14 minute read
Preventing Shingles: Raising Awareness and Promoting Vaccination
Advisor Dx
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Check out some of our latest cases below!
DERM DX
Diffuse Rash Affecting Fingertips
A 28-year-old woman presents with fever and diffuse, tender, erythematous to violaceous punctate lesions on her limbs, trunk, face, fingertips, and palms. She also has anemia, a positive Coombs test, and leukopenia. One year ago, the woman was diagnosed with systemic lupus erythematosus with cutaneous and renal involvement.
CAN YOU DIAGNOSE THIS CASE? • Subacute lupus erythematosus • Small-vessel vasculitis in systemic lupus erythematosus • Antiphospholipid syndrome • Urticarial vasculitis
● See the full case at ClinicalAdvisor.com/DermDx_July_August21
ORTHO DX
In partnership with
TheJopa.org Journal of Orthopedics for Physician Assistants
Hip Tightness After Total Hip Replacement
A 76-year-old man presents with right hip “tightness” that has progressed over the past 4 months. He denies significant pain in the hip and his gait remains unchanged. He underwent a hip replacement 1 year prior. The patient’s right hip internal rotation measures 15°; abduction, 20°; and hip flexion, 95°. Anteroposterior radiograph of the pelvis shows heterotopic ossification in the right hip.
WHAT IS THE BEST TREATMENT OPTION FOR THIS PATIENT? • Observation • Indomethacin for 6 weeks • External beam radiation • Surgical excision
● See the full case at ClinicalAdvisor.com/OrthoDx_July_August21
Conference Roundup
Highlights From AANP and AAPA 2021 Virtual Spring Meetings
■ American Association of Nurse Practitioners ■ American Academy of PAs
AAPA ADOPTS PHYSICIAN ASSOCIATE AS OFFICIAL TITLE FOR PROFESSION
The American Academy of PAs (AAPA) House of Delegates passed a resolution to affirm Physician Associate as the official title of the PA profession. A majority of delegates voted for the name change (198 to 68) during the AAPA 2021 conference.
The PA profession was created more than 50 years ago. During that time, there have been several efforts to have the American Academy of PAs endorse a different title. Many PAs have long disliked the word “assistant,” often feeling that this misrepresents the profession and the work PAs do.
“Changing our title from assistant to associate is going back to our PA roots. PAs have had many titles throughout the years, one of which is physician associate,” noted Melinda Moore Gottschalk, MPAS, PA-C, DFAAPA, from the University of Mary Hardin-Baylor PA Program. “PAs in some universities are still graduated as a physician associate.”
“I’ve long supported the name of Physician Associate for our profession. I’ll admit my bias up front. I graduated from the Yale Physician Associate Program over 22 years ago, which has been the name since the Yale PA Program’s inception,” Jonathan Weber, MA, PA-C, said in an interview with Clinical Advisor.
In a letter to its members, AAPA acknowledged that this is a complicated issue. “Title change implementation is a complex and intricately interwoven undertaking requiring a thoughtful and well-timed strategy involving a variety of stakeholders — not only other national PA organizations (PAEA, NCCPA, and ARC-PA), PA programs, and AAPA constituent organizations, but also state and federal governments, regulators, and employers,” the AAPA wrote.
DO PAs NEED A DOCTORAL DEGREE?
Do PAs need a doctoral degree? It depends. For persons in academia and particularly individuals seeking higher leadership positions, a doctoral credential may be valuable. However, for PAs in clinical practice, the value of a doctoral credential needs further investigation, according to research presented at AAPA 2021.
Gerald Kayingo, PhD, MBA, PA-C, from the PA Leadership and Learning Academy, and colleagues studied job advertisements posted between 2014 and 2020.
Of the 612 unique job postings from 232 PA programs, 50% of employers preferred or required a doctoral degree for leadership positions such as chair or program director. That number decreased to 36% for regular faculty positions.
However, only approximately 24% of PA faculty and 45% to 48% of program directors reported having a doctoral degree, most commonly a Doctor of Philosophy.
“Thirty-six percent in the job market are saying, ‘give us a candidate with a doctoral degree.’ However, only 27% have appropriate credentials,” Dr Kayingo explained. A wage gap analysis revealed the following: • Median income is $105,000 for a certified PA in clinical practice, $97,000 for certified PA faculty, and $103,000 for PA faculty with a doctoral degree. • A certified PA program director earns a median of $131,000; that number increases to $140,000 with a doctorate.
“A doctorate degree made a huge difference if that candidate ended up assuming a leadership role,” Dr Kayingo said. However, for regular faculty, the doctorate did not seem to provide a financial benefit.
Having a doctoral degree is financially beneficial for PA faculty with leadership roles.
Continues on page 18
GENDER WAGE GAP PERSISTS FOR PAs
Gender pay disparities in the PA profession have been well-documented for decades. Although the gap is closing in the wake of social reckonings and advocacy for women’s rights, the gap persists, according to results presented at AAPA 2021.
“While PAs are doing better in comparison with non-PA women, there is still a wage gap,” said coauthor Amy E. Baker, MS, PA-C, program director for the Physician Assistant Program at West Chester University. Baker and her colleagues found that women who are PAs earn approximately 90% of their male counterparts’ salaries. This compares with women nationally, who earn on average 82 cents for every dollar a man makes.
The findings are based on data collected by the AAPA, Physician Assistant Education Association (PAEA), and the National Certification Commission of Physician Assistants (NCCPA).
In the PAEA 2017 Faculty and Directors Survey, the mean salary among men was $9432 higher than that among women ($102,638 vs $93,206, respectively). Nationwide data from the NCCPA also indicated a significant gender salary disparity.
Data from the 2018 AAPA Salary Report, in which salary information was cross referenced with various employment factors (eg, average number of hours worked per week and on-call duties) showed that the mean salary among men was $11,500 higher than that among women ($112,500 vs $101,000, respectively).
Although clinically practicing PAs earn higher salaries than academics, the gender pay disparity is greater for those in clinical practice. Among PAs in clinical practice, women earned 83% of men’s
Conference Roundup salaries; among PA faculty, women earned 91% of men’s compensation. When the Continued from page 14M49431_PP-US-REL-CT-2100114_Myfembree_BriefSummary_BW_CommonA_size_Mv04_ClinicalAdvisor_LEFT_PG4 49431 Giant Creative Strategy AAPA data was adjusted for factors such n/a bp as experience, specialty, leadership roles, 07/07/21 and weekly hours worked, the salary for PMSxxxx PMSxxxx PMSxxxx PMSxxxx 6:08 am women faculty members rose to 94% of their male counterparts. The disparity was slightly less for full-time PA faculty than for all PAs. To reduce the inequity, the researchers recommended these approaches: • Perform regular pay equity analyses to ensure that salaries among all PAs remain based on relevant variables, such as education, length of employment, positions, and contributions to the institution or clinic • Determine compensation in a group setting and make an overall effort to increase transparency pertaining to salary • Offer salary negotiation education and advocacy training for practicing PAs and PA students.
Conference Roundup
NP-LED CALLS WITH THE CHRONICALLY ILL REDUCE ED VISITS
For chronically ill, home-based patients, telephone access to nurse practitioners (NPs) is associated with decreased emergency department (ED) visits, according to findings presented at AANP 2021.
The research was part of an academic-clinical partnership between the University of Rhode Island College of Nursing and local federally qualified health centers. Through the initiative, Denise Coppa, PhD, FNP-C, FAANP, FAAN, and colleagues studied the value of telephone encounters in patients with chronic conditions including diabetes, congestive heart failure, COPD, asthma, hypertension, and psychiatric illnesses who had 3 or more ED visits or hospitalizations within the previous 6 months.
Electronic medical record data were collected between April 15, 2016, and June 30, 2018, and compared with 2 periods before initiation of the homebased primary care program.
The cohort included 157 patients; 98% had difficulty accessing health care, 54% were on Medicare, 21% were on Medicaid, and 1% were uninsured.
Although patients with 4 or more telephone encounters had an increased number of ED visits during the home care intervention, these patients were likely the most medically compromised, the authors noted. This increase was offset by a decrease in ED visits among patients with 1 to 3 telephone encounters. The overall number of ED visits was decreased by 13% (P =.03) with each 1-unit increase in the number of telephone encounters for patients with hypertension, diabetes, heart disease, dyslipidemia, and arthritis, the researchers reported.
“Providing NPs with a cost-effective, easy-to-use, telephone model to decrease recidivism provided positive outcomes for both the patient and the health care system. Medical homes and appropriate follow-up are an evidencebased approach to providing the support patients need to decrease repeated ED visits,” commented AANP 2021 attendee Mary Koslap-Petroco, DNP, PPCNPBC, CPNP, FAANP, of Stony Brook University School of Nursing in Stony Brook, New York.
“Federal support for academic-community partnerships imports potential for improved patient outcomes, decreased ED visits and hospitalizations, and health care costs,” the researchers concluded. Telephone encounters by NPs with home-based primary care “patients are necessary and worthwhile.”
PAIN MANAGEMENT EDUCATION FOR APRNs IS STILL LACKING
Many early-career advanced practice register nurses (APRNs) report low confidence and competence in managing chronic and acute pain, according to research presented at AANP 2021.
Data from the 2020 AANP Member Educational Needs assessment survey showed that 1 in 5 of the more than 6000 respondents would like additional continuing education on pain management. Pain management also ranked eighth on a list of areas in which NPs requested additional resources.
To assess the current state of pain education for APRNs, the researchers conducted a nationwide survey of APRNs.
Overall, 69% of APRNs reported receiving less than 5 hours of pain management education during primary training; 24% reported receiving 5 to 10 hours of pain education; 5% received more than 10 hours; and 2% did not recall or did not respond to this question. Most reported that on-the-job training served as their primary mode of pain management education followed by self-directed continuing education activities.
Fifty-two percent of respondents (n=144) reported spending at least 50% of their time managing pain in daily practice. Of those respondents, 78 worked in either pain management or palliative care specialty whereas the remaining worked in family or internal medicine, among other specialties.
Respondents in primary care, internal medicine, or surgery reported spending less time on pain management practices compared with APRNs in other specialties.
When asked about their level of preparation for caring for patients with basic chronic or acute pain management needs, 67% of participants felt neutral to unprepared to do so during their first year of clinical practice.
These results are indicative of “low confidence and perceived competence in providing pain management across acute and chronic pain settings,” the researchers noted.
“For those who focus their careers in pain management as a specialty, a system for certification would help to facilitate a metric of quality control and further delineation of competency in practice,” they concluded.
Most APRNs received less than 5 hours of pain management education in training.
Conference Roundup
Four resources to support NPs in implementing opioid guidelines were highlighted by the CDC’s Loretta Jackson Brown, PhD, RN, CNN, in a poster session at AANP 2021.
The CDC provides 2 free, interactive, online training modules for health care providers, including NPs: 1. A Nurse’s Call to Action for Safer
Opioid Prescribing Practices 2. Using the Prescription Drug
Monitoring Program to Promote
Patient Safety in Opioid Prescribing and Dispensing
The third tool is the CDC’s Quality Improvement and Care Coordination handbook, and the fourth is the CDC Opioid Guideline App for use during patient interactions. The free app includes a morphine milligram equivalents calculator, an interactive interviewing feature, and summary of key recommendations.
Dr Brown highlighted the following 3 main focus areas of the CDC Guideline for Prescribing Opioids for Chronic Pain: 1. Determine when to initiate or continue opioids for chronic pain 2. Determine opioid selection, dosage, duration, follow-up, and discontinuation 3. Assess risk for misuse and addressing harms of opioid use
Nurse practitioners should educate patients on all risks, potential side effects, and interactions associated with opioid therapies and be familiar with nonopioid and nonpharmacologic alternatives for chronic pain management. Long-acting or extended-release formulations should be reserved for patients with severe, continuous pain, Dr Brown explained. The CDC recommends identifying potential drug interactions, such as benzodiazepines, that may increase the risk for overdose.
“By implementing the CDC guideline recommendations, NPs will improve the safety and effectiveness of pain treatment
for their patients by reducing the risk associated with long-term opioid therapy,” Dr Brown noted.
GOING BEYOND FAST WHEN DIAGNOSING ACUTE STROKE
Stroke diagnosis can be challenging for clinicians, primarily because the clinical manifestations, patient-reported symptoms, and physical examination findings are highly variable. Subtle stroke signs are frequently missed, researchers reported at AANP 2021.
The FAST acronym — face, arm, speech, and time — is widely used to identify stroke symptoms, but the tool can exclude more subtle signs and symptoms. To describe the limitations of currently available stroke screening as well as newer modifications made to these tools to improve diagnostic accuracy, Stephanie Rosser, DNP, APRN, of The University of Texas Medical Branch School of Nursing in Galveston, Texas, conducted a literature review.
Twenty-four articles were reviewed and 8 were included in the final analysis: 4 systematic reviews and 4 case-control, cohort, or descriptive studies.
In the first systematic review, the Melbourne Ambulance Stroke Scale (MASS), Medic Prehospital Assessment for Code Stroke (MedPACS), and Ontario Prehospital Stroke Screening (OPSS) tools were evaluated only in a single prehospital setting, with high variability in the sensitivity and specificity of the studies. The remaining 3 systematic reviews, found that the Cincinnati PreHospital Stroke Scale (CPSS) had a high degree of both sensitivity and specificity in field settings and should be used preferentially over other scales.
Zhelev et al found that both Recognition of Stroke in the Emergency Room (ROSIER) and FAST demonstrated similar levels of accuracy in ED settings. However, the ROSIER scale was evaluated in more studies with “consistently higher sensitivity” compared with FAST, making it the test of choice. Meyran and colleagues reported that both FAST and OPSS were associated with “a positive increase in the number of patients who received timely reperfusion treatment.”
The case-control, cohort, and descriptive studies found that patients who presented with typical posterior stroke symptoms (nausea, vomiting, and dizziness) received delayed evaluation and 14% of stroke diagnoses were missed using the FAST acronym. However, adding balance and eye examination to the acronym (BE-FAST) reduced the number of missed strokes.
Results of a study by Oostema and colleagues showed that adding the finger-to-nose test to the CPSS improved recognition of posterior stroke in field settings, Dr Rosser explained.
Current stroke screening tools generally perform well when patients display overt signs of stroke such as hemiparesis and neglect, but lack sensitivity in recognizing more subtle signs associated with posterior circulating stroke, Dr Rosser concluded. ■
The ROSIER scale, BE-FAST, and CPSS may have improved accuracy in stroke diagnosis.
Preventing Shingles: Raising Awareness and Promoting Vaccination
Despite availability of a highly effective shingles vaccine and almost universal risk among those born before 1980, Americans are not getting vaccinated.
The US falls short in immunizing adults against herpes zoster.
An estimated 1 million people develop herpes zoster (HZ), or shingles, each year in the United States, and approximately 1 in 3 Americans will develop HZ in their lifetime.1 HZ occurs because of reactivation of the varicella-zoster virus, which causes varicella (chickenpox) and remains dormant in the dorsal root ganglia.2
When the HZ virus becomes reactivated later in life, patients develop a painful, maculopapular rash that matures into vesicles and commonly appears along 1 or 2 adjacent dermatomes along the face and/or torso. The rash usually does not cross the body’s midline. Before blisters appear, patients may feel pain, tingling, and/or itching along the nerve endings infected by the virus. The blisters begin to scab over in 7 to 10 days and clear up completely within 2 to 4 weeks.1,2
Any patient who has had varicella can develop HZ and the risk increases with age, especially in patients older than 50 years. Conditions that may compromise the immune system, such as HIV, lymphoma, and leukemia, also raise the risk for HZ. Treatments that suppress the immune system, such as radiation, chemotherapy, or steroids, increase an individual’s risk for shingles.2
Although some patients may not remember having chickenpox, more than 99% of Americans born before 1980 have had it.1 In the early 1990s, an average of 4 million people developed varicella and 100 to 150 died of the disease every year.1 Since the first varicella vaccine became available
