TheraSim : TheraSim Clinical Insight

Clinicians: 52,000 Patient Case Sims: 73,000 Countries: 120

TheraSim Clinical Insight #1

October 2007

Doug Blevins, MD, TheraSim Clinical Director
David Hadden, CEO

TheraSim Clinical Insights is a Quarterly article that highlights trends in the clinical thinking of thousands of doctors as relates to the prevention and management of chronic and infectious diseases. The data which forms the basis of these reports are collected using the TheraSim Clinical Simulator,
a simulation-based patient case tool. TheraSim compares the choices clinician’s make in fully interactive patient simulations, with best practices in the form of guidelines and evidence. Differences are measured between the therapeutic approaches of the TheraSim clinician users and best practices.

The therapeutic benefits of salicylic acid, the active ingredient in aspirin, were documented as far back as Hippocrates in the 5th century. Today, aspirin has yet to be bested by any other analgesic, alone or in combination with aspirin. We continue to see an ever expanding base of clinical evidence espousing aspirin’s benefits in reducing the risk of heart attack and stroke, and recent studies are even suggestive that aspirin can help reduce the risk of certain types of cancers. A definitive miracle drug, aspirin is perhaps the corner stone of self-medication. While a permanent resident in most medicine cabinets, aspirin might struggle to get an OTC* approval from the FDA today due to it’s gastrointestinal side effects, drug interactions and increased risk of hemorrhagic stroke.

MILESTONES IN THE HISTORY OF ASPIRIN

	400 BC - Hippocrates recommends willow bark infusions for labor pains
	1753 - 50 fever patients improved after an infusion of willow bark
	1897 - Aspirin created by adding an acetyl group to salicylic acid, the bark’s active agent, to reduce stomach irritative effects
	1950 - Aspirin: the best-selling painkiller
	1969 - Aspirin: taken to the moon aboard Apollo by Neal Armstrong
	1999 - Aspirin: voted Drug of the Century (edging out penicillin)

Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that also has benefits in the treatment and prevention of heart attack, stroke, and peripheral artery disease. These conditions are responsible for nearly 1 million US deaths yearly. It also offers a modest degree of protection against colorectal cancer. In low doses, aspirin inhibits platelet clumping, has analgesic effects at medium doses and anti-inflammatory actions at high doses.

USE IN CARDIOVASCULAR DISEASE

In nearly 200 clinical trials studying more than 135,000 patients, aspirin use prevented 36-38 vascular events per 1000 for each of the following conditions:

	myocardial infarction (MI)
	Ischemic (not hemorrhagic) stroke
	angina
	coronary artery bypass graft surgery
	angioplasty
	transient ischemic attacks

Consequently, most providers recommend 75-325 mg of aspirin daily for those with these conditions.

PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE

Several large trials, mainly with men, conclude that aspirin prevents a first heart attack in people who have no signs or symptoms of cardiovascular disease (primary prevention), though such trials were inconclusive concerning stroke and cardiovascular death. In one trial involving women, aspirin reduced the risk of a first stroke and also decreased the risk of a first heart attack among those age 65 and over. In patients with low risk for cardiovascular events, the benefit of primary prevention should be weighed against the risk of gastrointestinal side effects and bleeding.

The United States Preventive Services Task Force and the American Heart Association recommend aspirin 75-325 mg daily for apparently healthy men and women in whom the 10-year risk of having a coronary event of is least 6 to 10 percent (using Framingham risk tables). Most patients experiencing a possible MI or unstable angina should take 325 mg of aspirin immediately and 81-325 mg daily thereafter.

ASPIRIN USE IN THERASIM CLINICAL CASE SIMULATIONS

During the past 12 months, aspirin-related clinician performance was recorded during nearly 5,000 sessions involving 17 separate TheraSim clinical case simulations in which clinical evidence, guidelines and faculty review agree that the clinician should order aspirin. These cases were spread out among 12 different internet-based CME acute coronary syndromes, dyslipidemia, type 2 diabetes, rheumatoid arthritis, asthma and HIV medicine programs.

The TheraSim Health Metrics Dashboard recorded correct aspirin ordering behavior in 50% of the sessions, though clinician success related to the aspirin competency varied from 16% to 93% for individual cases. At present, those using the TheraSim Clinical Simulator have a direct link to dyslipidemia, diabetes, cardiovascular disease and other aspirin-related guidelines and monographs. In addition, poor choices made during the simulation elicit educational alerts and warnings. Finally, editorial comments, literature citations and a summary of performance metrics are offered at the end of the user’s session, allowing the user to improve clinical behavior through case simulation.

Appropriate management decisions regarding aspirin are but one of a multitude of diagnostic and therapeutic competencies available on current TheraSim clinical case simulations. We appreciate your feedback about this article and welcome suggestions for future topics.