The PAFP Foundation’s Residency Program Collaborative (RPC) – a learning collaborative of 27 teams from family medicine residency programs – is the largest in the country. The Community Health Center Collaborative (CHCC) brings together 21 teams.
The goals of the collaboratives are improved patient outcomes and transformation to patient-centered medical homes so that the practices 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 Nov. 2 learning session.
Below are notes, tips and tweets from the March 7 learning session.
TOPICS: Treatment-Resistant Depression: When an SSRI Isn't Enough | Colorectal Cancer Screening and the Changing Landscape of Primary Care | Recognition and Diagnosis of Prediabetes | A1C Challenge | Diabetes: Supporting Safety and Insulin Management | Complex Liquid Management
TREATMENT-RESISTANT DEPRESSION: WHEN AN SSRI ISN’T ENOUGH
Mahendra T. Bhati, MD, Assistant Professor of Clinical Psychiatry, Hospital of the University of Penn
Use evidence-based dosages of depression meds. Inappropriate dosing and duration are the most common cause for failure to respond.
Jump a class in drugs if tx isn’t working. Don’t use one SSRI after another in depression tx.
Bidirectional relationship between depression and diabetes. Scientists talking now about “metabolic depression.” Glucose can impact mood!
Exercise is one of the most underprescribed interventions for depression.
Depression is a “syndrome” not just the depletion of serotonin.
The role of estrogen is so complex in the role of depression that there are no hard answers.
Depression strongly associated with completed suicide.
Early childhood stress risk factor for depression later in life.
Screen patients for depression if there’s sleep apnea associated with obesity.
The monoamine hypothesis, although incomplete, has directed treatment since 1960 but scientists are now looking at other treatments.
Therapy can be just as effective as meds in treating depression. Severe depression better treated with meds.
Is use of an antidepressant appropriate? Is it really depression? If you treat a medical condition, will the depression improve? Screen for medical causes of depression first.
Increasing relapses makes it hard to tx a person’s depression. You may need to keep them on meds for their lifetime.
About 20 percent fail to respond to conventional tx for depression. 60 percent of them never reach total remission.
STAR*D is largest study of resistant depression done on primary care and psychiatrist offices. Directs tx for resistant depression.
STAR*D includes four levels of treatments for depression. At each step, there’re diminishing returns on treatment.
Substance abuse is huge and interferes with depression treatment. Make sure all medical conditions are well treated to assist psychiatric conditions.
Anxiety also interferes with depression tx.
Other treatments are coming out of the pipeline for depression tx but getting them is complicated – they’re often not covered.
Let the med take more time to work.
Field moving more toward mono-therapy for depression based on studies of the past 2-3 years.
Atypical antipsychotics, which are heavily advertised, have an increased side effect burden and there’s no long-term data.
Lithium reduces risk of suicide but only in patients with bipolar depression
Psychostimulants won’t get a depression patient to remission but it helps with fatigue and apathy.
Vagal nerve stimulation is an option too. Provides a “bottom up” treatment. But no insurance company will pay for it.
Left side stroke patients at increased risk for depression.
CAD patients increased morbidity if they have comorbid depression.
Hard to screen for bipolar because patients don’t think anything’s wrong with them.
Mood disorders questionnaire – 10 questions – pretty good screening tool for bipolar.
COLORECTAL CANCER SCREENING AND THE CHANGING LANDSCAPE OF PRIMARY CARE
Jorge J. Scheirer, MD, FACP, MBI, Vice President and Chief Medical Information Officer, Reading Health System; CHCC Faculty Chairman
Know the updated CRC screening guidelines. Offer the full menu of options for screening.
CRC literature shows that life years gained is the same with colonoscopy and stool tests.
FIT vs. colonoscopy study: the tests detected about the same number of cancers. FIT is a good test “operationally” because patients take the test.
No EHR? Use your billing system to find patients who have been MIA for 2 years.
Check out the USPSTF CRC screening menu.
CRC screening colonoscopies are $$ and patients with high-deductible accounts would have to pay for it.
FIT is specific to intact human blood and looks for blood in the colon.
FIT: some improved patient participation.
Give patient FIT if he has actively bleeding hemorrhoids? No!
FIT probably not a good idea if patient is menstruating.
Reluctant patients? Recommend at each visit and offer choices.
CRC open access colonoscopy compresses the number of visits to reduce barriers.
FIT or FOBT tests: have a tracking mechanism to make sure you get it back.
Stool test at the time of rectal exam is not an effective CRC screen. Digital rectal exam is just 5% effective in detecting CRC.
Bringing in patients for CRC screening is an opportunity to update care.
Put the CRC screen result in a searchable field in your system.
Use standing orders to make sure your patients get the recommendation for a CRC screen.
Give patients a deadline for the CRC screen. Provide a “return by” date with the FIT.
Have a plan to assess and report CRC screening rates for the practice and each clinician.
4 essentials: recommend at every visit, office policy, reminder system, communication (in-office and with patients) system.
RECOGNITION AND DIAGNOSIS OF PREDIABETES
Lindsay A. Bischoff, MD, Assistant Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, Jefferson Medical College
Best way to prevent progression of prediabetes: 5-10% weight loss.
Who screen for prediabetes? Everyone >45 years. Check the ADA recommendations for the full list.
Prevent overt progression of prediabetes to DM: lifestyle modification then Rx.
Prediabetes screening recommendations from WHO are similar to ADA.
Prediabetes often diagnosed at time of complications.
Goals for DX of prediabetes:
- Preserve beta-cell function
- Delay/prevent progression to DM
- Delay/prevent complications of DM
Progression of prediabetes to DM somewhat population dependent. Race plays a role.
Lifestyle modification more effective than Rx to prevent progression of prediabetes.
In the real world of prediabetes tx, you make the call. What will work for your patient?
Risk/benefit profile for prediabetes meds other than metformin is questionable.
Use patient self-management for prediabetes tx lifestyle modification – develop specific activities and goals.
Recommended f/u after dx. Dr. Bishoff suggests not less than 3 mos. She uses every 6 mos.
Prediabetes Q&A. USPSTF recommendations are much different than ADA. Dr. Bishoff prefers ADA. Likely reason: there is no data that says prediabetes screening will lower overall mortality.
A1C CHALLENGE
Practices in the Collaborative are in the midst of an ”A1c Challenge;” they must get at least 20 patients under 9% by Sept. 30. Advice from the faculty:
Don’t work harder – you’ll burn out. Be smart about it.
Do a Root Cause Analysis or use the 5 Whys to figure out why patients are A1c>9.
Stay tuned! The PAFP will share best practices in the Progress Notes newsletter.
DIABETES: SUPPORTING SAFETY AND INSULIN MANAGEMENT
Kathleen Hill, CRNP, CDE, HHC, CLS
Decrease diabetes A1c by 1% to decrease complications by 21% - lots bang for your buck!
Some patients newly diagnosed with diabetes may need insulin because they have had DM for a long time.
All patients with diabetes will need insulin – don’t use insulin as a threat – patients feel badly enough.
Disinformation on diabetes is a click away. Listen with respect, give them the info they need, point them in the right direction.
Insulin will cause weight gain in patients with diabetes because the body can now use the glucose – encourage activity and fewer calories in refined carbs.
Rapid-acting insulin & a fatty meal. Take it 10 minutes into a meal. Fat delays carb absorption.
Help patients with diabetes feel safe to share what they’re doing. Practice that “game face” and help them get back on track.
There’s no magic to night-time dosing of Lantus. If the patient with diabetes needs to take in the AM for a good reason, it’s OK.
Check syringes of patients with diabetes to make sure the syringe will hold the dosage prescribed.
Double check elements of insulin injection with the patient because they don’t always get a formal education on injection.
Fever in a patient with an insulin pump? Check connection for infection.
Always make sure your patients know what hypoglycemia looks like. Make sure they associate the right symptoms with hypoglycemia. Encourage them to report hypoglycemia episodes to the doc.
Newly diagnosed diabetes patient: ID bracelet and glucose tablets.
Diabetes sick day management: patient still should take insulin and check sugars.
Ask patients with diabetes what they understand about their disease. The more they know, the more engaged they’ll be.
For patients with diabetes, be alert for things that get in the way of insulin management – like ability to pay or literacy. Illiteracy won’t be disclosed easily by patients.
Patients with diabetes need a patient self-management reminder. Use a form (for them and you!). These are shared tools!
Patients with diabetes need to be reminded that even if they’re feeling better, that they still need to go doc appointments.
Nonproviders: be sure to let physicians know if you see signs of depression in patients with diabetes.
Nonproviders insulin management lecture Q&A: how about skim milk for hypoglycemic? OK but quick sugar is better. Juice is good too.
COMPLEX LIQUID MANAGEMENT
Sarah Winter, PharmD, PGY2 Family Medicine Pharmacy Resident, and Scott Bragg, PharmD, PGY2 Family Medicine Pharmacy Resident, UPMC St. Margaret Hospital
LDL management approach from NIH: detection, eval, tx.
LDL goal influenced by several factors: CHD, family history, HTN, smoking age, lower HDL.
Medication nonadherence can be both intended and unintended.
What drives a patient to take a medication as they should if they don’t even know what they’re taking?
Muscle aches with statins? Pick another statin