462 -Statins and Myopathy?, Time It Takes to Provide Good Care, JOMO

From the Literature

1)  Better Data on Statins and Muscle Symptoms

For patients that we know would benefit from statins, a common sticking point is the risk of muscle and joint symptoms. The authors of a Lancet systematic review with meta-analysis wanted to find the best quality data to fully evaluate the risk of these muscle symptoms due to statins.

The authors used several methods to ensure the quality of the data they analyzed:

·         They used an individual patient data meta-analysis – rather than combining the overall rates and averages found in the studies, they brought each study patient’s individual data into the analysis as if they were members of one big trial.

·         They restricted the included studies to those that tried to recruit over 1000 patients (which helps ensure a diverse sample) and lasted at least 2 years (to allow time to assess adverse events).

·         They restricted the included study designs to statins vs. placebo and comparisons of different statin dosages.

·         They included only randomized, double-blinded trials and made sure there were robust, individual patient data about adverse events.

·         They carefully distinguished between subjective muscle pains and myopathy.

They found data from 19 trials of any statins vs. placebo (123,940 patients) and four trials of higher vs. lower dose statins (30,724 patients). The average follow up was 4.3 years. Over the first year of statin therapy, the absolute risk of muscle symptoms compared to placebo was 11 (95% CI 6 to 16) per 1000 person-years and was zero after that. Remembering that the relative and absolute risk numbers only talk about the differences between the groups, the authors helpfully calculated that only 1 in 15 complaints of muscle pains in these trials can be attributed to statins. Higher intensity statins caused more muscle pains that moderate and lower intensity (RR 1.03, 95%CI 1.01 − 1.06), and the pains lasted longer, but the authors note these effects should be weighed against the known preventive benefits. A very small proportion of myopathies seen could be attributed to statins, 0.08 per 1,000 person-years.

John’s Comments:

Overall, we can tell our patients starting statins that the risk of muscle symptoms is very low overall, and essentially nil after the first year. The risk is greater with higher-intensity statins than with low or moderate intensity. Myopathy due to statins is two orders of magnitude less common.

I’m not sure this information can change the mind of the patient that develops muscle aches after starting a statin –a chronological relationship (whether coincidence or not) is powerfully convincing. But it may be helpful to “inoculate” our patients with the best information about side effects before they start statins. In this Take 3 from 2020, we quoted the statin-associated muscle symptoms (SAMS) rate from the trials as < 1/1000, but the discontinuation rate to be ~10%. The current study updates those numbers, but the overall point remains – muscle pains are a common complaint in the patients who also need statins, and statins do not account for the vast majority of these symptoms.

Reference:

·         Blazing M, Braunwald E, de Lemos J, et al. Effect of statin therapy on muscle symptoms: an individual participant data meta-analysis of large-scale, randomised, double-blind trials. The Lancet. Published online August 2022:S0140673622015458. doi:10.1016/S0140-6736(22)01545-8

From the Literature

 2)  How Much Time Would It Really Take to Do Our Job Well?

Studies from the early 2000s indicated it would require at least 18 hours/day for a primary care physician (PCP) to provide guideline recommended preventive and chronic care management, not accounting for other tasks.  This is one explanation as to why many patients do not receive guideline recommended preventive, chronic disease, and acute care.  Since these studies were published, team-based care models such as the Patient-Centered Medical Home (PCMH) and the Comprehensive Primary Care Plus (CPC+) have been promoted as a way to overcome some of these challenges. 

 Given these changes, the authors of this study re-investigated the amount of time needed to provide 2020 standards of preventive, chronic disease, and acute care without and with team-based care. Preventive care included all Grade A and B preventive care services and immunizations recommended by the United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP), respectively.  The total annual time for each service was calculated based on USPSTF guidelines, their citations, and a literature search describing their annual visit frequency and time per visit.

The study design involved a computer simulation model applying preventive and chronic disease care guidelines to hypothetical patient panels of 2500 patients, representative of the US population based on the 2017–2018 National Health and Nutrition Examination Survey (NHANES).  Time was calculated based on a PCP providing this care alone and by a PCP as part of a team-based care mode (CPC+).  Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care.

The simulation found that PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management.  With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for administrative tasks).  Much of the preventive care time was for disease and preventive counseling.  The authors note that their findings support a 2012 study are supported by a Our findings support a 2012 study which concluded that non-PCPs could complete 77% of preventive care guidelines and 47% of chronic disease care.

In their discussion, the authors indicate that these results are based on ideal conditions including robust team-based care, and that in usual practice their estimates are likely low.  They conclude that PCPs do not have enough time to provide recommended preventive care along with chronic and acute disease management.  With team-based care the time requirements would decrease by over half, but still be excessive.  They surmise that given the large gap between the time required to provide guideline-based care and the limits of a clinic day, many clinicians are likely not completing specific services, not completing them according to the guidelines, or working overtime.  If time pressures are driving a gap between guideline-based and clinical medicine, it might explain why national health outcomes are worse than expected.

 Mark’s Comments:

I recognize none of this is “news” for our readers but see it as an affirmation as to why no matter how hard we work, it seems our work is never done – because it’s not!  The consequence is that we are constantly making “triage” decisions when it comes to the care we provide, which often prioritizes the most pressing issues over things like preventive care.   We’re also triaging the important but very time-intensive patient counseling and education, which is why I often find myself laughing with each successive guideline that defaults to “shared decision making” in helping to determine a plan of care. 

The challenges of the pandemic have unfortunately only exacerbated this dynamic, and while team-based care could help alleviate time pressure, it has too often not lived up to its promise due to economic realities and staffing shortages/turnover.   

 Ultimately, given how our present system is structured, including reimbursement models, something has to give.  Unfortunately, what that “something” too often involves is both care quality and the physical and emotional health of clinicians and our care teams.  

 References:

·         Porter J et al.  Revisiting the Time Needed to Provide Adult Primary Care.  JGIM.  Published online 1 July 2022.  Abstract

·         Altschuler J et al. Estimating a reasonable patient panel size for primary care physicians with team based task delegation. Ann Fam Med. 2012;10(5):396-400. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Saying “No” to Regain your JOMO

“The difference between successful people and really successful people is that really successful people say no to almost everything.”  ― Warren Buffet

How are you?  When I ask colleagues this question in the context of their professional lives and present schedule, adjectives such as “overly busy,” ”surviving,” overwhelmed,” “running on fumes,” and even “at the end of my rope” are consistently used.  Yet one of the biggest challenges for many of those same physicians is their inability to say “no.” 

Earlier in our career when opportunities for serving on committees, presenting at conferences, and writing started to appear frequently, one of my now PeerRxMed buddies and I used to challenge each other to share our “significant no’s” when we regularly met.  These “no’s” were to opportunities that I now call my “temptations and distractions,”  As our schedules became over-full, we found that what under normal circumstances would have been wonderful, even an honor to do instead felt tedious, burdensome, and exhausting.  Indeed, what should have been joy-filled lacked any sense of joy at all.  Despite that, saying no was incredibly difficult for us and therefore often didn’t happen.  When we were able to muster up the courage and overcome the guilt to do so, we ironically often felt elation because we had said no.

Over the course of the pandemic, there is an acronym that has gained popularity which describes this phenomenon; JOMO or the Joy Of Missing Out.  JOMO is seen as an antidote to the more pervasive phenomenon of FOMO or Fear Of Missing Out, exemplified by our society’s obsession with social media.   During our “pandemic pause,” many found that instead of “missing out” on the things they weren’t able to do, they discovered their overfull lives were often causing them to miss out on many of the simple things in life (like “doing nothing,” engaging in hobbies, and spending time with loved ones) that actually brought them great joy.   The pandemic provided a “legitimate excuse” to say no to activities that many found they weren’t actually interested in participating but felt a professional and/or social obligation to do so. 

So how can one learn to say “no” more effectively?  “Saying No Experts” have found certain techniques can be quite useful in helping you to both say no and not feel like you’re letting someone down and/or missing out on the “opportunity of a lifetime” in the process of doing so.  The first step is to spend some time becoming clear about your priorities and therefore being better able to discern if opportunities are right for you.  The next step is to realize that there will be many more “good” opportunities that come your way than you can ever say “yes” to, so saying “no” is something that you should expect to happen regularly.  And then there is “how to say no” in a way that leaves you feeling less guilty about it.  Those same experts encourage that practicing the actual phrases ahead of time can allow them to become more natural for you.  In fact, one of them has provided "50 Ways to Nicely Say No" to help get you started.

If it’s reassuring for you, I’ve never had a colleague express regret about having better aligned their priorities with their time.  I have, however, had many express regrets when they didn’t.  So why not take some time this week to examine your schedule, and see where there might be opportunities to say no?  Perhaps you could discuss these with your PeerRxMed partner and even practice!  What may be waiting on the other side of your next “no, thank you” is the joy of missing out, and as you now know, that’s likely not really missing out at all.

______________

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