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
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.
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Anticoagulation (AC) Bridging
AC Bridging Algorithm
AC Bridging Document
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.
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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.
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Bariatric Surgery
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).
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Effect of Calcium Intake on CV Events
Effect of Calcium Intake on CV Events
Clinical Question
Does calcium supplmentation with or without Vitaim D increase the risk of cardiovascular events in post-menopausal women?
Bottom Line
Meta-analysis suggest an increase risk of myocardial infarction in women on calcium supplements with or without the addition of vitamin D. Other studies suggest vitamin D supplementation has beneficial effects. The IOM recommends a daily total of 1,000-1,200mg 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?
Abbreviated 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?
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.
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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?
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).
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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?
Abbreviated 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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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?
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.
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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?
Abbreviated 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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Hip Fracture and Zoledronate
Hip Fracture 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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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).
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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?
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.
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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?
Abbreviated 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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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?
Abbreviated 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
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.
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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?
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.
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Screening for Colorectal Cancer
Colorectal Cancer Screening
Clinical Question
What is the recommended way to screen for colorectal cancer?
Abbreviated 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?
Abbreviated 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 Therapy in Primary Prevention
Statin Therapy in Primary Prevention
Clinical Question
Does treatment with a statin reduce CV events in patients without CV disease but CV risk factors?
Abbreviated Bottom Line
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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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?
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.
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Tuberculosis Testing
Tuberculosis Testing
Clinical Question
How do interferon release assays compare with the tuberculin skin test (TST) for the diagnosis of active and latent Mycobacterium tuberculosis infection?
Abbreviated Bottom Line
For diagnosis of latent (asymptomatic) M. tuberculosis infection (LTBI) both tests are recommended depending on the guideline and the specific clinical scenario encountered.
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