402 - Decision Fatigue, IBS Management, Mixing COVID and Other Vaccines

From the Literature

1) Decision Fatigue and Appropriate Prescribing

We like to think that in our decision making, we are objective and immune to the vagaries of emotion, fatigue, hunger, recent events, and the influence of others. However, more and more research into the cognitive science of our daily practice suggests otherwise.

In a JAMA Network Open research letter, a research team from the University of Pennsylvania looked at the association of appointment time with appropriate prescribing of statins. As a standard to determine which patients were eligible for statins, they used the USPSTF criteria for statin prescription as well as an LDL > 190 mg/dl (suggestive of familial hyperlipidemia). They used the clinician as the unit of analysis to account for variable shift work times and broke down the appointment times by hour. The authors controlled for multiple reasonable confounders – patient comorbidities, patient demographics, insurance, etc.

Over 10 thousand unique eligible patient visits were analyzed, in which statins were prescribed only 35% of the time overall. However, there was a notable difference between the rate of prescription in the afternoon compared to the morning (33.4% vs. 37.5%). The trend was significant over all afternoon hours. The authors note that this study was limited to a single health system and is observational data only.

This research team has done two similar studies. A study of breast and colon cancer screening rates showed that rate of orders for these tests by clinicians decreased from morning to afternoon, but also the rate at which patients completed the ordered studies varied by the time of the appointment at which their test was ordered. In a study on seasonal influenza vaccination, orders decreased in the afternoon, but an active reminder intervention increased rates overall throughout the day.

John’s Comments:

The findings here are robust across the studies and should give us pause. The solution to this problem is not avoidance, so don’t everyone go rushing to your practice manager to cancel your afternoon office hours! Instead, we must find ways to counter this effect – reminder systems, participation of the whole team, and consideration of ways to conduct prevention outreach that don’t depend on our fatigue levels.

References:

• Hare AJ et al. Assessment of Primary Care Appointment Times and Appropriate Prescribing of Statins for At-Risk Patients. JAMA Netw Open. 2021 May 11;4(5):e219050. Link
• Hsiang EY et al. Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening. JAMA Netw Open. 2019 May 10;2(5):e193403. Link
• Kim RH et al. Variations in Influenza Vaccination by Clinic Appointment Time and an Active Choice Intervention in the Electronic Health Record to Increase Influenza Vaccination. JAMA Netw Open. 2018 Sep 14;1(5):e181770. Link

From the Literature and the American College of Gastroenterology

2)  Management of Irritable Bowel Syndrome – A Practice Guideline

Irritable bowel syndrome (IBS) is a chronic, often debilitating, and highly prevalent disorder of gut-brain interaction. In clinical practice, IBS is characterized by symptoms of recurrent abdominal pain and disordered defecation. The Rome IV criteria (2016) can be used to diagnose IBS for both clinical and research purposes. These criteria require a symptom of recurrent abdominal pain on average at least 1 d/wk in the last 3 mo (with symptom onset at least 6 months before diagnosis) associated with 2 or more of the following:

1. Related to defecation

2. Associated with a change in the frequency of stool

3. Associated with a change in the form (appearance) of stool

Using the GRADE methodology, the American College of Gastroenterology (ACG) recently published updated guidance for the diagnosis and treatment of IBS. The guideline included 25 specific recommendations. They included:

• Recommend that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. Strong recommendation; moderate quality of evidence.
• Suggest that fecal calprotectin (or fecal lactoferrin) and C- reactive protein be checked in patients without alarm features and with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. Strong recommendation; moderate quality of evidence for C-reactive protein and fecal calprotectin. Strong recommendation; very low quality of evidence for fecal lactoferrin.
• Recommend against routine stool testing for enteric pathogens in all patients with IBS. Conditional recommendation; low quality of evidence.
• Recommend against routine colonoscopy in patients with IBS symptoms younger than 45 years without warning signs. Conditional recommendation; low quality of evidence.
• Suggest a positive diagnostic strategy as compared to a diagnostic strategy of exclusion for patients with symptoms of IBSs to improve time to initiate appropriate therapy. Consensus recommendation; unable to assess using GRADE methodology.
• Recommend a positive diagnostic strategy as compared to a diagnostic strategy of exclusion for patients with symptoms of IBSs to improve cost-effectiveness. Strong recommendation; high quality of evidence.
• Suggest that categorizing patients based on an accurate IBS subtype improves patient therapy (IBS-D, IBS-C, IBS-M [mixed], and those without a significant pattern of abnormal stool (IBS-U). Consensus recommendation; unable to assess using GRADE methodology.
• Do not recommend testing for food allergies and food sensitivities in all patients with IBS unless there are reproducible symptoms concerning for a food allergy. Consensus recommendation; unable to assess using GRADE methodology
• Suggest that anorectal physiology testing be performed in patients with IBS and symptoms suggestive of a pelvic floor disorder and/or refractory constipation not responsive to standard medical therapy. Consensus recommendation; unable to assess using GRADE methodology.
• Recommend a limited trial of a low FODMAP diet in patients with IBS to improve global IBS symptoms. Conditional recommendation; very low quality of evidence.
• Suggest that soluble, but not insoluble, fiber be used to treat global IBS symptoms. Strong recommendation; moderate quality of evidence.
• Recommend against the use of antispasmodics for the treatment of global IBS symptoms. Conditional recommendation; low quality of evidence.
• Suggest the use of peppermint to provide relief of global IBS symptoms. Conditional recommendation; low quality of evidence.
• Suggest against probiotics for the treatment of global IBS symptoms. Conditional recommendation; very low quality of evidence.
• Suggest against PEG products to relieve global IBS symptoms in those with IBS-C. Conditional recommendation; low quality of evidence.
• Recommend the use of chloride channel activators (lubiprostone) to treat global IBS-C symptoms. Strong recommendations; moderate quality of evidence.
• Recommend the use of guanylate cyclase activators (linaclotide, plecanatide) to treat global IBS-C symptoms. Strong recommendation; high quality of evidence.
• Suggest that the 5-HT4 agonist tegaserod be used to treat IBS-C symptoms in women younger than 65 years with <1 cardiovascular risk factors who have not adequately responded to secretagogues. Strong/conditional recommendation; low quality of evidence.
• Do not suggest the use of bile acid sequestrants to treat global IBS-D symptoms. Conditional recommendation; very low quality of evidence.
• Recommend the use of rifaximin to treat global IBS-D symptoms. Strong recommendation; moderate quality of evidence.
• Recommend that alosetron be used to relieve global IBS-D symptoms in women with severe symptoms who have failed conventional therapy. Conditional recommendation; low quality of evidence.
• Suggest that mixed opioid agonists/antagonists be used to treat global IBS-D symptoms. Conditional recommendation; moderate quality of evidence.
• Recommend that tricyclic antidepressants be used to treat global symptoms of IBS. Strong recommendation; moderate quality of evidence.
• Suggest that gut-directed psychotherapies be used to treat global IBS symptoms. Conditional recommendations; very low quality of evidence.
• Recommend against the use of fecal transplant for the treatment of global IBS symptoms. Strong recommendation; very low quality of evidence.

Mark’s Comments:

As I review patient records as part of my educator and leadership roles, I come across many “legacy” diagnoses of IBS. This guideline reminded me of the importance of not making assumptions about how these past diagnoses were made and digging a bit deeper into the history. I think it is important to note that many recommendations for some of the newer pharmaceutical agents don’t have particularly strong evidence behind them. At the end of the day from a clinical perspective, we’re still left with a diagnosis that is based on history and the need to customize treatment for individual patients, which includes “trial and error,” and unfortunately, that can be quite challenging for us and frustrating for those who are experiencing IBS symptoms.

Reference:

Lacy BE et al. ACG Clinical Guideline: Management of Irritable Bowel Syndrome. Am J Gastrolenterol 2021;116(1):17-44

From the Centers for Disease Control and Prevention

3) COVID-19 Vaccines with Other Vaccines

When they were first released, “out of an abundance of caution,” the COVID-19 vaccines came with guidance not to give any other routine vaccine within 2 weeks of administration of a COVID-19 vaccine. This policy, in practice, has delayed other vaccinations and created some difficulties with scheduling and possibly some hesitancy about getting a COVID-19 vaccination.

The CDC has released new guidance stating that, in general, it is acceptable to co-administer COVID and other vaccines – not really because of any specific data about co-administration, but because they have lots of data about the good safety records of the COVID vaccines themselves. If there is a concern about reactogenicity of either COVID or the other vaccines (i.e., if the patient needs to ensure good immunity and/or minimize side effects), it still may be best to separate them, but for average-risk patients, it is OK to administer them same-day or within 2 weeks of each other.

Keep the injections sites separated by one inch (if using the same deltoid muscle), or, if you are giving Td or adjuvanted (i.e., more reactogenic) vaccines at the same time, use separate arms.

John’s Comments:

The CDC is constantly tuning its recommendations during the pandemic; sometimes based on direct evidence. Sometimes, as in this case, it’s based on experience with other vaccines and a consideration of the consequences of maintaining this guidance (e.g., immunization delay). Remember, if your patient has an adverse reaction to any vaccine, remember to report that reaction to the Vaccine Adverse Events Reporting System (http://vaers.hhs.gov ).

Reference:

Interim Clinical Considerations for Use of COVID-19 Vaccines | CDC [Internet]. 2021 [cited 2021 Jun 1]. Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org