Lipids in the Elderly

Clinical Question
Does routine monitoring of lipids improve cardiovascular outcomes in elderly people on statins for secondary prevention?

Bottom Line

Coronary heart disease events and death are reduced in patients age 70-82 treated with statin compared with placebo. Improved adherence to statin therapy is associated with physician follow up visits and lipid testing. Frequent monitoring is costly however, and testing more often than every 3 years in statin-treated people “at target” may be inaccurate due to short-term within-person variation.

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Niacin as Secondary Prevention of Coronary Heart Disease

Niacin as Secondary Prevention

Clinical Question
Does niacin alone or in combination with statins benefit patients with cardiovascular disease?

 
Bottom Line

The only study comparing niacin to placebo in the secondary prevention of coronary heart disease found no evidence of benefit for the primary endpoints (total and disease-specific mortality).

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Osteoporosis Screening & Management

Osteoporosis

Clinical Question
When is osteoporosis screening with bone densitometry cost effective?

Bottom Line

Screening for osteoporosis is recommended for women aged > 65 or in women less than age 65 whose 10-year fracture risk (9.3%) is equal to or greater than that of a 65-year-old white woman without additional risk factors.

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Primary Prevention of Heart Disease

Primary Prevention of Heart Disease

Clinical Question
Does treatment with a statin reduce CV events in patients without CV disease but with CV risk factors (Primary Prevention)?

Bottom Line

The key finding of the meta-analysis referenced above is that the statin trials consistently demonstrate a relative risk reduction (RRR) in cardiovascular events and all cause mortality in patients without previous CV disease but with CV risk factors.

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Procalcitonin Testing for Acute Respiratory Illness

Procalcitonin Testing

Clinical Question
In primary care outpatients with acute respiratory illnesses, does obtaining a procalcitonin level result in improved patient-oriented outcomes?

Bottom Line

Procalcitonin testing in the primary care setting to help decide whether to prescribe antibiotics cannot be recommended based on current evidence.

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PSA Screening

PSA Screening 

Clinical Question
Should PSA screening for asymptomatic prostate cancer be automatically included in the annual preventive examination for males over 50 years of age?

Bottom Line

There is insufficient evidence to automatically include prostate specific antigen (PSA) screening in the periodic health examination without first engaging patients in shared decision-making regarding the potential benefits and possible harms.

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Pulmonary Embolism and SimpiRED D-dimer

Pulmonary Embolism and SimpiRED D-dimer
Wells Criteria for PE Probability

Clinical Question
In outpatients with low pretest probability for pulmonary embolism according to Wells criteria, and a normal SimpliRED ddimer test, does further testing lead to better patient oriented outcomes compared to clinical follow up alone?

Bottom Line

The combination of a low clinical probability of pulmonary embolism and a normal SimpliRED D-dimer test make pulmonary embolism (PE) very unlikely. Clinical follow up in lieu of further testing is a reasonable option in these low risk patients.

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Robotic Surgery

Robotic Surgery 

Clinical Question 
Does Robotic Surgery offer benefits in patient care?


Bottom Line

Robotically assisted surgery may offer certain advantages as a less invasive procedure compared to an open procedure as well as in technically difficult to perform laparoscopy cases. However, the costs are higher and the potential benefits are not necessarily obtained in a community setting. Definite improved clinical outcomes have not been proven. 

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Screening for Colorectal Cancer

Colorectal Cancer Screening 

Clinical Question
What is the recommended way to screen for colorectal cancer?

Bottom Line
Clinical Summary of US Preventive Services TAsk Force Recommendation.

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Screening for Vitamin-D Deficiency

Vitamin-D 

Clinical Question 
In what clinical setting is screening for 25- OH Vitamin D deficiency useful?


Bottom Line

Screening for Vitamin D deficiency is not recommended. Measuring 25-OH Vitamin D levels is only necessary in the evaluation of suspected disorders of calcium regulation or metabolic bone disease. In other patients supplementation with Vitamin D at a does of 1000IU daily can be offered without a need for measuring 25-OH Vitamin D levels. The risk of hypocalcaemia with supplementation at this level is insignificant. 

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Target LDL in Patients with Ischemic Vascular Disease

Target LDL in Patients with Ischemic Vascular Disease

IVD and Statin Trials - Appendix

Clinical Question
Does the adoption of a target LDL < 100 mg/dL for all patients with ischemic vascular disease (IVD) result in improved patient-oriented outcomes? 

Bottom Line

Clinicians treating IVD patients should consider the NCEP ATP-III recommended LDL target of less than 100 mg/dL as a minimum therapeutic goal. Lowering LDL cholesterol further below 100 mg/dL may result in even greater reductions in the risk of future coronary events. In general, statin therapy for secondary prevention should be increased as much as possible toward maximal doses.

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Testosterone Therapy CVD risk

Testosterone Therapy and CVD

Clinical Question
In men over age 65 does testosterone therapy increase the risk of CV events? 

Bottom Line

The clinical long-term CV risks of testosterone therapy remain largely unknown due to inconsistent results of poor quality studies (level of evidence 2).

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Treating Barrett’s with Radiofrequency Ablation

Treating Barrett’s with Radiofrequency Ablation

Clinical Question
Does the use of radiofrequency ablation for the management of Barrett’s esophagus with low-grade dysplasia compared to standard management lead to decreased mortality or other improved patient outcomes?s? 

Bottom Line

One clinical trial demonstrated a higher rate of complete ablation and reduced disease progression to cancer compared to sham procedure. This was a fairly small study however, and a shift of a single incident cancer would have resulted in a loss of statistical significance. These results should therefore be interpreted with caution. There are no long-term data regarding patient outcomes.

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Treating Urinary Incontinence with PTNS

PTNS

Clinical Question
In patients with urinary incontinence does posterior tibial nerve stimulation (PTNS) compared to placebo or anticholinergic drugs result in improved patient outcomes?

Bottom line
PTNS is effective in the treatment of women with urinary incontinence who are intolerant or failed anticholinergic drug therapy.

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Tuberculosis Testing

Tuberculosis Testing

Clinical Question
How do interferon-y release assays (IGRAs) compare with the tuberculin skin test (TST) for the diagnosis of active and latent Mycobacterium tuberculosis infection?

Bottom Line

Neither IGRAs nor TSTs should be used to diagnose active (symptomatic) infection where direct microbiological testing is the appropriate strategy.

For diagnosis of latent (asymptomatic) M. tuberculosis infection (LTBI) both tests are recommended depending on the guideline and the specific clinical scenario encountered.

  • For screening high risk individuals the Madison Public Health Department uses an IGRA test.
  • For low risk individuals a “dual strategy” (an IGRA only after a positive TST) has been reported to be more cost effective than an IGRA.
  • For patients before initiation of biologic therapy screen with either IGRA or TST
  • For patients on biologic therapy retest only if there are additional risk factors for TB exposure e.g. travel to endemic areas, personal contact etc.

If retesting is indicated IGRA may be the more sensitive test. (Strength of Recommendation-Grade C) .

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Use of Troponin to Rule Out a Myocardial Infarction

Use of Troponin to Rule Out a Myocardial Infarction

Clinical Question
What is the minimal amount of time to rule out Myocardial Infarction using serial troponin I measurements?

Bottom Line

An undetectable highly sensitive troponin I (below the level of detection of the assay) on admission in patients presenting with chest pain is effective in ruling out myocardial infarction (MI). When any detectable troponin is noted on admission, then serial measurements of a highly sensitive Troponin I (hsTnI) or contemporary/standard Troponin I (cTnI) on admission and three hours later had a Negative Predictive Value of 99% (rule out MI).

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