Top POEMs of 2017 Consistent with the Principles of the Choosing Wisely Campaign: Respiratory Disease

Top 20 POEMs of 2017 Consistent with the Principles of the Choosing Wisely Campaign

High False-Positive Rate with Lung Cancer Screening

Clinical question
What can patients expect when they undergo computed tomography to screen for lung cancer?

Bottom line
If you are thinking about adding lung cancer screening to your delivery of preventive care, be sure to prepare patients. They are likely to receive a positive result, most of the positive results will not be lung cancer, and 1 in 4 patients will require additional tracking (ie, follow-up scans). In this study, more than half (59.7%) of the current or former smokers screened for lung cancer using low-dose computed tomography (CT) had a positive result of some sort. However, 97.5% of them were falsely positive, and half of the patients who screened positive were identified as needing to undergo additional monitoring. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Kinsinger LS, Anderson C, Kim J, et al. Implementation of lung cancer screening in the Veterans Health Administration. JAMA Intern Med 2017;177(3):399-406.

Study design: Cohort (prospective)

Funding source: Government

Setting: Outpatient (primary care)

Synopsis
This study was conducted in 8 academic medical centers among 93,033 primary care patients. From this group (96.3% of whom were men), the researchers identified 4246 current or former (quit date less than 15 years ago) cigarette smokers who had smoked a minimum of 30 pack-years and invited them to be screened for lung cancer using low-dose CT. Of these, 2106 patients had the screening CT. Overall, 1257 screened patients (59.7%) had a positive finding, including 1184 patients (56.2%) who had 1 or more nodules that needed to be followed. A total of 73 patients (3.5% of all patients screened) had findings suspicious for possible lung cancer and 31 (1.5%) had that diagnosis confirmed within the following year. So, let's run the numbers: This means that for appropriately screened patients undergoing CT, more than half the patients will have a positive finding and 94% of these patients will need additional follow-up. One patient in 17 will be told they may have lung cancer but only 1 in 42 patients with a positive result will actually have lung cancer. Overall, 97.5% of patients with a positive CT scan will not have lung cancer.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

One Third of Adults with Diagnosed Asthma Can Be Weaned Off All Asthma Meds

Clinical question
How many adults with physician-diagnosed asthma can safely taper off their asthma medications?

Bottom line
This study found that current asthma was ruled out after repeated testing in one third of adults with physician-diagnosed asthma. Patients ruled out for current asthma were less likely to be using asthma medications or daily-controlling medications and less likely to have undergone testing for airflow limitation at the time of initial diagnosis. After 1 year of follow-up, 2.9% of the patients who tapered off their asthma medications presented with respiratory symptoms and resumed treatment. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Aaron SD, Vandemheen KL, FitzGerald JM, et al, for the Canadian Respiratory Research Network. Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA 2017:317(3):269-279.

Study design: Cohort (prospective)

Funding source: Industry + govt

Setting: Population-based

Synopsis
These investigators randomly dialed both landline and cellular phones in Canada to identify a true cohort of adults, 18 years or older, with physician-diagnosed asthma within the previous 5 years. Exclusion criteria included pregnancy, smoking history greater than 10 pack-years, or the use of long-term oral steroids. Review of medical records allowed collection of data on the determination of the original diagnosis of asthma. All participants (N = 701) underwent assessment with baseline spirometry and continued symptom monitoring using standard tools, as well as serial bronchial challenge testing. Patients using daily medications and not confirmed to have asthma with either baseline spirometry or serial bronchial challenge testing had their medications gradually tapered off over 4 study visits. Patients with continued negative test results for asthma were followed up clinically and with repeated bronchial challenges over 1 year. Two pulmonologists independently reviewed all medical records to determine agreement with the final diagnosis for all participants. Discrepancies were resolved by consensus agreement with a third reviewer. A total of 613 patients (87.4%) completed the study assessment procedures. Of these, 203 (33.1%) had a diagnosis of current asthma ruled out. Patients ruled out for current asthma were less likely to be using asthma medications or daily asthma-controlling medications and less likely to have spirometry or bronchial challenge testing performed at the initial time of initial diagnosis. After 1 year of follow-up, 6 patients (2.9%) in the group who were ruled out for current asthma and tapered off their asthma medications presented with respiratory symptoms and resumed treatment. In 12 patients, a serious alternative respiratory diagnosis—including ischemic heart disease, subglottic stenosis, and bronchiectasis—was diagnosed.

David Slawson, MD
Professor and Vice Chair for Education and Scholarship
University of North Carolina Chapel Hill, Carolinas HealthCare System
Charlotte, NC

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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