As part of its work to improve patient outcomes and transform to patient-centered medical homes, the PAFP Foundation’s Residency Program and Community Health Center Collaborative met in Hershey, Pa. for its one-day spring learning session. This meeting was one of three annual face-to-face educational events that are included in a year-round interdisciplinary learning program. The residency program group is the largest single-state residency program learning collaborative in the United States.
Collaborative teams submit monthly quality data to the PAFP Foundation on diabetes, ischemic vascular disease, smoking, depression and body mass index screening. An asthma quality measure was introduced in summer 2013 and will be mandatory in November 2014 when ICD-10 will make it easier for practices to identify patients with persistent asthma. The PAFP Foundation provides EHR technical assistance to practices to ensure that they collect and report the most accurate data.
This one-day collaborative meeting included 86 participants and faculty from residency program practices and 38 participants and faculty from community health centers.
Tweets and Notes
The PAFP knows you can’t make it to every event but, follow us on Twitter for highlights from all of our big events. Here is a sampling of Tweets from faculty, staff and attendees, as well as some notes from select lectures.
TOPICS: Asthma and Cigarette Smoking | Smoking Cessation | Weighing the Evidence: Tackling Obesity in Primary Carel | Addressing the Communication Gap around Obseity | An Update on Weight Loss Surgery
ASTHMA AND CIGARETTE SMOKING
As soon as you put asthma on a patient’s problem list, get them on an inhaler.
A 15 percent decrease in PEF or FEV1 is compatible with exercise-induced asthma.
Cigarette smoke has a pro-inflammatory effect in the cascade of asthma inflammation.
Smoking with asthma increases lung function decline, steroid resistance and risk of persistent obstruction.
Tobacco leads to the same oxidative stresses and inflammation in diabetes and heart disease.
Smoking cessation is cost-effective, and it has a significant impact on morbidity of asthma.
Leukotriene modifiers are the treatment of choice for aspirin-induced asthma.
Dr. Leone: “Chronic smoking is an external sign of the internal changes caused in the brain by nicotine”
Triad: Aspirin-induced asthma, Rhinitis, nasal polyps
The long-term patch (>14 weeks) plus a self-administered form of nicotine replacement therapy works better than a single form.
Patch may help prevent cravings. Gum gives a little more of acute boost than patch. Still not as high as actual cigarettes.
Buproprion SR is safe with continued smoking; start 7-10 days prior to quit date; less weight gain; duration 8-12 weeks, with NRT.
Using >1 nicotine replacement agent (patch + gum, patch + inhaler) increases likelihood 8-fold that someone will quit smoking.
What about electronic cigarettes? Reproduces the smoking behavior and delivers nicotine, but data lacking on long-term effects of exposure.
SMOKING CESSATION
Eight million Americans live with at least one serious chronic disease from smoking, and 440,000 Americans die from tobacco use every year.
Because of rapid delivery in smoking, cardiovascular effects are greater with cigarettes than nicotine replacement therapies.
Pennsylvania practices, are you using fax to quit to support your patients tobacco cessation? http://www.portal.state.pa.us/portal/server.pt?open=514&objID=1140507&mode=2
Patients will likely live tobacco-free if still not using at age 26. Keep counseling non-smoking patients to avoid tobacco up to age 24.
Help patients understand that their brain is sending them signals to smoke. It’s not an issue of desire to quit or will power.
You can discuss how much money patients would save by quitting tobacco, but that’s not an effective strategy for most patients.
The 5 As: Ask about tobacco. Advise to quit. Assess willingness. Assist quit attempt. Arrange follow-up.
Center for Tobacco Research & Intervention – ctri.wisc.edu – has lots of good tobacco cessation resources.
WEIGHING THE EVIDENCE: TACKLING OBESITY IN PRIMARY CARE
Counseling odds declining among patients with greatest need: hypertension, diabetes, obesity. Are we giving up?
Obesity is the fastest-growing public health concern.
It's not the specific diet you try, it's the less calories. http://www.nejm.org/doi/full/10.1056/NEJMoa0804748
We are not surprised that obesity is increasing … until we see it depicted like this: http://m.youtube.com/watch?v=dQWWLDsi5xY&autoplay=1 …
If clinicians are bad at estimating the calories in our food and drink, what can we expect of patients?
A calorie deficit of 500 calories a day can cause a 1 lb weight loss in a week – which can be 52 lbs per year.
Evidence-based weight-loss tips: eat nutrient-dense breakfast, eat small servings, limit screen time and limit food/energy intake.
Obesity ask ideas: “Are you ok if we discussed your weight?” or “Are you concerned about the effects of your weight has on your health?”
Those who monitor their physical activity are more likely to exercise and had more weight loss.
ADDRESSING THE COMMUNICATION GAP AROUND OBESITY
Provider body type can be barrier to communication about obesity. Obese docs feel like poor models. Thin docs may feel insensitive.
Effective communication on obesity is two-way street. You need to listen, too.
Adults want to know “why” they are doing something. Tell obese patients why they need to lose weight.
Updating weight is the first thing you do in a visit; use it to start obesity conversation. Let the doc know to close the gap.
Weight-loss barrier: Some obese patients don’t want to lose weight because they don’t want to buy new clothes.
Patients find the word “obese” offensive. Use unhealthy weight, overweight or high BMI. Obese belongs in the patient record not the conversation.
Weight-loss push back from patients? Compromise. “Where do you think you can reduce?” Use the plate visual.
Get the weight-loss goal in the patient record so somebody at the practice can address the next visit. What if you’re not there?
Culturally sensitive weight loss? How to combat Latino meat-and-carb diet? Address portions and suggest greens they like. Adjust meal preparation.
AN UPDATE ON WEIGHT LOSS SURGERY
Erroneous weight-loss surgery myths: too risky, easy way out, patients should have more will power, you gain it back.
The NIH Consensus Guidelines for Weight-loss Surgery are over 20 years old. Time for an update.
Roux-en-Y Gastric Bypass facts: restrictive and malabsorptive, significant weight loss and resolution of comorbidities.
Vertical Sleeve Gastrectomy: mild malabsorption, similar weight lost to GBP.
Adjustable Gastric Band: purely restrictive, considered “safer” but with a high failure rate.