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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.
Abdominal Aortic Aneurysm (AAA) Screen
Clinical Question
Does screening for AAA in men ages 65-74 decrease morbidity and/or
mortality?
Abbreviated 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.
Anticoagulation (AC) Bridging
Clinical Question
Do patients on long term oral anticoagulant therapy who
require short term interruption of warfarin
for an elective invasive procedure benefit by receiving
bridging therapy
with heparin (fractionated or unfractionated)?
Abbreviated Bottom Line: See algorithm.
Atypical Antipsychotics and Dementia
Atypical Antipsychotics and Dementia
Clinical Question
In patients with Alzheimer's disease who are psychotic, aggressive, or agitated, how effective and safe are the use of atypical antipsychotic medication?
Abbreviated 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.
Bariatric Surgery
Clinical Question
In patients with a BMI >40, do those who undergo a bariatric
surgery procedure, compared to those managed medically, have
better outcomes?
Abbreviated Bottom Line
Bariatric surgery (banding, gastroplasty or bypass procedures)
compared to medical management can improve obesity and some
of its major complications notably diabetes, dyslipidemia,
hypertension, and obstructive sleep apnea. In addition, recent
data suggest a benefit of surgery on total mortality after
10-year follow up (ARR= 1.31%, NNT=77).
Bisphosphonates and ONJ
Clinical Question
Are patients on bisphosphonate
therapy at risk for developing osteonecrosis of the jaw (ONJ)?
Abbreviated Bottom Line
Osteonecrosis of the jaw has been described in patients on bisphosphonate
therapy.
All reports have been either case reports or small case series.
The nature of the association has not been definitively established.
Coronary Artery Calcium (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?
Abbreviated 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.
Carotid Intima
Clinical Question
In patients at risk for coronary atherosclerosis, does
the use of carotid intima media thickness (IMT) measurement
lead to better outcomes?
Abbreviated Bottom Line
The clinical utility of Carotid Intima Media Thickness
(IMT) measurement will remain unclear until prospective clinical
trials are performed using patient oriented outcomes.
Chest CT and Lung Cancer
Clinical Question:
In patients at increased risk for lung cancer, does screening
with routine chest CT result in improved survival or quality of
life compared to patients who are diagnosed on the basis of symptoms?
Abbreviated Bottom Line:
Although spiral CT can detect early lung cancer, the evidence
remains insufficient to demonstrate that chest CT screening for
patients at increased risk for lung cancer decreases mortality
or improves quality of life.
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COX-2
COX-2
Patient Education:
NSAIDs and COX-2 Inhibitors
Clinical Question
In patients requiring anti-inflammatory therapy, should COX-2
inhibitors be used?
Abbreviated Bottom Line
The current, available evidence does not clearly demonstrate a
safe dose or duration of dosing for coxibs free of excess cardiotoxicity.
Colorectal Cancer (CRC) Screening
Clinical Question
When screening average-risk patients over 50 years of age for colorectal cancer
(CRC), is colonoscopy alone, or yearly fecal occult blood test (FOBT) plus
either sigmoidoscopy or barium enema (BE) better than yearly FOBT alone?
Abbreviated Bottom Line
Screening for CRC in average-risk individuals aged 50 and older has received
an “A” recommendation from the USPSTF. However, current evidence
is insufficient to determine which screening modality or combination is superior.
Strategies include: (1) annual FOBT alone; (2) annual FOBT and either sigmoidoscopy
or barium enema (BE) every 5 years; or (3) colonoscopy alone every 10 years.
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?
Abbreviated 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).
Diabetes Mellitus (DM) Diet
Clinical Question
In patients with Type 2 DM, do low fat diets compared to
low carbohydrate diets lead to better patient-oriented outcomes?
Abbreviated Bottom Line
There are no high quality data on the efficacy of any particular
diet in the treatment of Type 2 DM. Reduced energy diets appear to be more
important than any particular combination of fat or carbohydrate intake.
When combined with exercise, reduced energy diets lead to better glycemic
control.
DVT - Once Daily Low Molecular Weight Heparin
Once
Daily LMWH
Clinical Question
In patients with deep venous thrombosis (DVT), does once daily
(1.5 mg/kg) low molecular weight heparin (LMWH) dosing result
in similar efficacy and adverse events as twice daily (1.0 mg/kg)
therapy?
Abbreviated Bottom Line
Once daily LMWH is as effective as twice daily therapy in preventing
recurrent thromboembolism and does not result in higher mortality
or major bleeding.
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.
Early Prostate Cancer
Clinical Question
Is radical prostatectomy (RP) compared to watchful waiting (WW) a more effective
treatment for early prostate cancer?
Abbreviated Bottom Line
Compared to WW, RP appears to confer a mortality benefit in healthy men under
75 with symptomatic, localized, well- to moderately well-differentiated prostate
cancer.
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?
Abbreviated 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.
Floppy Iris Syndrome
Clinical Question
Is there a causal association between alpha-1 adrenergic antagonist exposure and the intraoperative floppy iris syndrome (IFIS)?
Abbreviated Bottom Line
While a causal relationship has not been established, an awareness of this association will allow changes in operative technique that may reduce the rate of operative complications.
Glomerular Filtration Rate (GFR) Calculation
Clinical Question
Which derived formula for glomerular filtration rate (GFR) most
closely approximates the physiologic value?
Abbreviated Bottom Line
The Modification of Diet in Renal Disease (MDRD) and the Cockroft-Gault
(C-G) equations provide useful estimates of GFR in adults.
Hydroquinone
Clinical Question
Do patients treated with topical formulations containing Hydroquinone
(HQ) experience increased rates of exogenous ochronosis, leukemia or
lymphoma?
Abbreviated Bottom Line
Although animal models have raised the possibility of carcinogenic potential, no human studies
have demonstrated more serious toxicity.
Hip Fx and Zoledronate
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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iFOB Test
Clinical Question
In patients undergoing CRC screening, is immune fecal occult blood
(iFOB) testing with HemeSelect®, compared to current Dean
Clinic FOBT (Hemoccult II Sensa®) associated with better patient-oriented
outcomes?
Abbreviated Bottom Line
iFOB has greater specificity but less sensitivity than Hemoccult
II Sensa®. To our knowledge, there are no prospective studies
addressing whether this approach leads to decreased CRC or overall
mortality.
Intensive Statin Rx
Clinical Question
In patients with coronary heart disease (CHD), does high dose statin therapy
provide greater clinical benefit compared to regular dose statin therapy?
Abbreviated Bottom Line
The cited meta-analysis does not demonstrate a mortality benefit with the use
of intensive statin therapy compared to regular statin therapy for CHD patients,
but it does show a consistent clinical benefit in terms of reduced cardiovascular
events.
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?
Abbreviated 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).
IVD and Lipid Management
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?
Abbreviated 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.
Mammography Between Ages 40 and 50
Mammography Between Ages 40 and 50
Patient Education: Weighing Benefits and Harms
Clinical Question
Does mammography screening in women ages 40 to 50 significantly reduce mortality
and/or morbidity?
Abbreviated 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.
Methotrexate
Clinical Question
Should patients on methotrexate (MTX) therapy be monitored at a specific and
consistent interval?
Abbreviated Bottom Line
It is unclear whether liver test monitoring in the setting of MTX therapy should
be standardized across different departments that are using it for different
disease entities.
MRI and Hardware Safety
Clinical Question
Do patients with cardiac rhythm management devices have an absolute contraindication
to MRI scanning?
Abbreviated Bottom Line
Given the potential for significant adverse events such as
lead heating, arrhythmogenesis, and device movement, further
study is required before endorsing use of MRI in patients
with pacemakers or ICDs.
Mumps Algorithm
Clinical Question
What is the Dean Health System consensus on the approach to the patient with
suspected mumps?
Abbreviated Bottom Line
See algorithm.
NMR Lipoprofile
Clinical Question
Should NMR lipoprofile be clinically used to assess cardiovascular
risk?
Abbreviated Bottom Line
At this time, there is insufficient evidence to show that NMR
lipoprofile should be used for routine cardiovascular risk screening.
NSAID GI Toxicity
Clinical Question
Do patients taking prolonged non-steroidal anti-inflammatory
drugs (NSAIDs) and gastro-protective medications experience
fewer adverse gastrointestinal (GI) complications as compared
to patients taking NSAIDs who do not take gastro-protective
medications?
Abbreviated Bottom Line
Gastro-protective medications reduce the risk of NSAID induced
peptic ulcer disease in high risk patients. If NSAIDs are
used in high risk patients, the lowest effective NSAID
dose should be used with a mucosoprotective agent such
as omeprazole 20 mg qd.
Perioperative Statin Use
Clinical Question
Should patients discontinue statins prior to general anesthesia in order to
prevent rhabdomyolysis or other complications?
Abbreviated Bottom Line
Pre-operative exam physicians should advise patients taking statins and contemplating
major surgery to continue statins unless there are other risk factors that
could contribute to rhabdomyolysis.
Pertussis
Clinical Question
What is the DHS consensus on the approach to the patient with suspected pertussis?
Abbreviated Bottom Line
See algorithm.
PETs for OME
Clinical Question
In pediatric patients with otitis media with effusion (OME),
does insertion of tympanastomy tubes compared to conservative
(non-operative) management result in improved hearing and
developmental outcomes?
Abbreviated Bottom Line
Although short term gains in hearing have been noted, tympanostomy
tube insertion compared to conservative management has
not been shown to result in long term improvements in speech
and language development.
Post CABG/PCI Cardiac Testing
Post
CABG/PCI Cardiac Testing
Clinical Question:
In patients who have undergone percutaneous coronary intervention
(PCI) or coronary artery bypass surgery (CABG) and who remain asymptomatic,
does regular periodic exercise testing result in improved patient
outcomes?
Abbreviated Bottom Line:
There is no evidence that a strategy of regular periodic exercise
testing improves patient-oriented outcomes.
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PPI Use and Hip Fracture
Clinical Question
Are patients on long term acid suppression therapy, compared to patients not receiving such therapy, at increased risk of developing hip fractures?
Abbreviated Bottom Line
A causal association between long term acid suppression therapy and hip fracture has not been established.
PSA Screening
PSA Screening
PSA Patient Education
DHS Urology Department Statement
Clinical Question
Should PSA screening for asymptomatic prostate cancer be
automatically included in the annual preventive examination
for males over 50 years of age?
Abbreviated 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.
PT and Low Back Pain
Clinical Question
Do patients with low back pain who undergo physical therapy have better outcomes
than those who are encouraged to pursue a self-paced fitness program or given
an advice booklet in the office?
Abbreviated Bottom Line
Physical therapy provides no advantage in functional recovery.
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?
Abbreviated
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.
Renal Artery Stenosis (RAS) and Stenting
RAS
and Stenting
AHRQ
RAS Clinician Guide
Clinical Question
In patients with hypertension and atherosclerotic renal artery stenosis (RAS),
does percutaneous transluminal renal artery angioplasty plus stenting (PTRA-S)
improve renal function, blood pressure control or mortality compared to aggressive
medical therapy alone?
Abbreviated Bottom Line
It remains unclear whether percutaneous transluminal renal artery angioplasty
plus stenting (PTRA-S) provides more clinical benefit than aggressive medical
therapy alone. The identification of patients with RAS who are considered appropriate
candidates for PTRA-S is currently based on expert opinion.
Spirometry (Asthma) CPA
Clinical Question
In the routine primary care management of asthma patients,
does the addition of point-of-care spirometry in the
primary care office, compared to referral spirometry,
result in
better patient-oriented outcomes?
Abbreviated Bottom Line
Patient-oriented effectiveness studies comparing point-of-care
spirometry in the primary care office to referral spirometry
have not been performed.
Tamoxifen
Clinical Question
In women taking tamoxifen, does the use of SSRIs (and other
agents) that strongly inhibit CYP2D6, compared to the use
of weaker inhibitors of CYP2D6, result in worse patient
oriented outcomes such as mortality, time-to-recurrence,
or relapse free survival?
Abbreviated Bottom Line
Although the evidence is not conclusive, it seems prudent
to avoid prescribing strong CYP2D6 inhibitors such as fluoxetine,
paroxetine, bupropion, and quinidine in tamoxifen-treated
women.
Thyroid Screen for Diabetes Mellitus (DM) and Depression
Thyroid Screen for DM and Depression
Clinical Question
In depressed diabetics, does systematic screening for thyroid disease produce
superior outcomes compared to symptom-based case finding or to no screening?
Abbreviated Bottom Line
Evidence is insufficient to recommend systematic screening for thyroid disease
in any chronic disease subgroup, including depressed diabetics.
Virtual Colonoscopy
Virtual Colonoscopy - Patient Education
Clinical Question
In a general patient population undergoing colorectal cancer (CRC) screening
is virtual colonoscopy superior to standard colonoscopy in detection of polyps,
patient comfort, or cost?
Abbreviated Bottom Line
It is too early to recommend virtual colonoscopy for the general patient population.
Very Low Calorie Diet and Weight Loss
Clinical Question
In obese patients (BMI >30), does one particular very low calorie diet (VLCD)
achieve superior results with regard to weight loss maintenance?
Abbreviated Bottom Line
Taken together, the evidence is insufficient to recommend one specific VLCD
over another.
VTE Prophylaxis After Knee or Hip Surgery
VTE Prophylaxis After Knee or Hip Surgery
Clinical Question
Are any of the currently available anti-thrombotic strategies superior in the
prevention of thromboembolic complications of major lower extremity orthopedic
surgery?
Abbreviated Bottom Line
The use of aspirin alone is a Grade 1A recommendation against.
For the specific recommended combinations of LMWH and warfarin see VTE PDF
document.
