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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
Antibiotic Prophylaxis after a Total Joint Replacement
Atypical Antipsychotics and Dementia
Bisphosphonate Drug Holidays
Effect of Calcium Intake on CV Events
Coronary Artery Calcium (CAC) Score
DVT and SimpiRED D-dimer
Effect of PPI’s on fracture Risk
Fecal Occult Blood Testing (FOBT) for Colorectal Cancer
Fecal Transplantation Treatment for C Difficile
Guidelines for Managing Hypertension
HBV Reactivation during Immunosuppression Therapy with Biologics
HCV Screening by Birth
Hip Fracture and Zoledronate
Hepatitis B Vaccination in DM
Lung CA Screening with Low Dose CT
Mammography Between Ages 40 and 49
Monitoring Lipids in the Elderly
Niacin as Secondary Prevention of Coronary Heart Disease
Osteoporosis Screening & Management
PSA Screening
Pulmonary Embolism and SimpliRED D-dimer
Screening for Colorectal Cancer
Screening for Vitamin-D Deficiency
Statin and the Risk of Diabetes
Stool DNA Testing for Colorectal Cancer Screening
Testosterone Therapy CVD risk
The Risk of Cardiovascular Disease due to Oral Contraceptives in Women with Hypertension
Tuberculosis Testing
UTI in women over age 65, is a urine test necessary?

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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Antibiotic Prophylaxis after a Total Joint Replacements

Antibiotic Prophylaxis after a Total Joint Replacements

Clinical Question
In patients who have undergone hip or knee replacement surgery does routine antibiotic prophylaxis prevent late prosthetic joint infections?

Bottom Line
Evidence is lacking about the effectiveness and benefit of prophylactic antibiotic therapy for invasive procedures in patients who have previously undergone prosthetic joint replacement. The American Association of Orthopedic Surgeons (AAOS) recommends that practitioners consider discontinuing the routine use of prophylactic antibiotics in hip and knee joint replacement patients undergoing dental procedures due to limited evidence (AAOS 2012).

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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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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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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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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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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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Guidelines for Managing Hypertension

Guidelines for Managing Hypertension

Clinical Question
What are the JNC 8 thresholds for starting therapy and the desired goals for adults with hypertension?

Bottom Line
For adults 60 and older without diabetes or chronic kidney disease the threshold for both initiating therapy and goal has been increased to a blood pressure below 150/90mm Hg. For all other adults, it remains below 140/90 mm Hg.

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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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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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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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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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Statin and the Risk of Diabetes

Statin and the Risk of Diabetes

Clinical Question
Do statins increase the risk of developing type 2 Diabetes Mellitus?


Bottom Line

Yes, there is an increased risk especially in those on more potent statins and who have risk factors for diabetes. However the reduction in major cardiovascular events with statin use outweighs the risk of developing diabetes in most patients.

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Stool DNA Testing for Colorectal Cancer Screening

Colorectal Cancer Screening using Cologuard

Clinical Question
Is the negative predictive value (NPV) of the Cologuard stool test high enough to avoid colonoscopy if negative?


Bottom Line

The negative predictive value of the Cologuard stool DNA test for colorectal cancer is 99.9%. The NPV of the Fecal Immunochemical Test (FIT) is also high at 99.7%. Both fecal based tests are less sensitive in detecting advanced precancerous lesions.

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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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The Risk of Cardiovascular Disease due to Oral Contraceptives in Women with Hypertension

The Risk of Cardiovascular Disease due to Oral Contraceptives in Women with Hypertension

Clinical Question
What is the relative risk of CVD in women on combination oral contraceptive who have a history of hypertension?

Bottom Line

The risk of stroke and myocardial infarction is increased, comparable to women with other known cardiovascular risks including smoking, diabetes, hyperlipidemia and age over 35 years. The risks appear to be additive.

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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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UTI in women over age 65, is a urine test necessary?

Managing UTI in women over age 65

Clinical Question
In women over age 65 with symptoms suggestive of a UTI are urine tests (dipstick, UA, and/or urine culture) necessary?

Bottom Line

UTI treatment in women over age 65 should be based on both clinical assessment and urinalysis with urine culture. This is because many older women lack acute urinary symptoms, have increased co-morbidities and have an increased incidence of asymptomatic bacturia which makes the diagnosis challenging.

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