The PAFP Foundation’s Residency Program Collaborative – a learning collaborative of 27 teams from family medicine residency programs – is the largest in the country. The Community Health Center Collaborative brings together 21 teams.
The goals of the collaboratives are improved patient outcomes and transformation to patient-centered medical homes so that they can both teach and practice patient-centered care. Both types of practices serve large at-risk patient populations and both are key players in primary care workforce development so it makes sense that they hold their tri-annual learning sessions together.
Collaborative teams submit monthly quality data to the PAFP Foundation on diabetes, ischemic vascular disease, depression and BMI screening. Learning session lectures are focused on how to improve quality in those clinical areas. Below are notes, tips and tweets from the May 31 learning session.
TOPICS: Performance Improvement | Obesity and Prediabetes | Recommended Use of Aspirin and Other Antithrombotic Medications Among Adults with IVD | Point-of-Care Testing for HbA1c | Therapeutic Approaches in Resistant Hypertension | Oral Health
PERFORMANCE IMPROVEMENT
William Warning, MD, RPC Faculty Chairman
Don’t want to do performance improvement because you think your patients are challenging? Every practice has those patients. Advice from Dr. Bill Warning: “Some patients have barriers you can't overcome; don’t focus on them. Find patients whose barriers you can address – help them first.”
Dr. Warning is featured in the July 2013 Consumer Reports article about patient-centered medical homes, which names physician feedback as a PCMH hallmark.
OBESITY AND PREDIABETES
Janine Kyrillos, MD, Director, Preventive Health Care Program, Director of Medical Weight Management, Thomas Jefferson University Hospital
Risk factors for prediabetes are many. Check out ADA and/or USPSTF prediabetes indicators.
New AACE prediabetes management algorithm – lifestyle, then low-risk meds then meds like TZD
Think “avoid weight gain” v just “lose weight” for prediabetes tx.
Controlling stress is an effective weight-maintenance strategy.
Lots of patients use antihistamines to sleep but they can cause weight gain. Find another way to manage that problem.
Prediabetes obesity tx is cumulative – lifestyle then meds then surgery.
Prediabetes diets? The one that works is the one the patient can stick with!
Side effects of fat-blocking weight lose meds keep patients mindful of lifestyle changes. Eating fatty foods creates nasty side effects.
New weight loss med for prediabetes: phentermine/topirmate combo has better weight loss outcomes. You’ll need to learn the prescribing ritual b/c it’s schedule IV.
Wow – long list of weight loss meds for prediabetes in the pipeline.
Metformin – new studies support the higher dose, Dr. K says starts with 500.
Sugar substitutes? What do we tell our patients? Dr. K: probably cause hunger, but we don’t know yet. Still better to drink sugar free sodas.
Obesity is not a character flaw.
1 out 3 patients over 20 have prediabetes, 50% over 65.
Without intervention, prediabetes can become full-blown diabetes plus increased risk for eye and kidney disease.
RECOMMENDED USE OF ASPIRIN AND OTHER ANTITHROMBOTIC MEDICATIONS AMONG ADULTS WITH IVD
Samir B.
Pancholy, MD, FACP, FACC, FSCAI, Program Director of Cardiology
Fellowship of The Wright Center for Graduate Medical Education
Carefully consider risk when
prescribing aspirin for primary or secondary prevention. Does benefit
outweigh risk?
Regular aspirin risk assessments on
patients will likely change your prescribing behavior.
There’s no one recommendation for
aspirin use – get into the habit of doing a risk/benefit analysis
before prescribing.
Lower dose of aspirin is just as good
as higher dose – 80mg is probably the better dosage from a
risk/benefit standpoint.
Aspirin in diabetes – mixed results,
modest benefit (at the most). Recent studies haven’t shown
statistically significant benefit.
You’ll need to counsel patients on
aspirin use for prevention because everyone believes everybody should
be on aspirin.
Mortality reduction is actually pretty
rare (across all drugs), but ticagrelor actually was shown to reduce
mortality.
Flowchart for class I and class IIa
recommendations for initial management of UA/NSETMI – check it out
to implement all these antiplatelets into practice.
POINT-OF-CARE TESTING FOR HBA1C
Dr.
Linda Thomas, CHCC Faculty
Point of care (POC) A1c testing helps
to capture a teachable moment with patients not controlling their
glucose.
Dr. Thomas’ experience with POC A1c:
patients and docs like it, staff didn’t complain (much or for long)
– helps practice better serve patients.
You can even test patients who probably
didn’t fast, particularly if they’re profoundly uncontrolled. At
least you have a number to work with and convince the patient to take
their meds.
Avoid this problem: you do a POC test
and then the front office staff send the patient to the lab and the
patient gets stuck with the bill. Be sure to communicate with the
billing office.
Consider evidence-based v. what works
and is affordable.
Micromanaging patients can improve
outcomes but also lead to patients being unable to self-manage.
Instituting POC testing requires a
complete process plan that includes billing staff.
Not much literature about outcomes
connected with POC A1c testing but include fewer ER visits.
THERAPEUTIC APPROACHES IN RESISTANT HYPERTENSION
Samir B.
Pancholy, MD, FACP, FACC, FSCAI, Program Director of Cardiology
Fellowship of The Wright Center for Graduate Medical Education
Resistant HTN: patient fails on 3 meds.
White coat HTN remains a common
problem.
High BP is the leading cause of
mortality worldwide – US and PA are not immune!
Consider secondary causes of resistant
HTN i.e. obstructive sleep apnea is a common secondary cause.
Revascularization looks worse and worse as the
trials get better.
Kidneys signal brain and contribute neurogenic
HTN.
Know how take properly measure BP.
http://pafp.com/pafpcom.aspx?id=740
Lifestyle HTN tx: lose weight, DASH diet, and
abstain from alcohol.
When to refer: multiple visits for HTN with no
improvement (aka clinical inertia!)
ORAL HEALTH
C. Eve J. Kimball, MD, All About
Children Partners, P.C.
Many health issues closely associated
with dental carries. Work to resolve oral health issues, and you'll
be able to resolve others.
The lack of oral health access in the
country leads to many other preventable medial conditions.
Early childhood dental carries:
chronic, progressive, multifactorial. Faster progression in kids than
adults.
71% water supplies in PA are
fluoridated. Need to be thoughtful when Rx supplementation; not
always good, risk fluorosis.
Be aware of fluoride guidelines in
supplementation:
www.aapd.org/media/Policies_Guidelines/G_fluoridetherapy.pdf
Does your water have enough fluoride to
prevent caries? See http://water.epa.gov/drink/local/
Kids need a dental home at age 1. Refer
earlier & immediately if issues are present at a younger age
(family hx).
Progressive periodontal disease problem
for adults with diabetes. Risks include smoking, hormonal changes,
meds, genetics, illness.
Early childhood dental carries: sippy
cups matter! Only water in the sippy cup, NO JUICE! Snacks matter,
too. Ask & teach parents.
Get to know your pediatric dentist - do
they see kids at 12 mo, do they take insurance? will they give access
dental emergencies?
