Researchers identify the most accurate risk prediction models for selecting whom to screen

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Researchers identify the most accurate risk prediction models for selecting whom to screen for lung cancer

Findings may be used to inform future lung cancer screening guidelines

Abstract: http://annals.org/aim/article/doi/10.7326/M17-2701

Editorial: http://annals.org/aim/article/doi/10.7326/M18-0986

URLs go live when the embargo lifts

Four risk prediction models have been shown to be most accurate for selecting the highest risk ever-smokers for lung cancer screening. Researchers suggest that this data can be used to inform future lung cancer screening guidelines. The findings are published in Annals of Internal Medicine.

There is growing recognition that, rather than selecting smokers for screening by using simple dichotomized risk factors, individualized risk calculations that account for certain demographic, clinical, and smoking characteristics could substantially enhance the effectiveness and efficiency of CT screening programs. As such, recent lung cancer screening guidelines from the National Comprehensive Cancer Network permit using individualized risk models to refer ever-smokers for screening. However, different models select different screening populations and it is not known how well they perform.

Researchers from the National Cancer Institute (NCI) and the American Cancer Society compared the U.S. screening populations selected by 9 risk models (the Bach model; the Spitz model; the Liverpool Lung Project [LLP] model; the LLP Incidence Risk Model [LLPi]; the Hoggart model; the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Model 2012 [PLCOM2012]; the Pittsburgh Predictor; the Lung Cancer Risk Assessment Tool [LCRAT]; and the Lung Cancer Death Risk Assessment Tool [LCDRAT]) and evaluated model predictions in two large U.S. cohorts. They found that the models differed widely in the number of ever-smokers they selected (7.6 million to 26 million), and there was no consensus on which ever-smokers to select for screening. These disagreements were due to the different predictive performance of the models. Four models (the Bach model; PLCOM2012; LCRAT, and LCDRAT) performed best, as measured by their ability to accurately predict risk and their ability to distinguish high-risk individuals from low-risk individuals. These models picked similar numbers of ever-smokers and showed the best agreement on which ever-smokers to select.

The researchers suggest that these findings can help future guidelines recommend the best risk models to refer persons at highest risk for lung cancer, the leading type of cancer death in the U.S., for lung cancer screening.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Hormuzd A. Katki, PhD, please contact Jennifer Loukissas at loukissj@mail.nih.gov.

2. A novel Medicaid drug purchasing strategy could help states pay for hep C treatment

Opinion piece outlines strategy for expanding HCV treatment while increasing drug profits

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0186

URLs go live when the embargo lifts

Implementing a novel Medicaid drug purchasing strategy could help states pay for life-saving hepatitis C virus (HCV) treatment for its most vulnerable populations. An Ideas and Opinions piece outlining a strategy for expanding HCV treatment is published in Annals of Internal Medicine.

Up to 2.9 million persons in the U.S. are living with chronic HCV and the annual death toll exceeds that from HIV and 59 other infectious diseases combined. A recent report from the National Academies of Sciences, Engineering, and Medicine concluded that new curative HCV treatments could avert nearly 30,000 deaths and reduce incidence of HCV by 90 percent by 2030. As such, the report suggests that all patients with chronic HCV, regardless of disease stage, should receive these treatments. However, with costs in the tens of thousands per patient and limitations on prescribing for some Medicaid beneficiaries, access is an issue.

Researchers from the University of Southern California suggest that by encouraging competition among drug manufacturers for an HCV contract, a state could save money and vastly expand treatment. Under this type of agreement, a state would make a deal with one manufacturer for a discounted lump-sum payment for the HCV treatment. The company would agree to provide a 100 percent rebate on drug purchases for the state's Medicaid recipients during the contract. Having no additional costs during this time, the state could dramatically expand treatment.

The authors explain that the state contract approach works because it takes advantage of competition and decouples revenues from price per pill. The primary way for companies to increase revenue currently is to increase price, which limits access. The lump-sum payment allows the company to increase revenue without limiting access. Different states can contract with different manufacturers, so more than one manufacturer can benefit from this type of deal.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Neeraj Sood, PhD, please contact Emily Gersema at gersema@usc.edu.

3. Hyoscyamine may be used to avoid pacemaker placement during atrial fibrillation

Abstract: http://annals.org/aim/article/doi/10.7326/L18-0037

URLs go live when the embargo lifts

Clinicians should be aware that an anticholinergic drug (hyoscyamine) may be used in selected patients who would otherwise require a pacemaker for slow ventricular response during atrial fibrillation. A brief case report is published in Annals of Internal Medicine.

Cardiologists from the Mayo Clinic in Jacksonville, Florida describe the case of a 98-year-old man with atrial fibrillation and several comorbidities. The patient had symptomatic bradycardia (abnormally slow ventricular response), which is typically treated with a pacemaker. However, because of the patient's comorbidities, the physicians opted to treat the patient first with medication therapy. They administered intravenous glycopyrrolate, 0.1 mg, and his heart rate increased substantially for 30 minutes. The physicians then administered 0.125 mg of sublingual, immediate-release hyoscyamine and observed a similar but more prolonged response. The patient was discharged the next day with a resting heart rate between 70 and 80 beats/min while receiving the same type and dose of hyoscyamine 4 times daily. At 4 weeks follow-up, he had experienced no syncope and his heart rate remained normal.

According to the researchers, this is the first report of hyoscyamine or any other anticholinergic drug being used to avoid pacemaker placement in a patient with symptoms caused by a slow ventricular response during atrial fibrillation. Clinicians may wish to consider using this approach in similar patients whose comorbidities make using a pacemaker undesirable. Future research seek to determine if this successful outcome could be realized more generally.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Scott A. Helgeson, MD, please contact the Mayo Clinic newsroom at newsbureau@mayo.edu.

Also new in this issue:

Inpatient Notes: Getting Past the "Black Box"--Opportunities for Hospitalists to Improve Postacute Care Transitions

Christine D. Jones, MD, MS, and Robert E. Burke, MD, MS

Annals of Internal Medicine

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0940

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