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ISSUE 1 VOLUME 1

FEB/MAR 2022

COLUMNS 18 BEST PRACTICES RURAL MEDICINE A look at common challenges and creative solutions for health-care professionals working in rural settings.

22 SUPPLEMENT SPOTLIGHT MELATONIN MISCONCEPTIONS Before you recommend melatonin for sleepless patients, consider how it works.

COVER STORY

An FBI special agent shares his top strategies for defusing difficult situations and creating calm

24 FOCUS ON GERIATRICS DEMENTIA VS. DELIRIUM How to differentiate these copycat conditions.

28 CLINICAL CARE: RESPIRATORY ASTHMA UPDATE New guidelines and studies aim to improve asthma control

32 CLINICAL CARE: SEXUAL HEALTH SEXUALLY TRANSMITTED INFECTIONS A guide to clinical diagnosis and treatment.

DEPARTMENTS

FEATURES

EDITOR’S NOTE

THE CONVENIENT CARE ASSOCIATION

14 THE FUTURE OF CONVENIENT CARE

GUEST EDITORIAL: THE CONVENIENT CARE REVOLUTION

36 SEASONAL

SPOTLIGHT

FLU CARE

Pandemic-driven changes boost demand for clinics and reinforce the importance of retail health to the nation’s health-care system.

The convenient care industry provides quality health care without the wait. By Kristene Diggins, DNP, FAANP, MBA, CNE, NEA-BC

Why was the flu a no-show last year, and how can we keep it from coming back?

39 5 MINUTES WITH ...

KRISTENE DIGGINS, DNP, FAANP, MBA, CNE, NEA-BC

Convenient Care Clinician is published 5 times a year by EnsembleIQ, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Subscription rate in the United States: $70 one year; $136 two year; $14 single issue copy; Canada and Mexico: $92 one year; $162 two year; $16 single issue copy; Foreign: $100 one year; $186 two year; $16 single issue copy. Postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Please send address changes to Convenient Care Clinician, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Vol. 1 No. 1, February/March 2022. Copyright 2022 by EnsembleIQ. All rights reserved.

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EDITOR’S NOTE

A Time for Transformation

An EnsembleIQ Publication 8550 W. Bryn Mawr Ave Suite 200 Chicago, IL 60631 Senior Vice President, Publisher John Kenlon (516) 650-2064, jkenlon@ensembleiq.com

EDITORIAL Editor-in-Chief | Editorial Director Nigel F. Maynard nigelmaynard@ensembleiq.com Executive Editor Carrie Adkins-Ali cadkinsali@ensembleiq.com

Dear readers,

SALES & BUSINESS

Carrie Adkins-Ali Executive Editor

WITH INTENTION AND INSPIRATION, WE CAN CRAFT A BETTER HEALTH-CARE SYSTEM FOR PATIENTS, A BETTER WORKPLACE FOR CLINICIANS, AND A BETTER AND HEALTHIER FUTURE.

Since childhood, I’ve had a fascination with suspension bridges. They’re symbolic of adventure, travel, and a little bit of danger. They’re also an excellent metaphor for something we’re all experiencing at this very moment: the liminal space. This is the space between the known and unknown. It’s the bridge that’s suspended between the mountain we’re leaving and the one we’re headed for. It’s where we experience a distinctly unpleasant and fearful sensation as the bridge sways in the wind and the ground stretches terrifyingly far below. We stand on this bridge many times: when we transition from universities to our careers, when we’re between jobs or relationships, and, of course, when we’re wondering what the post-COVID world will be like. Most people don’t like the liminal space, and we often freeze or try to flee to avoid the discomfort. But while we’re paying attention to the dizzying height or the stomach-churning fear of falling, something interesting is happening: We are transforming. Retail health care is in its own liminal space. As we leave behind the old health-care model, we’re traversing a swaying—and sometimes scary—bridge to something better. Patients are enjoying unprecedented access to health care—with transparent pricing, no less— and retailers are planning to broaden available services even more. Simple services, like care for coughs, colds, and ear infections, are making way for more complex issues, so your patients have access to an ever-greater range of options—and you have increasing room to flex and grow your skills. Sure, there are some missing planks we need to step over—that’s part of the liminal space, after all—but with intention and inspiration, we can craft a better health-care system for patients, a better workplace for clinicians, and a better and healthier future. To that end, with this premier issue of Convenient Care Clinician, I aim to arm you with the tools you need to thrive in these strange, uncertain times. You’ll find clinical updates, practice tips, and even advice from a former FBI agent on how to deal with difficult people. The magazine must go through its own transformation as it moves from a publication for you to a publication by you. Please write to me at cadkinsali@ensembleiq.com to tell me what you like, what you need, and what you want to see. Whether you want to read a specific article or contribute your own, this is your publication, and I can’t wait to see where you’ll take it. C

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EDITORIAL ADVISORY BOARD Nate Bronstein, MSEd, MPA, MSSP, Convenient Care Association Meggen Brown, MSN, FNP-BC, Kroger Health/The Little Clinic Kristene Diggins, DNP, FAANP, MBA, CNE, NEA-BC, CVS Health Tine Hansen-Turton, MGA, JD, FCPP, FAAN, Convenient Care Association Pete Nordeen, Bellin Health/Bellin FastCare Angela Patterson, DNP, FNP-BC, NEA-BC, FAANP, CVS Health Mark R. Watkins, MD, Kroger Health/ The Little Clinic

CORPORATE OFFICERS Chief Executive Officer, Jennifer Litterick Chief Financial Officer, Jane Volland Chief Human Resources Officer, Ann Jadown EVP, Operations, Derek Estey EVP, Content, Joe Territo

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GUEST COLUMN

The Convenient Care Association Greetings from the industry association dedicated to convenient care clinicians On behalf of everyone at the Convenient Care Association (CCA), we are so pleased to introduce you to our new industry magazine, Convenient Care Clinician. For those of you who don’t know us, CCA is your industry association. We believe that all people should have access to affordable, high-quality health care, which you are providing daily to millions of people. We are so proud to serve as your national trade association of companies and health-care systems that provide consumers with accessible, affordable, quality health care in retailbased locations. We have come a long way in helping to expand the retail-based convenient care footprint from the 100 clinics that existed at our founding in 2006 to the more than 3,300 clinics that now operate in 44 states, the District of Columbia, Canada, and Mexico. Since 2000, convenient care clinics around the country have employed amazing nurse practitioners (NPs) and physician assistants (PAs) in retail settings to ensure that people can access care. With more than 60% of Americans now living within a 10-minute drive of a retail health clinic, the companies we represent provide care to more than 50 million patients each year. Our industry growth has been substantial, but the endeavor of bringing care to all Americans is far from over. As we look ahead to a post-pandemic world, there are still many communities where health-care access remains strained. With an estimated projected physician shortfall of nearly 139,000 providers by 2033, our mission has never been more important. Such a shortfall will mean higher wait times, reduced access to care, and an overall decrease in the health outcomes of Americans. Fortunately, the role of convenient care clinicians, NPs, and PAs can help to close these gaps. In some states, such as Pennsylvania, a full acceptance of NPs and PAs would almost instantly reduce provider shortages by up to 89%. This is one of the many reasons we will continue to serve as the unified voice of our clinics and you as providers. We’ve already seen clinics step up through the COVID-19 pandemic, the floods in Texas, the fires in California, the opioid crisis, and the refugee crises here and abroad. Together, we can provide the accessible, affordable and high-quality care all people deserve. To learn more about CCA and how to engage with us, visit www.ccaclinics. org. Or email Nate Bronstein directly at Nbronstein@CCAClinics.org/ C

Meet the CCA Staff Tine Hansen-Turton, MGA, JD, FCPP, FAAN Executive Administrator/Director Contact: tine@ccaclinics.org Tine Hansen-Turton has 25 years of experience serving in CEO, CSO, and COO roles in nonprofit, private, and government organizations. Tine provides strategy support to the CCA board of directors. She has successfully advocated for more than 700 state and federal bills and laws that support NPs and PAs and their ability to serve as primary care providers, prescribe medications, receive reimbursement, and work to the fullest scope of their licenses.

Nate Bronstein, MPA, MSSP, MsED Chief Operating Officer Contact: nbronstein@CCAClinics.org Nate Bronstein is a former science teacher and policy wonk turned public health and education entrepreneur. Nate runs the National Trade Association for Retail Health Clinics, where he works directly with executive leadership from all of the major retail health clinic operators, as well as more than 40 health-care companies. Nate’s work includes improving health plans, finding and supporting new health-care technologies, supporting providers, and consulting with government officials.

Michael Clark, MPA Policy Director Contact: mike@socialinnovationspartners.org Mike Clark has researched, published, and worked in the areas of collective impact, financial innovation, impact investing, and social entrepreneurship. He is the lead researcher and policy analyst regarding the social impacts of paying direct-service workers low wages.

Lois Sperow, CPA, MBA Controller Lois Betz Sperow is a certified public accountant specializing in nonprofits, associations, and socialservice organizations. She takes the fiduciary duty of non-profit dollars extremely seriously and she helps management, staff, and board members to do the same.

REFERENCE Boyle P. U.S. Physician Shortage Growing. AAMC, 26 June 2020.

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programs offered by the Convenient Care Association Sexually Transmitted Infections The Continuing Care Association and DKBMed present three free accredited activities that provide essential knowledge in HIV management, including a “Meet the Patients” activity that allows you to review real clinician interactions with trained standardized patients. • Part 1 - The Landscape of HIV & Starting the Conversation • Part 2 - Now What? Testing & Treatment • Part 3 - Meet the Patient

Update on the Diagnosis and Management of Asthma Presented by Dr. Jay Portnoy, an allergist in the section of Allergy, Asthma & Immunology and Medical Director of Telemedicine at Children’s Mercy Hospital in Kansas City, Missouri. An application has been submitted to obtain .5 CME credits for this webinar.

Pet Allergies & Component Resolved Diagnosis (Diagnostic Testing for Allergies) Earn 1 CME learning about the best practices and latest updates surrounding the treatment of pet allergies and conducting a component resolved diagnosis.

Food Allergies and Component Resolved Diagnostics Presented by Dr. Santiago Martinez, Clinical Professor at Florida State University of Medicine.

Stinging Insects and Allergen Components Supported by an educational grant from Phadia US Inc. a part of Thermo Fisher Scientific.

Update on the Diagnosis and Management of Rhinitis Presented by Dr. Jay Portnoy, Children’s Mercy Hospital in Kansas City. An application has been submitted to obtain 5 CME credits for this webinar.

Access these educational offerings at https://convenientcareclinician.com/continuing-medical-education

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3/18/22 12:03 PM

GUEST COLUMN

BY KRISTENE DIGGINS, DNP, FAANP, MBA, CNE, NEA-BC

The Convenient Care Revolution The convenient care industry provides quality health care without the wait

Dr. Kristene Diggins is a clinical investigator provider with CVS MinuteClinic, an adjunct DNP faculty member for Purdue Global University, and a founding member of the Convenient Care Clinician editorial advisory board.

Patients continually rank convenience as one of the most important aspects of health care.1 However, in traditional healthcare settings, long waits and difficulty scheduling appointments are commonplace. There’s a better option right around the corner: the convenient care industry. Convenient care is dedicated to providing quality health care within local communities that’s easily accessible for patients. This health-care model puts convenience back in the hands of patients. As a health-care provider in this industry for 15 years, I’ve seen the ability to self-schedule appointments revolutionize health care by allowing patients to determine when and where they see a clinician. Time and again, I’ve watched patients who could not otherwise see their local clinicians access timely care in our clinics. Life-Changing Care That convenience allows vital—and often unanticipated—health-care needs to be met. I have a lifetime of evidentiary stories from the patients I’ve been honored to care for. Here are a few examples: A patient came in for a routine Department of Transportation truck driver’s physical, only to discover that he had been suffering from uncontrolled diabetes for many years. A young man self-scheduled an appointment for a chronic sore throat that turned out to be throat cancer. His quick access to convenient care allowed him to see a specialist just in time for surgical resolution. An elderly couple has their blood pressure monitored at my clinic because they don’t have transportation to regularly see their primary care clinician. A young athlete came in for an annual sports physical. During the exam, the

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TIME AND AGAIN, I’VE WATCHED PATIENTS WHO COULD NOT OTHERWISE SEE THEIR LOCAL CLINICIANS ACCESS TIMELY CARE IN OUR CLINICS.

clinician noted a serious cardiac arrhythmia and sent him for an urgent visit with a cardiologist. We later learned that the patient’s arrhythmia would’ve claimed his life if he had returned to sports without a much-needed ablation. Meeting Community Needs The evidence is clear that our communities are in great need of convenient care. In addition to convenience, our patients can also count on top-quality care that is based on Joint Commission standards. C REFERENCE 1. Masteron L. Convenience more important to patients than quality of care, survey finds. Healthcare Dive. January 7, 2019. Accessed November 30, 2021. https://www. healthcaredive.com/news/ conveniencemore-important-to-patients-than-quality-ofcare-survey-finds/545365/.

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ent care in conveni top stories This week’s

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3/18/22 12:05 PM

COVER STORY

BY ROCHELLE NATALONI

At-a-Glance •

Anger and violence are becoming more common in the workplace.

•

Jack Schafer, PhD, a former special agent for the FBI’s National Security Division’s Behavioral Analysis Program, drew on years of working with terrorists, fugitives, and criminals to develop a three-step anger-defusal program.

•

Step 1. Make empathic statements to calm the patient’s fight-or-flight response.

•

Step 2. Allow the angry person to vent so he or she can emotionally prepare to consider solutions.

•

Step 3. Make statements that direct the angry person to take a course of action that leads toward conflict resolution.

•

Remember that you’re the one in control. Don’t let another person control you or your emotions.

STOP PATIENT

HOSTILITY An FBI special agent shares his top strategies for defusing difficult situations and creating calm

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Health-care providers in all settings, from hospitals to retail health clinics, are facing increasing anger from disgruntled patients. Reports of physical and verbal assaults on medical professionals—who just a year ago were being heralded as heroes— pepper the nightly news. About three in 10 nurses who took part in a recent survey facilitated by National Nurses United reported an increase in violence where they work. With the possibility of facing an angry patient on the upswing, it is critical for health-care professionals to be able to defuse a potentially combustible confrontation. Jack Schafer, PhD, a former special agent for the Federal Bureau of Investigation’s National Security Division’s Behavioral Analysis Program, says controlling angry people is challenging, but there are several effective strategies you can use to avoid confrontations and protect yourself.

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Three-Pronged Approach As a trained clinical psychologist and behaviorist with a 25-year-long career in law enforcement, Dr. Schafer drew on his years of dealing with terrorists, fugitives, and criminals to develop a three-pronged approach to breaking the anger cycle. Make empathic statements. Allow the angry person to vent. Offer presumptive statements. The combination of these three steps is a simple yet effective way to control angry people and defuse potentially dangerous situations.

Step 1

Make Empathic Statements. Breaking the anger cycle starts with empathy—being able to sense how another person feels and caring about it—and making empathic statements. These statements capture a person’s verbal message, physical status, or emotion and use parallel language to reflect those things back to that person. “The unique features about empathic statements are that they do not fuel anger, and you do not have to agree with the angry person. You merely reflect their message back to them,” explains Dr. Schafer. The basic formula for constructing empathic statements starts with the phrase, “So you …”. For example, you might say, “So you must be really frustrated.” “This formula keeps the focus on the other person and away from you,” Dr. Schafer notes. Once you’ve mastered the basic formula, you can graduate to more sophisticated statements by eliminating the “So you” preface. To people who are not angry, an empathic statement might seem patronizing, but to angry people, they do not. Dr. Schafer explains that angry people naturally think that others should listen to them, so they do not see personalized attention as unusual. But there’s more at play: “The angry person’s fight-or-flight mechanism is engaged and they are not logically

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COVER STORY

A Long-Simmering Problem Hostility toward health-care workers isn’t new, but it appears that the mandates and restrictions associated with containing the spread of COVID-19 turned up the heat on what was once a low simmer. Things like mask and vaccine mandates may have added fuel to the fire, but violence against U.S. health-care workers has been on the rise for at least a decade.

processing information.” As anger increases, a person’s ability to reason diminishes, he says in his book The Like Switch. “Angry individuals are not open to solutions when they are mad, because their ability to think logically is impaired,” he writes. Given these circumstances, he says, the key to breaking the anger cycle is to avoid trying to rationally engage angry people.

67%

Step 2

Let the Person Vent.

increase in the incidence of violence-related injuries from 2011 to 20181

Venting is a critical component in breaking the anger cycle because it reduces frustration. “Once angry people vent their frustrations, they become more open to solutions because they think more clearly when they are not angry,” says Dr. Schafer. Venting is a process, not a singular event. The initial venting is typically the strongest, and it allows angry people to burn off most of their anger at the onset of the exchange. When the person naturally pauses, construct another empathic statement. Empathic statements portray the target of the anger as nonthreatening, which reduces the impact of the angry person’s flight-or-fight response. “Since empathic statements encourage venting, the angry person will likely resume venting, but with less intensity,” Dr. Schafer notes. Continue constructing empathic statements between venting sessions until the person’s anger is spent. Nonverbal clues including slumping of the shoulders, deep exhaling, and sighing signal spent anger, he says, and indicate that it’s time to move on to step 3.

75%

30%

1,100

more likely health-care and social service workers are to experience workplace violence compared with people working in other fields1

Introduce Presumptive Statements. Presumptive statements direct the angry person to take a course of action that leads to conflict resolution. They bring the anger cycle full circle. For this to work, the venting process must be finished. “If the person’s anger has not been completely vented or fuel was intentionally or unintentionally added to the anger, the likelihood increases that the presumptive statement would be rejected,” explains Dr. Schafer. Presumptive statements should be phrased in a way that elicits agreement. For instance, in a scenario where a patient is angry about a long wait, Dr. Schafer suggests that you could say: “If you wait a little bit longer, we’re going to get accurate results and then send you on your way. This may take a little longer than you expected, but you probably want to be sure that we get this done correctly.” You can further defuse the situation by giving the person a limited choice. Avoid open-ended questions and instead stick to an either/or question, such as: “Do you want to wait a

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10.7

violence-related injuries per 10,000 full-time health-care workers in 20111

Step 3

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nurses who report the workplace violence they experience2

violence-related injuries per 10,000 full-time health-care workers in 20181

workplace assaults in the U.S. that involve health-care workers2

threats or violent acts against health-care workers and facilities worldwide in 20203

REFERENCES 1. U.S. Bureau of Labor Statistics. Fact Sheet: Workplace Violence in Healthcare, 2018. Updated April 2020. Accessed November 30, 2021. https://www.bls.gov/iif/oshwc/cfoi/ workplace-violence-healthcare-2018.htm 2. Darnell T. Violence against healthcare workers rising, state lawmakers told. Capitol Beat News Service. Sep 23, 2021. Accessed November 30, 2021. http://capitol-beat. org/2021/09/violence-against-healthcare-workers-risingstate-lawmakers-told 3. Insecurity Insight & UC Berkeley Human Rights Center. Violence Against Health Care: Attacks During a Pandemic. February 2021. Accessed November 30, 2021. https://storymaps. arcgis.com/stories/fd6a804a17b74f0aaa3d00b76b9ab192

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little longer or leave and make another appointment?” “Giving someone the feeling that they have some control over a situation can work wonders,” Dr. Schafer explains. “You are giving them ‘created power.’ You create power and give it to them, but if you created it, you can also quickly take it back. Created power is the psychology behind the either/or choice.” Patients often become angry because their expectation of what health-care providers can do is unrealistic. “Their

expectations don’t meet reality, so they get frustrated,” Dr. Schafer says. “When we provide an explanation, they relax because the world makes sense again.” That often soothes their frustration.

Adapting to Changing Times There was a time when the credentials embroidered on a lab coat or scrubs could be counted on to command a degree of respect. Those days are waning as mixed messages throughout society suggest that second-guessing clinical judgement is the “American way”. That paradigm, along with the stress and uncertainty of COVID19, opens health-care workers up to potentially combustible confrontations on any given day. Dr. Schafer’s formula for de-escalating these interactions puts medical professionals in the driver’s seat so they can steer the situations to peaceful resolutions. C

“If this anger cycle continues, at some point, the health-care provider’s fightor-flight threshold is crossed, causing a reduction in their ability to think logically,” says Dr. Schafer. “Once you’re in fight-or-flight mode, you can’t logically process information. When both parties are in that state, they are essentially circling the drain. If the cycle isn’t contained, one or both parties are eventually going to go down.” Here are a few tips to avoid what Dr. Schafer calls “the death spiral”.

Calm Yourself in the Heat of the Moment As a health-care worker, you’re not immune to stress. In fact, according to a recent survey conducted by the nonprofit Mental Health America, 93% of health-care workers were experiencing stress, 86% reported experiencing anxiety, 77% reported frustration, 76% reported exhaustion and burnout, and 75% said they were overwhelmed.1 Adding difficult and angry clients on top of that stress can lead to potentially incendiary situations. A difficult patient can push a health-care provider to respond in a way that adds fuel to the patient’s fire.

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•

Check your personal frustrations at the door when you get to work.

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Don’t take the aggressor’s words personally—even if they are about you and directed at you.

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Remember that you’re the one in control. “You don’t want to let that person control you or your emotions,” he says. “To do this, you have to suspend your ego to some degree.”

•

Consider the consequences. Engaging in a verbal altercation could open you up to disciplinary action by your employer. “You have to make a choice of whether you want to escalate the situation or avoid that.”

REFERENCE 1. Mental Health Alliance. The Mental health of Healthcare Workers in COVID-19. Accessed November 30, 2021. https://mhanational.org/ mental-health-healthcare-workers-covid-19

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FEATURE: LOOKING AHEAD

BY MARK HAMSTRA

The Future of Convenient Care Pandemic-driven changes boost demand for clinics and reinforce their importance to the nation’s health-care system. Retail health clinics including Kroger Health’s The Little Clinic, Walgreens’ VillageMD, and CVS’ MinuteClinic are emerging from the pandemic with enhanced technological capabilities, a growing array of services, and plans to expand their physical and virtual presences. Operators of these

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outlets are growing their telehealth offerings, enhancing their connectivity with other members of the health-care community, and adding more services that can help drive better outcomes for patients. While clinic operators are hoping to return to many of their normal day-to-day routines in 2022, they are coping with ongoing staffing pressures amid widespread labor shortages coupled

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At-a-Glance •

Retail health clinics are growing their telehealth offerings, enhancing their connectivity with other members of the health-care community, and adding more services.

•

Clinic operators are preparing to face an increase in mental health issues.

•

Retail clinic operators say they plan to continue to invest in remote health-care services.

stress — everyone’s experiencing some degree of that,” says Dr. Watkins. Clive Fields, MD, chief medical officer and cofounder at VillageMD, which has a partnership with Walgreens and operates several clinics in the drug retailer’s stores, agrees that mental health issues will be a key area of focus in the year ahead. He cites the apparent impact of the pandemic on behavioral health, noting increased anxiety, depression, and loneliness, especially among seniors. “It’s clearly an area where we plan on reinvesting in the integration of behavioral health and behavioral health services inside our community primary care locations,” Dr. Fields says.

with increased patient visits owing to COVID testing and vaccinations. Further, consumers have pent-up demand for medical services after postponing health-care activities during the pandemic, and many of those people are expected to turn to retail clinics for care in the year ahead. Mental Health Services In addition, clinic operators say they are preparing to face an increase in mental health issues such as depression and anxiety among their patients, brought on by isolation and other disruptions during the past two years. Marc Watkins, MD, chief medical officer at Cincinnati-based Kroger Health, president of the Convenient Care Association, and member of the Convenient Care Clinician editorial advisory board, says that while vaccinations and testing will be significant areas of focus at The Little Clinic in 2022, the company will also strive to ensure that patients are aware of the clinics’ broad array of services, including mental health care. “I think it’s important for us coming out of the pandemic to identify folks that may be struggling with things like anxiety, depression,

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Telehealth Expands in Retail Clinics Telehealth emerged as an important element of clinical care during the pandemic, and retail clinic operators say they plan to continue to invest in remote healthcare services. Angela Patterson, DNP, FNP-BC, NEA-BC, FAANP, vice president at CVS Health and chief nurse practitioner officer at its MinuteClinic subsidiary, says the increasing demand for virtual care during the pandemic led the company to launch a new telehealth service, E-Clinic, to complement its existing Video Visit platform. The company also accelerated the expansion of staffing and services for its virtual care offerings, which she says CVS plans to grow even more in 2022. The company now employs nurse practitioners and physician assistants who deliver care solely via telehealth, as well as providers who deliver care both virtually and in its brick-and-mortar clinics. The combination of virtual and in-person care is a trend that bodes well for the retail clinic industry, says Dr. Patterson, who serves on the Convenient Care Clinician editorial advisory board.

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FEATURE: LOOKING AHEAD “Now that patients are discovering the benefits and quality of virtual care delivery, there is an incredible opportunity for initial patient engagement through virtual care followed by in-clinic visits for testing, lab services, chronic disease monitoring, counseling, and more comprehensive wellness examinations,” Dr. Patterson says. In addition, she notes that “a good percentage” of CVS’ telehealth patients can be evaluated and given a prescription or care plan without the need for an in-clinic visit, which frees up the clinics for services that require in-person interaction. VillageMD also seeks to unite its multiple platforms, including its brick-and-mortar offices, with onsite doctors and the comprehensive primary-care it offers through telehealth and remote patient monitoring under its Village at Home umbrella. “I think we’re seeing a move from the hospital as the center of health-care delivery to the primary-care office, but we’re seeing a primary-care office that is much different than the one that my father worked in during the ’80s and ’90s,” says Dr. Fields. “We’re seeing a primary-care doctor’s office that is advanced in terms of technology and analytics, has multiple platforms that can deliver care, and has an extension from the retail site into the home.” The company continues to expand the primary-care services it offers, as well as other ancillary diagnostic services. “Nobody likes to drive to the Texas Medical Center to have their blood pressure checked, and there’s really no reason that they should have to do that, with the technology we have now to bring the expertise of those medical

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centers into the communities where people work, live, and play,” says Dr. Fields. Clinics Connect with Other Providers Dr. Watkins says The Little Clinic will focus on driving successful outcomes for patients in 2022 by ensuring that it plays an increasingly important role in the “continuum of care” among other health-care solutions in the communities where it operates. “We would like to continue to collaborate in the space that is a multidisciplinary approach to care, coordinated with not only our pharmacies, but our health care partners around the country so that health-care is less fragmented,” he says. That will involve taking steps to improve interoperability among health-care providers, Dr. Watkins explains, such as creating systems that better share records with patients’ primary care physicians, for example. A key element of this effort revolves around closing gaps in patient care, he says. Clinicians may notice that a patient is in the age range for a specific type of cancer screening and discuss it with the patient, for example. This benefits the patient and ensures that clinicians are operating “at the top of their license,” he says, or performing value-added tasks beyond the routine services for which patients may have an immediate need. The Little Clinic participates in the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP), and Dr. Watkins says the company will focus on optimizing its potential through that initiative in the coming year. Similarly, another important initiative for The Little Clinic in 2022 revolves around supporting primary care physicians’ efforts to conduct annual wellness checkups with their patients, which Watkins says helps relieve the strain on local doctors. Optimizing Patient Care VillageMD, meanwhile, also seeks to optimize patient care by leveraging technology to suggest services for patients. Its proprietary data analytics system, called docOS, collects patient data and uses it to segment patients according to risk and help optimize their care by suggesting appropriate testing, for example. “It’s not about seeing more patients; it’s about seeing the same patients more often, because our data continue to show that the more touches a patient has with their primary care provider or primary care team, the better their ultimate outcomes, measured in terms of quality and total cost of care,” says Dr. Fields. The VillageMD model for optimizing patient outcomes has been key to its success, he says, as is the integration of pharmacy services with its primary care offerings. The fact that the company’s pharmacy partners at Walgreens have access to VillageMD’s electronic medical records helps smooth communications between the two providers and ensures that patients, physicians, and pharmacists are all on the same page, Dr. Fields says.

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Underserved Communities The Little Clinic views its vast retail presence as part of the solution to providing health care to underserved communities, Dr. Watkins says. “We’ve seen primary care practices and urgent cares close and not reopen throughout the pandemic,” he adds. “We want to be part of the solution and get people into our doors to help them through whatever they need our assistance with.” VillageMD is also focused on delivering care in underserved communities and communities with elderly and minority populations, says Dr. Fields. In fact, VillageMD has committed to opening half of its retail locations in underserved communities, he says. In 2022, the company anticipates opening between 100 and 150 retail locations in both existing and new markets. VillageMD typically operates with two physicians, several clinicians, and other personnel, providing care in person and through technology to reach people in their homes. The setting for these “pods” of care providers are “no longer 500 square feet, two plastic chairs, and a nurse practitioner,” says Dr. Fields. “Now it’s 3,000 to 5,000 square feet, 12 exam rooms, and a highly functional and technologically enabled office.”

Food as Medicine at Kroger At Kroger, another initiative that has evolved during the pandemic is the company’s Food as Medicine program, through which the retailer’s registered dietitians help patients with diet-related initiatives such as creating tailored meal plans to address conditions including diabetes, chronic kidney disease, and obesity.

Clinics Double Down on Convenience In 2022, CVS’ MinuteClinic plans to enhance its practice model to provide more care for patients when and where it is convenient for them, Dr. Patterson says. “We will be actively expanding our service offerings to become more primary-care-enabled, adding more than 50 new clinical services in a variety of areas, including mental health, women’s health, and sexual health,” she says. In addition, MinuteClinic is expanding its clinical care teams beyond nurse practitioners and physician assistants to create what Dr. Patterson describes as an integrated health care delivery team. This includes hiring registered nurses, licensed practical nurses, licensed vocational nurses, healthcare concierges, and social workers, as well as expanding its base of collaborating physicians. “We are focused on developing an environment that enables our providers and nurses to practice to the top of their education and training to deliver quality care that makes a difference in our communities,” she says.

“We know that obesity is going to replace smoking as the No. 1 modifiable risk factor among all cancer risks,” says Marc Watkins, MD, chief medical officer at Kroger Health, “so we’re really doubling down with our clinics and our dietitians — creating and understanding and delivering solutions that help people live healthier lives. We’re going to lean on our internal teams at Kroger Health and The Little Clinic to really move that forward.” The company will be encouraging conversations around nutrition with all of its patients, he says, leveraging Kroger’s status as the largest traditional supermarket chain in the country.

Staffing Challenges Staffing remains a challenge for the entire industry, Dr. Patterson says. The strain of serving patients during the pandemic has led to fatigue and has impacted retention and hiring. CVS’ MinuteClinic is seeking to overcome that challenge by offering “the benefits of a leading health care organization that is purpose-driven and deeply committed to supporting our providers’ needs,” Dr. Patterson says. The company also seeks to attract workers by offering career advancement opportunities in areas such as leadership and management, education, clinical trials, research, and mental health. C

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“We really want to win with food first,” says Dr. Watkins. “We think if we win with food, that also can be a benefit to the overall health of the populations that we serve.”

FEBRUARY/MARCH 2022

3/17/22 11:35 AM

BEST PRACTICES

BY KAREN APPOLD

Rural Medicine A look at common challenges and creative solutions for health care professionals working in rural settings. Providing care in a rural setting is full of rewards and challenges for Danielle Howa Pendergrass, DNP, APRN, WHNP-BC, FAANP. “The joy of living and working in a community with social cohesion is incomparable,” says the president and clinician at Eastern Utah Women’s Health in Price, Utah. Lori Moseley, DNP, FNP-BC, CDE, a nurse practitioner at MinuteClinic in Lancaster, S.C., agrees. “I live in this community and have worked here for seven years, so I know many of the people who come in for care,” she says. “And if I don’t know them personally, I usually know someone who does. Because of that, my patients trust me,” which makes them more likely to follow medical advice. It’s not always easy, though, and finances often crop up as a barrier to care.

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The Cost of Care For Dr. Moseley’s patients, like many patients in rural areas, the cost of care is a significant barrier. After a visit, it can be difficult for some patients to afford needed prescriptions, she says, so she’s ready to help. “Often, I pull out my phone, find their medicine, and show them the prices,” she says. “I ask if they can afford a drug before prescribing it.” If they can’t, Dr. Moseley talks to them about online discount programs that can save a substantial sum. “A lot of people don’t know anything about those types of programs,” she says. Many of Dr. Howa Pendergrass’ patients face similar concerns. Most of her patients work in the volatile mining, trucking, and energy industries. “Many families have jobs and insurance one day and are laid off the next,” she says. “As a result, many people simply can’t afford to access health care.” Further, many of her patients have lower socioeconomic status, which comes with “lower health literacy, inability to purchase healthy foods due to food deserts, and no public transportation options.”

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With a mission statement of equitable access to care for all, regardless of insurance status, Dr. Howa Pendergrass works tirelessly to secure federal, state, and local funding to provide care for three vast rural counties. Here are just a few of her strategies: • The clinic became a Health Resources and Services Administration (HRSA)-designated site. HRSA programs provide health care to people who are geographically isolated and economically or medically vulnerable. • The clinic works with community partners to share resources and coordinate the care of marginalized citizens. • The clinic also became a research site, enabling it to provide no-cost services for qualifying patients. Grants and studies cover primary care visits, services for all methods of contraception, screening and treatment for sexually transmitted infections, mental and behavioral health care, and care for pregnant women using substances. Sliding-scale fees help patients as well, adds Ed Friedmann, PA, BS, physician assistant and clinic administrator at the Redfield Medical Clinic in Redfield, Iowa. If a patient doesn’t have health insurance or has a high deductible, Friedmann will charge based on income. “Most patients want to pay their way. If they pay $20 or so, they feel better about it,” he says. “In a small town, we try to take care of each other.”

At a Glance •

For many patients in rural areas, the cost of care is a significant barrier. Community resources, research partnerships, and sliding fee scales can help patients access care.

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Patients may need help finding transportation or may need home care to stay well.

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Telehealth gives rural patients access to a wide variety of specialists with no transportation needed, but they may need your help to use technology.

Getting Patients to the Care In addition to financial challenges, many rural patients don’t have reliable transportation to get to a clinic or a specialist.

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BEST PRACTICES

Challenging Archaic Rules To improve care in rural areas, clinicians need to educate lawmakers. Archaic governmental regulations—such as a law in Iowa that requires physician oversight at clinics staffed by experienced PAs that are more than 30 miles from a physician’s office—limit access to care, notes Ed Friedmann, PA, BS, physician assistant and clinic administrator at the Redfield Medical Clinic in Redfield, Iowa. “If you can trust a PA up to 30 miles away, then you can trust them up to 60 or more miles away,” he says. With modern technology making it easy to communicate with physicians as needed, the regulation is not necessary. “Tell the people who make policy decisions about your problems and how they can be improved,” urges Friedmann, who has worked with Congressional members and the state legislature to change laws. “When I started practicing in 1977, PAs didn’t have prescribing privileges, and now we do. You might be amazed at how responsive lawmakers can be about improving access to care.”

Dr. Moseley notes that most specialists in her area are a 40-minute drive away—a distance that patients sometimes don’t want to travel. When that happens, “I don’t sugarcoat it,” she says. “I tell them that we have done all we can at MinuteClinic and they have to go to a higher level of care.” Getting to a specialist—or even a local clinic—can be further complicated by a lack of transportation, Friedmann adds. That’s where clinics and communities need to get creative: • A van service can help patients get to routine appointments, but the need to plan ahead can make it difficult for acute situations. • In Friedmann’s community, a group of retired volunteers steps in to provide rides for acute needs and specialty appointments. • In Lexington, Neb., in-town patients can use a local, community-supported bus system that is handicapped accessible, says Roger D. Wells, PA-C, MS, a physician assistant and family medicine specialist at Lexington Regional Health Care. • Patients can sometimes turn to a local employer or family member to get a ride. • Home care may be the best option for some patients. In a growing number of states, PAs and NPs can now certify patients for home health care, so Friedmann makes house calls outside of clinic hours in the evening or on weekends. While those ideas work for some patients, there will always be others who don’t have access to vans or volunteers, buses or bosses. For them, telehealth is a game-changer. Employing Telehealth Telehealth can take care right into patients’ homes, no matter how far away they may be, and it connects urban and rural providers, says Sarah Hohman, deputy director of Government Affairs at the National Association of Rural Health Clinics in Alexandria, Va. There are a wide variety of HIPAA-compliant platforms to choose from. Telehealth also provides access to specialists who aren’t plentiful in rural areas. For example, Eastern Utah Women’s Health collaborates with a mental health clinic to offer telepsychiatry. The facility became the first integrated behavioral and physical health clinic in the state.

Case in point: On Jan. 1, a federal law became effective that allows PAs to get direct Medicare payments, like NPs do, instead of the payments going through an employer. “Our clinic can now get paid directly for necessary lab and EKG services.”

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FEBRUARY/MARCH 2022

3/17/22 11:36 AM

Communication Strategies For patients for whom English is a second language, use plain language when speaking and back it up with written handouts, emails, and texts, advises Danielle Howa Pendergrass, DNP, APRN, WHNP-BC, FAANP, president and clinician at Eastern Utah Women’s Health in Price, Utah. She also uses videos to allow patients to quickly learn and visualize skills such as taking their own blood pressure or using contraceptives. “Return demonstration through role-playing when learning new techniques or synthesizing information is helpful to assess understanding and confidence in a new skill,” she says. Given its large Spanish- and Somali-speaking populations, Lexington Regional Health Care has in-house interpreters for those languages, says Roger D. Wells, PA-C, MS, a physician assistant and family medicine specialist at Lexington Regional Health Care. Computer-assisted interpreters are available for patients with other language requirements. Translation services are becoming more broadly available through telehealth and other technologies. Wells tries to be cognizant of varying cultural care preferences. For example, some patients prefer limited eye contact, some women don’t want their care administered by men, and some people find shaking hands socially inappropriate. “Be honest and upfront with patients,” Wells says. “Tell them that you don’t always understand their needs or preferences. Let them guide you in the social arena, and then discuss their diagnosis and adjust acceptable alternatives for treatments.”

BE HONEST AND UPFRONT WITH PATIENTS. TELL THEM THAT YOU DON’T ALWAYS UNDERSTAND THEIR NEEDS OR PREFERENCES. LET THEM GUIDE YOU. — Roger D. Wells, PA-C, MS Help Less Tech-Savvy Patients Telehealth is only as useful as a patient’s access to it, so Dr. Howa Pendergrass’ clinic partners with local libraries to provide internet access to patients who don’t have it at home. To help patients feel comfortable with using new technology, the clinic uses emails, text messages, and video instructions on how to use any device to “see” a provider. Patients are also encouraged to text or call with questions before a visit. “This decreases anxiety and confusion about using a new service,” Dr. Howa Pendergrass says. “The traditional telephone has worked well for years,” Friedmann adds. “It’s not uncommon for a patient to call and ask whether or

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not they should come in to see me. Sometimes, I can even prescribe systemic treatment in the interim,” saving them a trip. Relationship Building While they are faced with a multitude of challenges, health-care professionals working in rural areas often say that the sense of community makes it all worthwhile. “We care about our patients and we want to make sure they know that,” Dr. Moseley says. That means she takes extra time to make sure her patients know what they need, whether that means writing instructions, walking through the store to show patients the over-the-counter medication she recommends, or helping them find the most affordable medication. “I want every patient to feel like their needs are the most important thing to me at that moment.” C

FEBRUARY/MARCH 2022

3/17/22 11:37 AM

SUPPLEMENT SPOTLIGHT

BY CARRIE ADKINS-ALI

Melatonin Misconceptions Before you recommend melatonin for sleepless patients, consider how it works Most people who have struggled with insomnia have had at least one health-care provider recommend melatonin. But this overthe-counter supplement isn’t a miracle med for all kinds of sleeplessness. Before you recommend it to your patients, consider what this hormone can—and can’t—do. Our bodies already make melatonin. Nestled in the center of the brain, the pineal gland communicates with receptors in the retina to let us know when it’s light or dark. When it senses darkness, it releases high levels of melatonin to prepare us for sleep. When it senses light, it shuts melatonin production down.

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Around age 40, the body begins to produce less melatonin, which can lead to age-related sleep problems. By age 90, melatonin levels are a mere 20% of what they were in the young adult years, notes Cinthya Pena-Orbea, MD, a sleep specialist at the Cleveland Clinic, Ohio. Melatonin Affects Sleep Onset Time Melatonin supplementation is far from a cure-all for insomnia. In fact, studies show that it may shave a mere seven or eight minutes off of the wait to fall asleep and lengthen sleep time by about the same amount. The American College of Physicians’ guidelines strongly recommend the use of cognitive behavioral therapy for insomnia (CBT-I) instead for simple insomnia. But sleep disorders other than simple insomnia are different. Because melatonin

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affects the body’s circadian rhythm, it can help with issues such as delayed sleep phase syndrome, which is when people consistently fall asleep very late and wake up late the next day. It may help shift workers, who often struggle to work at night, when melatonin levels naturally rise, and to sleep during the day, when they fall. Studies suggest, however, that light therapy is more effective for this condition than melatonin supplements (See the article “Seasonal Affective Disorder” at www.ConvenientCareClinician.com to see which light boxes are recommended by Yale Professor Paul Desan, MD.) The strongest case for supplemental melatonin comes from studies on jet lag. Multiple studies show that taking melatonin close to bedtime when you arrive in a different time zone can help reduce jet-lag symptoms.

Cognitive Behavioral Therapy for Insomnia

Dosage There is no general consensus regarding dosage. Melatonin supplements often come in doses of 3 to 5 milligrams (mg), but studies suggest that as little as 0.3 to 0.5 mg per day might be more effective than higher doses in many people. Taking too much of the hormone can cause morning grogginess, headaches, reduced focus, and dizziness, so it’s best to start small and take it about an hour or two before bedtime.

Cognitive behavioral therapy for insomnia helps people with insomnia identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. The therapy has multiple components:

Safety Short-term use of melatonin supplements appears to be safe, but there isn’t enough data to assess long-term safety. Check your patient’s medication list before recommending melatonin: It can interact with other drugs, such as blood thinners, anticonvulsants, some blood pressure medications, and diabetes medications. Melatonin may stay active for a longer time in older people, and it can cause dizziness and drowsiness that can increase the risk of falls. Sleep Recommendations Patients can help their natural—and supplemental—melatonin do its job better with a few simple strategies: • Keep the lights low before bed. Even dim light can interfere with a person’s circadian rhythm and melatonin secretion. • Avoid blue light from computers, smartphones, and tablets for two to three hours before bed. If your patient can’t avoid such devices, they can try using a blue-light filter or an app like F. Lux or Night Shift to adjust the screen to nighttime mode. Compact fluorescent light bulbs and LED bulbs produce more blue light than incandescent bulbs. • Dim red light is the best choice for night lights. • Get exposure to daylight during the morning. Sunlight helps the body produce serotonin, which is the precursor to melatonin. C

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Sleep-hygiene practices that foster and maintain sleep include keeping the bedroom dark and quiet, engaging in regular exercise, and limiting the consumption of caffeine, alcohol, and tobacco.

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Stimulus control therapy trains the brain to associate the bed with sleep or sex and nothing else. It means no working, watching television, or worrying while lying in bed.

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Relaxation training uses practices such as progressive muscle relaxation and diaphragmatic breathing to create a positive state for sleep.

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Cognitive therapy helps identify and challenge incorrect and unhelpful thoughts about sleep, such as: “I know this is going to be a bad night. I won’t feel rested tomorrow. Why can’t I sleep like everyone else?”

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3/17/22 11:38 AM

FOCUS ON GERIATRICS

BY LESLIE GOLDMAN, MPH

Dementia vs. Delirium How to differentiate these copycat conditions Ms. Bell, 83, arrived at the clinic with her daughter, who reported that for the past two days her mother had seemed unusually tired. The night before her clinic visit, the normally talkative senior, who had been diagnosed with dementia a few years prior, didn’t respond when her daughter asked if she knew what day it was and simply stared off into space. After performing a thorough medical history and exam, Ms. Bell’s nurse practitioner suspected worsening dementia. But she was wrong. Had she run a nasal PCR test, she

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would have discovered that Ms. Bell was positive for COVID-19, and the infection was causing delirium, a state of sudden confusion induced by some sort of physical or emotional stressor. Underrecognized Diagnosis Many patients with memory, thinking, language, and behavioral difficulties are misdiagnosed as having dementia,1,2 when delirium is to blame. Delirium is significantly underrecognized, says Carolyn K. Clevenger, DNP, GNP-BC, AGPCNP-BC, FAANP, FGSA, FAAN, a past president of the Gerontological Advanced Practice Nurses Association and clinical director of the Emory Integrated Memory Care Clinic in Atlanta.

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Delirium isn’t a disease, but rather a cluster of symptoms that include trouble maintaining focus and attention, disorientation or impaired judgment, and possible (usually visual) hallucinations.3 These symptoms can manifest when a person has an underlying illness; is dehydrated, recovering from surgery, or taking multiple medications; recently stopped taking a medication;4 or has sensory issues such as low vision or hearing impairment. Delirium is toxic to the brain and increases 12-month mortality risk, which underscores the importance of recognition and intervention, Dr. Clevenger adds. Dig Deeper When patients present with symptoms that could also indicate dementia, health-care providers often don’t look deeper. “Clinicians tend not to look for the underlying cause,” Dr. Clevenger says. “We just think, ‘Oh, they’re older,’ and chalk their confusion up to dementia.” Between 35% and 50% of people ages 85 and older indeed have dementia, she adds, “but the danger zone for clinicians is when we assume it’s 100%. Because even at 50%, that means half those people don’t have dementia.” In fact, there is up to a 40% incidence of delirium among nursing home residents.5 It’s the most common surgical complication among older adults, with a 50% incidence following high-risk operations such as cardiac surgery or hip fracture repair,6 and is the most common presenting symptom in geriatric COVID-19. “Not coughing, not fever,” Dr. Clevenger says, “but delirium.” Though delirium and dementia share several overlapping features, and clinicians frequently use the terms interchangeably, they’re distinct diagnoses, says Bhanu Gogia, MD, a vascular neurology fellow at Harvard Medical School’s Beth Israel Deaconess Medical Center in Boston. “People with dementia are more likely to experience delirium, and age is a predisposing factor for both, but if a known dementia patient … has a new feature,” it makes sense to suspect delirium, Dr. Gogia says. That’s critical, as the condition is linked with substantial rates of cognitive deterioration7 and increased mortality,1 but delirium is actually easily reversed once the underlying cause is diagnosed and treated. Further complicating matters, two types of delirium exist. A quarter of cases are hyperactive, characterized by restless, agitated, stereotypically “delirious” behavior.6 More common, though, is hypoactive, or “quiet,” delirium, like Ms. Bell’s. “That gets missed,” Dr. Clevenger says, with caregivers and clinicians assuming a lethargic patient just “had a rough night and is tired, but that person is just as delirious as the person pulling out their IV.”

ability to think clearly or focus, and performing a brief standardized screening, nurse practitioners, physician assistants, doctors, and other health care providers are in a prime position to correctly spot delirium. Despite the aforementioned parallel symptoms, delirium and dementia—the most common causes of altered mental status in elderly patients5—have discernible differences: Sudden onset. Delirium symptoms appear suddenly, within hours to days,8 and loved ones can typically pinpoint when they began. Dementia has a slow, insidious presentation,9 so

At-a-Glance

Key Distinguishing Features Symptoms of both delirium and dementia can fluctuate, worsening at night.1,11 But fortunately, by paying close attention to a patient’s cognitive status, asking about new changes in the

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Up to half of patients with memory, thinking, language, and behavioral difficulties are misdiagnosed as having dementia, when delirium is to blame.

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By paying close attention to a patient’s cognitive status, asking about new changes in the ability to think clearly or focus, and performing a brief standardized screening, nurse practitioners, physician assistants, doctors, and other health care providers are in a prime position to correctly spot delirium.

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Delirium symptoms appear suddenly, while dementia has a slower, insidious presentation.

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Delirium is characterized by altered awareness, which primarily impacts attention, while dementia is more about deficits in memory, problem solving, and judgment.

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With delirium, intervention should be swift and address the cause. Delirium can often be resolved within hours to days.

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Dementia has no cure, but families and caregivers can take steps to help patients.

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FOCUS ON GERIATRICS

BY LESLIE GOLDMAN, MPH

it’s “hard to put your finger on the moment it started,” Dr. Clevenger explains. Delirium patients’ family members have told her things like: “My mom got lost driving once, but we thought she was just distracted,” or, “There was this one time she put Saran Wrap on the baked potatoes instead of foil. We thought it was strange, but assumed it was because she was cooking in a different kitchen than her own.” Difficulty maintaining attention. Delirium is characterized by altered awareness, which primarily impacts attention, Dr. Gogia says,5 while dementia is more about deficits in memory, problem solving, and judgment. The ability to pay attention may deteriorate in the late stages of dementia, but this occurs slowly and gradually. Different Causes Dementia is a progressive, irreversible neurodegenerative process resulting from the buildup of toxic proteins and other substances in the brain.5 Alzheimer’s disease causes most, but

not all, dementia.2 (Parkinson’s disease is another cause.)10 One in nine people ages 65 and older has Alzheimer’s dementia, but the rates of all-cause dementia are higher.11 Delirium, on the other hand, is a signal that something is amiss healthwise. “It can be your body telling you you’ve had a heart attack, are in kidney failure, have appendicitis, or are hypoxic,” Dr. Clevenger says. Other common culprits include pneumonia, urinary tract infections, dehydration, immobility, sleep deprivation, severe constipation, a history of alcoholism, uncontrolled hyper- or hypothyroidism, vitamin B deficiency, or even the psychological toll of social isolation.13 Prescribed drugs also frequently play a role in delirium, especially those with anticholinergic properties, sedating drugs like benzodiazepines or sleep-promoting drugs with names ending in PM, and narcotic analgesics.6,11 Factors such as these wouldn’t likely cause delirium in a young person with a healthy brain, Dr. Gogia says, but the wear and tear of aging increases susceptibility. Men are more prone to delirium, women to dementia.5,14 Delirium can follow a stroke, with a 2019 Stroke meta-analysis concluding that approximately one in four stroke patients will experience delirium in the acute period.13 Delirium can also develop after the stress of surgery, sometimes called “post-op confusion,” “ICU psychosis,” or “hospital dementia,” says board-certified geriatrician Leslie Kernisan, MD, MPH, a clinical instructor in the division of geriatrics at the University of California, San Francisco. Evaluation Delirium demands an urgent evaluation, Dr. Gogia says, while dementia is more likely to be diagnosed in an outpatient setting and requires a more detailed neurocognitive assessment. Drs. Gogia and Clevenger both note that as part of the history and physical, collecting details from the patient as well as their family and caregivers is invaluable when determining baseline mental and functional status.5 Several validated standardized assessment tools can help differentiate dementia from delirium. “These are going to be your best friend,” Dr. Clevenger says. “It’s not just about clinical judgment.” The MiniCog three-minute assessment can help detect dementia in its early stages. The Confusion Assessment Method is a five-minute screener to aid in delirium diagnosis. Clinicians should also consider the DSM-5 diagnostic criteria for delirium and dementia.5,15

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REFERENCES 1. Fick DM, Hodo DM, Lawrence F, Inouye SK. Recognizing delirium superimposed on dementia. J Gerontol Nurs. 2007;333(2):40-49. 2. Cleveland Clinic. Dementia. Accessed Dec. 13, 2021. https://my.clevelandclinic.org/health/diseases/9170-dementia

Chameleon Conditions

3. Francis J and Young GB. Patient Education: Delirium (Beyond the Basics). Accessed Dec. 13, 2021. https://www.uptodate.com/contents/delirium-beyond-the-basics

If a patient presents with confusion and cognitive impairment, dementia is just one of several possible causes. Any of the following conditions can look like dementia:

5. Gogia B, Frang X. Differentiating delirium versus dementia in the elderly. StatPearls. Accessed Dec. 13, 2021. https://www.ncbi.nlm.nih.gov/books/NBK570594/

4. Lippmann S, Perugula ML. Delirium or dementia? Innov Clin Neurosci. 2016;13(9-10):56-57.

6. Marcantonio E. Delirium in hospitalized older adults. N Engl J Med. 2017;377:1456-1466.

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Delirium

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Depression

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Normal pressure hydrocephalus (an abnormal buildup of fluid in the brain)

8. Brown TM, Boyle MF. Delirium. BMJ. 2002;325(7365):644-647.

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Parathyroid tumors (small, noncancerous tumors that release extra calcium, potentially impacting behavior)

9. Varghese R, Irfan M. Delirium versus dementia: a diagnostic conundrum in clinical practice. ePsychiatric Annals. 2017;47(5). Published online. Accessed Dec. 13, 2021. https://journals.healio.com/doi:10.3928/00485713-20170411-02

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Psychotic disorders (mental disorders characterized by irrational or intense beliefs or suspicions)

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Prion diseases (a group of rare, fatal brain disorders that cause rapidly progressive dementia)

10. Johns Hopkins Medicine. Parkinson’s Disease and Dementia. Accessed Dec. 13, 2021. https://www.hopkinsmedicine. org/health/conditions-and-diseases/parkinsons-disease/ parkinsons-disease-and-dementia

•

Lewy body dementia

7. Gross AL, Jones RN, Habtemariam DA, et al. Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med. 2012;172(17):1324-1331.

11. Alzheimer’s Association. Facts and Figures. Accessed Dec. 13, 2021.https://www.alz.org/alzheimers-dementia/facts-figures 12. Stewart MH, Arora VM. Sleep in hospitalized older adults. Sleep Med Clin. 2018;13(1):127-135. 13. Shaw RC, Walker G, Elliott E, Quinn TJ. Occurrence rate of delirium in acute stroke settings: systematic review and meta-analysis. Stroke. 2019;50(11):3028-3036.

If you suspect delirium, medical, lab (blood and urine), and imaging (brain and chest) tests pinpoint the underlying cause,3 as might a thorough medication review, including any nonprescription drugs, dietary supplements, and alcohol.6

14. Alzheimer’s Association. Women and Alzheimer’s. Accessed December 13, 2021. https://www.alz.org/alzheimers-dementia/ what-is-alzheimers/women-and-alzheimer-s 15. Alagiakrishnan K, Xiong GL. Delirium Clinical Presentation. Medscape. Accessed Dec. 13, 2021. https://emedicine.medscape. com/article/288890-clinical#b4

Treatment With delirium, intervention should be swift and address the cause.4 Delirium can often be resolved within hours to days. In fact, if dehydration is the cause, improvement could be seen in just minutes of drinking a glass of water or juice, Dr. Kernisan says. But sometimes, it can take weeks or longer for cognitive abilities to fully recover.3,16,17 During that time, antipsychotics may be prescribed to manage symptoms.18 Dementia has no cure. “Our goal is to keep the patient safe, support the caregiver, and delay disease progression,” Dr. Clevenger says. Memory-enhancing medications may be prescribed along with an emphasis on maximizing vascular brain health via aerobic exercise and blood pressure management.4 Providing structure to the day and maintaining a warm, welcoming environment can help with both dementia and delirium and may even help prevent delirium from occurring in the first place by minimizing disorientation and offering a sense of reassurance.6 C

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16. Kernisan L. 10 things to know about delirium. Better Health While Aging. Accessed Dec. 13, 2021. https:// betterhealthwhileaging.net/what-is-delirium-10-things-to-know/ 17. Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30-39. 18. Nikooie R, Neufeld K, Oh E, Wilson LM. Antipsychotics for treating delirium in hospitalized adults. Ann Intern Med. 2019 Oct 1;171(7):485-495. 19. Mental Health America. Paranoia and delusional disorders. Accessed Dec. 13, 2021. https://mhanational.org/conditions/ paranoia-and-delusional-disorders 20. Psychotic Disorders. Medline Plus. Accessed Dec. 13, 2021. https://medlineplus.gov/psychoticdisorders.html

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CLINICAL CARE: RESPIRATORY

BY CHRIS ILIADES, MD

Asthma Update New guidelines and studies aim to improve asthma control In 2020, for the first time in 13 years, there was a significant change in asthma-treatment recommendations. The 2020 Focused Updates to the Asthma Guidelines included a new recommendation to replace separate inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) inhalers with a single combination device that would be used daily for both prevention and rescue therapy.1,2 This recommendation was based on multiple studies showing that single maintenance and reliever therapy (SMART) offers better asthma control for patients ages 5 and older with moderate persistent asthma that is not well controlled. Combining asthma medications into a single inhaler is more effective and easier to use.2

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The Promise of Triple Therapy The new guidelines also recommended—for the first time—using a bronchodilator called a long-acting muscarinic antagonist (LAMA) in certain situations.2 Although a LAMA is not a preferred treatment in the current guidelines, there is a growing body of research that suggests it might play a bigger role in future guidelines. That role would be as a third addition to a single inhaler that would include an ICS, LABA, and LAMA for people with moderate to severe asthma.3,4 There have been several trials of this triple therapy. Two studies in 2019, both published in the journal Lancet, have had the most influence: • The TRIMARAN trial included 1,155 adults who had at least one serious asthma exacerbation per year, despite being on a moderate-dose ICS. This was a randomized, double-blind study conducted in 16 countries. Patients

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At-a-Glance

were randomly assigned to receive triple therapy with ICS, LABA, and LAMA in a single inhaler, or a single inhaler with just ICS and LABA. The researchers followed the patients for one year.5 • The TRIGGER study had a similar number of patients and was also international. In this randomized, double-blind trial, patients with at least one severe asthma exacerbation per year despite treatment with a high-dose ICS were randomly assigned to three groups. One group used a single inhaler with ICS and LABA. One group used a single inhaler with ICS and LABA, along with a second LAMA inhaler. The final group used ICS, LABA, and LAMA in a single inhaler.4 In both studies, patients treated with triple therapy had fewer exacerbations, better lung function, and the time between exacerbations was longer than patients in the ICS- and LABA-only group. Triple therapy was the same in the single inhaler group as in the group that added an inhaler for the LAMA.4 In May 2021, a systematic review and meta-analysis published in JAMA confirmed the findings of prior studies comparing

•

The 2020 Focused Updates to the Asthma Guidelines included a new recommendation to replace separate inhaled corticosteroid and long-acting beta-agonist inhalers with a single combination device for both prevention and rescue therapy.

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In the stepwise approach to managing long-term asthma, a step-up in treatment occurs whenever asthma is not well controlled.

•

Triple therapy with a long-acting muscarinic antagonist can reduce asthma exacerbations, improve lung function, and increase the time between exacerbations.

Classes of Asthma Medications 1,2 ABBREVIATION

DRUG TYPE

ACTION

USE

EXAMPLE DRUGS

ICS

inhaled corticosteroid anti-inflammatory

reduces swelling and tightening of the airway

most effective for long-term control

fluticasone (Flovent), budesonide (Pulmicort)

LABA

long-acting beta-agonist bronchodilator

acts through enhancement of 2 receptors, opens airways, and reduces swelling for at least 12 hours

used for moderate to severe asthma, not used alone, may trigger an asthma attack if not combined with an ICS

fluticasone and salmeterol (Advair Diskus); or budesonide and formoterol (Symbicort)

LAMA

long-acting muscarinic antagonist, long-acting bronchodilator

blocks acetylcholine receptors but not used without an ICS

frequently used to treat COPD, but have not been routinely used for asthma

tiotropium bromide (Respimat)

1. US Department of Health and Human Services. National Institutes of Health. Asthma Care Quick Reference: Diagnosing and Managing Asthma. Accessed November 23, 2021. https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf 2. Agusti A, Fabbri L, Lahousse L, Singh D, Papi A. Single inhaler triple therapy (SITT) in asthma: Systematic review and practice implications. Allergy. 2021.doi: 10.1111/all.15076. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/34478578/

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CLINICAL CARE: RESPIRATORY

BY CHRIS ILIADES, MD

triple-drug therapy to current guideline therapy. Canadian researchers led by a team from McMaster University wanted to answer the question: Does adding a LAMA to ICS and LABA improve clinical outcomes in patients with moderate to persistent asthma? They included 20 randomized trials, involving close to 12,000 patients, ranging in ages from 9 to 71.6 They found, with high certainty, a significant reduction of severe exacerbations and better asthma control in the triple-therapy patients compared with the ICS and LABA patients. Adding LAMA did not increase serious adverse events due to treatment. The lead

author of the analysis concluded that the benefit of triple-drug therapy outweighs the risks, and suggested a revision of the current guidelines, noting that optimal control with triple therapy will avoid the use of oral steroids, which have significant side effects, and the use of biologics that are significantly more expensive.3 Different Mechanism of Action In September 2021, the European Journal of Allergy and Clinical Immunology published a systematic review of triple therapy in a single inhaler for uncontrolled asthma in patients treated with an ICS and a LABA. They noted that up to 40% of patients remain uncontrolled despite the use of ICS and LABA.6 Because LAMAs act to block acetylcholine receptors and LABAs act through enhancement of 2 receptors, combination therapy is additive and may be synergistic. The research team reviewed all randomized phase 3 studies comparing triple therapy to other therapy through

Take a Stepwise Approach Picking the best long-term management plan for asthma is complex because it depends on a patient’s age and the severity level of their asthma. The stepwise approach to managing long-term asthma was developed to help guide those decisions. In this approach, a step-up in treatment occurs whenever asthma is not well controlled.1,2 Well-controlled asthma refers to symptoms, nighttime awakenings, or the need for a rescue medication occurring on two or fewer days per week. There should also be no interference with daily activity and no more than one exacerbation requiring systemic corticosteroids per year.1 An asthma exacerbation is defined as progressive worsening of symptoms that include shortness of breath, wheezing, cough, or chest tightness that results in decreased expiratory airflow.2 Step 1 for all ages refers to intermittent asthma, and the preferred treatment is a shortacting beta-agonist (SABA) used as a rescue medication. Steps 2 though 6 apply to persistent asthma that requires daily treatment. In step 2, the preferred treatment for all ages is a low-dose ICS.

Step 3 introduces SMART inhalers with ICS and a LABA as the preferred treatment. The guidelines vary by age, but for ages 12 and over, step 3 includes a low-dose ICS and LABA or a medium-dose ICS. Step 4 employs a medium-dose ICS and a LABA.

Step 5 moves to a high-dose ICS and LABA, and consideration of the oral biologic omalizumab (Xolair) for patients with allergies. Step 6 includes a high-dose ICS and LABA, as well as oral steroids or omalizumab for patients with allergies.

1. U.S. Department of Health and Human Services. National Institutes of Health. Asthma Care Quick Reference: Diagnosing and Managing Asthma. Accessed November 23, 2021. https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf 2. U.S. Department of Health and Human Services. National Institutes of Health. 2020 Focused Updates to the Asthma Management Guidelines: Clinician’s Guide. Accessed November 23, 2021. https://www.nhlbi.nih.gov/sites/default/files/ publications/AsthmaCliniciansGuideDesign-508.pdf

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February 2021, including the TRIMARAN, TRIGGER, and 27 other studies.6 They concluded that triple therapy is a safe and effective alternative for patients with uncontrolled asthma.

REFERENCE 1. US Department of Health and Human Services. National Institutes of Health. Asthma Care Quick Reference: Diagnosing and Managing Asthma. Accessed November 23, 2021. https://www.nhlbi.nih.gov/files/docs/guidelines/ asthma_qrg.pdf

Better Medication Compliance The researchers also commented that triple therapy may help patients comply with their treatment because it reduces the number of inhaler devices and instructions. This may eliminate confusion and reduce dosing and handling errors. This is a significant advantage because studies show that 50% to 75% of asthma patients fail to take their medications as directed. They concluded that the optimum place for triple therapy needs to be properly established within the existing guidelines.6

2. US Department of Health and Human Services. National Institutes of Health. 2020 Focused Updates to the Asthma Management Guidelines: Clinician’s Guide. Accessed November 23, 2021. https://www.nhlbi.nih.gov/sites/default/ files/publications/AsthmaCliniciansGuideDesign-508.pdf 3. Kim LHY, Saleh C, Whalen-Browne A, O’Byrne PM, Chu DK. Triple vs dual inhaler therapy and asthma outcomes in moderate to severe asthma. JAMA. 2021;325(24):2466-2479. DOI: 10.1001/jama.2021.7872. 4. Haley K. Triple therapy helps control severe asthma. Harvard Health. Accessed November 23, 2021. https://www.health.harvard.edu/blog/ triple-therapy-helps-control-severe-asthma-2020090220851

Current Guidelines and LAMA For now, the recommendation is to consider adding a LAMA to ICS if asthma is not controlled by ICS alone and a LABA is not tolerated. Although it is not a preferred treatment, the guidelines say that if a patient is not controlled with ICS and LABA, triple therapy is conditionally recommended as an option. Current guidelines say that triple therapy may offer a small potential benefit. The guidelines do not recommend adding LAMA for anyone under age 12, and LAMA should not be used for anyone at risk of urinary retention or with a diagnosis of glaucoma.1,2 C

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5. Mayo Clinic. Asthma Medications: Know your options. Accessed November 23, 2021. https://www.mayoclinic.org/ diseases-conditions/asthma/in-depth/asthma-medications/ art-20045557 6. Agusti A, Fabbri L, Lahousse L, Singh D, Papi A. Single inhaler triple therapy (SITT) in asthma: Systematic review and practice implications. Allergy. 2021.doi: 10.1111/all.15076. Online ahead of print. https://pubmed.ncbi.nlm.nih. gov/34478578/

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3/17/22 11:47 AM

CLINICAL CARE: SEXUAL HEALTH

BY CHRIS ILIADES, MD

Free Continuing Education The Convenient Care Association and DKBMed are offering three accredited activities on HIV management. Get the link at https://convenientcareclinician.com/ continuing-medical-education

Sexually Transmitted Infections A guide to clinical diagnosis and treatment STIs are caused by infectious bacteria, viruses, or parasites that are passed from person to person through oral, anal, or vaginal sexual contact. Common signs and symptoms allow clinical diagnosis and may include genital lesions, pain, dysuria, discharge, odors, bleeding, dyspareunia, lymphadenopathy, fever, and rash.1,2 Risk factors common to most STIs include unprotected sex, sex with multiple partners, a past history of STIs, and drug or alcohol abuse.3

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If left untreated, STIs can pass from mothers to infants, and they can cause pregnancy complications, pelvic inflammatory disease (PID), and infertility. Human papillomavirus (HPV) may be a cause of cervical cancers and oropharyngeal cancers.1,2 Fortunately, these complications can be prevented by early diagnosis and treatment. Knowing the presenting signs and symptoms of common STIs is the key to ordering the right diagnostic tests (blood tests, urine tests, and swab tests) and starting treatment.1,2 According to the World Health Organization, there are more than 30 different STIs, but the most common and important ones

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that can be diagnosed by their clinical presentation are chlamydia, gonorrhea, syphilis, HPV, genital herpes, and trichomoniasis.4 Human immunodeficiency virus (HIV) and hepatitis B can also be sexually transmitted, but they do not cause diagnostic genital signs and symptoms. Chlamydia Chlamydia, the most commonly reported STI in the United States, is caused by the bacterium Chlamydia trachomatis. It can be passed through oral, anal, or vaginal contact. This STI is reportable to the Centers for Disease Control and Prevention (CDC).1,2,5 Signs and symptoms may develop one to three weeks after exposure. In women, they include vaginal discharge, abnormal vaginal bleeding, lower pelvic pain, and frequent dysuria. If systemic infection occurs, there may be fever, abdominal pain, nausea, and fatigue. There may be lower abdominal or adnexal tenderness. On pelvic exam, mucopurulent inflammation and tenderness of the cervix may be found.1,2,5 In men, signs and symptoms may include testicular pain and tenderness. On rectal exam, there may be rectal pain or prostate pain.1 Diagnosis. The recommended diagnostic test is the nucleic acid amplification test (NAAT) which is obtained with a clean catch urine sample, vaginal swab, or urethral swab in men. The NAAT detects the RNA or DNA of an infecting organism and can be obtained from urine or from secretions swabbed from the site of infection.1 The CDC recommends yearly testing for sexually active women up to age 25. Treatment. The recommended treatment is a single, one-gram dose of azithromycin orally or 100 mg of oral doxycycline for seven days.1 Sexual partners should be tested. Sexual contact should be avoided until treatment is complete and there are no signs or symptoms. This infection has a high recurrence rate, so retesting at three to four months is advisable.2,5 Complications from untreated Chlamydia include pelvic inflammatory disease in women and prostatitis in men.1,2,5 Gonorrhea Gonorrhea is caused by the gram-negative bacterium Neisseria gonorrhoeae. It is the second most commonly reported STI in the United States. Gonorrhea infects the mucous membranes of the cervix, uterus, fallopian tubes, and urethra in women. In men, it invades the urethra. In men and women, it may invade the mouth, throat, and rectum.1 Signs and symptoms may develop one to 14 days after sexual contact. In women, they may include urinary frequency, urgency, and dysuria. Pelvic pain and vaginal bleeding may occur. There may also be pruritis of the vagina. Pelvic exam may show mucopurulent discharge in the vagina and inflammation of the cervix.1,2 Symptoms in men may include dysuria and testicular, rectal, or

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At-a-Glance •

There are more than 30 different STIs, but the most common and important ones that can be diagnosed by their clinical presentation are chlamydia, gonorrhea, syphilis, human papillomavirus, genital herpes, and trichomoniasis.

•

HIV and hepatitis B can also be sexually transmitted, but they do not cause diagnostic genital signs and symptoms.

•

Complications can be prevented by early diagnosis and treatment.

prostate pain. Signs may include testicular tenderness, meatal discharge, and tenderness of the rectum or prostate. Discharge may be white, yellow, or green.1,2 Diagnosis. The recommended diagnostic test is the NAAT from vulvovaginal or endocervical swabs in women, and urethral swab or first catch urine samples in men.1 Treatment. The recommended treatment is the third-generation cephalosporin ceftriaxone, given as 250 mg IM injection and one gram azithromycin orally.1 Sexual partners should be tested. The CDC recommends yearly testing for women under age 25. Reinfection is common, so retesting in three months is recommended. Sexual contact should be avoided until signs and symptoms have stopped.2 Complications from untreated gonorrhea in women include PID and infertility. Infection can spread to a baby in the birth canal.1,2 Syphilis Syphilis is caused by the spirochete Treponema pallidum. It is the third most reported STI, and the incidence has been increasing. Syphilis is most common in men who have sex with men. This STI

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CLINICAL CARE: SEXUAL HEALTH

BY CHRIS ILIADES, MD

occurs through direct sexual contact with an open sore, called a chancre. Syphilis can be spread through oral, anal, or vaginal contact, and a pregnant woman can spread this disease to an unborn child.1,2 Signs and symptoms. Syphilis has three stages. Signs and symptoms of the first or primary stage can occur from 10 to 90 days after contact. The classic sign is the chancre, which is a painless, raised, circular, and firm lesion. In some cases, there may be more than one. Typical locations are the genital and anal areas. The chancre will heal without treatment in three to six weeks.1,2 Untreated primary syphilis develops into a secondary stage, which may occur after the chancre heals or during healing. The classic signs are a rash and wart-like lesions. The rash does not itch and appears as a rough, brown to red rash on the palmar surfaces of the hands and feet. Raised, white to gray, wartlike lesions may appear in moist areas under the arms, in the groin, or inside the mouth. These are called condyloma lata. There may also be sores in the mouth, vagina, or anus. Some other symptoms of this stage are fever, swollen lymph nodes, sore throat, headache, and fatigue. Untreated secondary syphilis may go into a latent stage without signs or symptoms that can last for years.1,2

The final, tertiary stage of syphilis is rare, but potentially fatal, and can include a wide range of symptoms due to brain, nerve, eye, heart, liver, bone, and joint damage.1,2 Diagnosis of syphilis usually starts with treponemal serum tests to detect antibodies to T pallidum proteins. These include the fluorescent treponemal antibody absorption test (FTA-ABS), Treponema pallidum particle agglutination test (TP-PA), and various rapid treponemal assays. Two other common tests are the rapid plasma reagent (RPR) and the venereal disease research laboratory (VDRL) tests. If these tests are positive, further testing with treponoma serum tests is needed. All pregnant women should be tested for syphilis according to pregnancy screening guidelines.1,2 Treatment. The recommended treatment for primary, secondary, and early latent syphilis is penicillin G, 2.4 million units given in a single IM injection. Neurosyphilis and tertiary syphilis require higher doses given at multiple dose intervals.1 HPV HPV is a DNA virus that infects the squamous epithelial cells of the mouth, vagina, penis, and perineum. It is the most common unreported STI and is often asymptomatic. HPV may infect up to 80% of sexually active people at some time. In 70% to 90% of these infections, the virus is cleared by the immune system. There are many types of HPV, but only four types commonly cause disease. Types 6 and 11 cause wart-like growths of the external genital, perineal, and perianal areas in men and women. Types 16 and 18 are oncogenic and may cause cervical, vulval, penile, or esophageal cancer many years after infection.1,2 Signs and symptoms of types 6 and 11 are raised, cauliflower-like growths called condylomata acuminata.

Screening and Prevention Many people with STIs do not have signs or symptoms, but they may still have complications, be contagious to their sexual partners, and be in danger of mother-to-child transmission. Having an asymptomatic or undiagnosed STI triples the risk of acquiring HIV. Asymptomatic HPV is a leading cause of cervical cancer. These facts point to the importance of screening and prevention.1-4 CDC screening guidelines are available for chlamydia, gonorrhea, syphilis, herpes, trichomoniasis, HPV, and hepatitis B. You can find the guidelines at https://www.cdc.gov/std/treatment-guidelines/screeningrecommendations.htm. Vaccines can prevent only hepatitis B and HPV. Other STIs are prevented through education and counseling. The key preventive strategies are abstinence, mutual monogamy, limiting the number of sexual partners, and correct use of a male, latex condom for all vaginal, oral, or anal sexual activity.2

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Diagnosis and treatment. There is no antiviral medication to treat HPV and diagnostic tests are not necessary. The presence of condylomata is diagnostic. HPV is prevented by vaccination, which is recommended by the CDC for boys and girls ages 11 to 12 or up to age 26. Vaccination is also an option for men and women ages 27 through 45.1,2 Genital Herpes Both herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) can cause genital herpes. HSV-1 also causes orolabial cold sores. HSV-2 is the more common cause of genital herpes. About 12% of people ages 14 to 49 have HSV-2 infections, and these infections are twice as common in women. HSV infections occur as primary and reactivation infections. After the primary infection, the virus may become latent in nerve cells and commonly reactivates.1,2,6 This virus spreads during contact with an active lesion, either directly or through contact with oral or genital secretions. HSV-2 usually causes genital herpes during vaginal or anal sex. HSV-1 may cause genital herpes during oral sex. Primary infection may follow sexual contact in two to 12 days.1,2,6 Signs and symptoms of primary genital herpes infection are a cluster of tiny vesicles that open and cause burning pain. Vesicles may appear in the genitals of both men and women as well as on the thighs or buttocks. Painful lesions may last for two to four weeks during a primary or “breakout” infection. Along with these lesions, a primary infection may also cause systemic symptoms like fatigue, headache, and lymphadenopathy.1,2,6 Reactivation infections may have prodromal symptoms of itching, tingling, or burning before the appearance of vesicles. Reactivation infections tend to be shorter, less symptomatic, and less contagious than primary infections.1,2,6 Diagnosis. The most reliable diagnostic test is the NAAT. Viral cultures may also be done as well as serology for HSV antibody testing. Serologic testing is not recommended for screening because it does not distinguish between HSV-1 and 2 infections. There is no vaccine available. Treatment. HSV responds to antiviral medications, which can suppress infections but do not cure the disease. Common medications are acyclovir and valacyclovir. Primary infections should be treated, and reactivations may be treated when prodromal symptoms occur. People who have frequent reactivations may be treated with daily suppressive therapy. Patients should be told to avoid sexual contact during an active infection.1,2,6 Complications. HSV-2 can be spread to a newborn during vaginal delivery. Neonatal herpes can be a severe infection. Women with a history of HSV-2 should be closely monitored or treated during pregnancy. An active vaginal infection during labor may be an indication for cesarean section.2,6

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Trichomoniasis Trichomoniasis is a parasitic infection caused by a single-cell anaerobic protozoan. It causes microulcerations on mucosal surfaces of the vagina, cervix, and urethra in women and in the urethra of men. This infection usually only spreads through penile or vaginal contact. It is more common in women.1 Signs and symptoms may start from five to 28 days after contact. In women, the classic sign is a thin, discolored vaginal discharge with a foul, “fishy” odor. There may be slight vaginal bleeding seen as spotting. Common symptoms are burning pain on urination and painful sexual intercourse. On pelvic exam, the cervix may have a swollen and inflamed appearance called “strawberry cervix.” Men do not usually have any visible signs of infection. They may have a slight urethral discharge. Symptoms are dysuria and testicular pain. On physical exam the testicles may be tender and on rectal exam, there may be prostate tenderness.1,2 Diagnosis of this STI is with the NAAT swabbed from the urethra, vagina, cervix, or from a urine sample. A wet-mount slide will show motile flagellated protozoa. Treatment. Trichomonas is curable with metronidazole or tinidazole. Metronidazole can be given as a single 2-gram oral dose or as 500 mg BID for seven days. Tinidazole is a single 2-gram oral dose.1 Although this STI is curable, it recurs within three months in about 20 percent of cases. All sexual partners should be notified and treated. Reexamination in three months is recommended.2 C

REFERENCES 1. Garcia MR, Wray A. Sexually Transmitted Infections. StatPearls. National Library of Medicine, National Institutes of Health. July 2021. Accessed Dec. 9, 2021. https://www. ncbi.nlm.nih.gov/books/NBK560808 2. Centers for Disease Control and Prevention. STI Treatment Guidelines. Accessed Dec. 9, 2021. https://www.cdc.gov/std/ default.htm 3. Mayo Clinic. Sexually transmitted disease symptoms. Accessed Dec. 9, 2021. https://www.mayoclinic.org/diseasesconditions/sexually-transmitted-diseases-stds/in-depth/ std-symptoms/art-20047081 4. World Health Organization. Sexually transmitted infections. Nov. 22, 2021. Accessed Dec. 9, 2021. https://www.who.int/news-room/fact-sheets/detail/ sexually-transmitted-infections-(stis) 5. American Sexual Health Association. Chlamydia fast facts. Accessed Dec. 9, 2021. https://www.ashasexualhealth.org/ chlamydia-101/ 6. Mayo Clinic. Genital herpes. Accessed Dec. 9, 2021. https://www.ashasexualhealth.org/chlamydia-101/

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SEASONAL SPOTLIGHT

BY BILL GOTTLIEB

Flu Care Why was the flu a no-show last year, and how can we keep it from coming back? The COVID-19 pandemic has revolutionized our understanding and experience of viral infections of the respiratory system, including infection by the influenza virus, says Neil Schachter, MD, a pulmonologist and medical director of pulmonary rehabilitation at the Mount Sinai — National Jewish Health Respiratory Institute in New York City and the author of The Good Doctor’s Guide to Colds and Flu. Last year, for example, there was virtually no flu season. Typically, flu season lasts from October to April, with the official charts that track flu rates showing a huge statistical bump in the middle of winter and then a subsequent decline. But from October 2020, to April 2021, there was no bump whatsoever, domestically or internationally, says Dr. Schachter.

Why was the flu a no-show last year, and how can we keep it from coming back? Masks and Social Distancing “There is no definitive scientific proof that social distancing, masks and other pandemic-based preventive measures contributed to or were the major players in preventing the flu, but … this is probably what happened,” says Dr. Schachter. He explains that since the influenza virus, like COVID-19, can be spread via airborne transmission, it’s unsurprising that the flu “can be mitigated by the same protective barriers, such as masks, and by social distancing.” So, the most important advice to give patients for preventing the flu is the same advice as for preventing COVID-19: Wear a mask, practice social distancing, wash your hands frequently, and don’t touch your face.

At-a-Glance •

To prevent the flu, patients (and clinicians) should mask up, practice social distancing, wash their hands frequently, and avoid touching the face.

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With rare exceptions, everyone ages 6 months and older should get a flu vaccine early in the season every year.

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There are four antiviral drugs that are FDA-approved for the treatment of influenza.

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A variety of over-the-counter products can ease symptoms and make patients more comfortable.

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Vaccination: Yearly and Early Equally important for prevention is getting the yearly influenza vaccine. The Centers for Disease Control and Prevention (CDC) advise that, with rare exceptions, everyone ages 6 months and older be vaccinated.1 “The flu virus changes yearly, and vaccines are carefully formulated every year to provide protection against the most common and current strains,” says Jay Woody, MD, chief medical officer of Intuitive Health and co-founder of Legacy ER & Urgent Care, the first retail-based joint emergency room and urgent care center. “This means the vaccine [a patient] got last year isn’t necessarily going to be effective this year — which is why it’s important to get a flu shot every year.” Moreover, patients should get their annual influenza vaccinations as early in the flu season as possible. The flu vaccine takes up to three weeks to reach maximum efficiency, says Dr. Woody. There are nine different influenza vaccines this year, and all are “quadrivalent,” containing four types of influenza viruses that have been earmarked by the CDC as the most likely sources of flu infection this year. A table with all nine vaccines and their indications is available at the official CDC website. Some influenza vaccines might be more appropriate for a particular patient than others. • For instance, most vaccines are manufactured using eggbased technology, but there are two egg-free vaccines for patients with egg allergies: Flucelvax Quadrivalent (Influenza Vaccine; Seqirus) and Flublock Quadrivalent (Influenza Vaccine; Sanofi Pasteur). • For patients who are afraid of needles, there’s a vaccine called FluMist (Influenza Vaccine, live, intranasal; AstraZeneca) that’s administered by nasal absorption. • Patients over age 65 should consider a high-dose vaccine, such as Fluzone High-Dose Quadrivalent (Influenza Vaccine; Sanofi Pasteur).

Relieving Flu Symptoms Symptoms of the flu include fever, chills, coughing, chest discomfort, sore throat, a stuffy or runny nose, muscle aches (particularly in the back and legs), fatigue, and headaches. If an infected patient wants to feel a little better while the flu runs its course, there are many over-the-counter medications that can help reduce their symptoms:

Still Some Risk Be sure to let your patients know that getting vaccinated against the flu does not provide them with total immunity: The vaccines are only 40% to 60% effective, so patients should still follow other preventive measures once vaccinated. The flu virus is a much older virus than COVIID -19 and has had many more generations to evolve to evade the human immune system, explains Dr. Schachter. “The flu vaccine, along with social distancing and masks, are the best ways of protecting against the flu.”

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For fever, aches, and general fatigue: Patients can take acetaminophen or ibuprofen (whatever works best for the patient at the onset of flu symptoms. Patients can continue taking the chosen medication every four to six hours (follow the dosage instructions on the label) for the next four to five days. Aspirin should not be used for children and young adults under age 20 because of the possible complication of Reye’s syndrome, a rare but often fatal complication of the use of aspirin and related compounds in this age group.

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For coughing and sore throat: Lozenges with benzocaine can quiet the cough reflex and soothe throat pain.

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For sneezing and congestion: Patients can take a traditional antihistamine twice a day. The sedation that often accompanies antihistamines shouldn’t prove problematic if the patient feels too sick to work or play. Congestion can also be alleviated with a decongestant spray, but the spray should be used no longer than three days to avoid rebound congestion. Older individuals and people with hypertension or cardiovascular disease should avoid decongestants altogether.

Patients who are interested in home remedies can consider supplementing their diet with vitamin C, zinc lozenges, or the herbal remedy echinacea. Some studies suggest these remedies lessen flu symptoms and decrease the duration of the infection; however, other studies don’t, so results may be mixed.

Antiviral Medications If a patient does get the flu, there are four antiviral drugs that are FDA-approved for the treatment of influenza: peramivir (Rapivab; BioCryst Pharmaceuticals), zanamivir (Relenza;

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SEASONAL SPOTLIGHT

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GlaxoSmithKline), oseltamivir phosphate (Tamiflu; Hoffmann-La Roche Inc.), and baloxavir marboxil (Xofluza; Genentech). Dr. Schachter says all four are best used in the first two or three days after the onset of flu symptoms, and also offers some drug-specific notes: • Rapivab is administered intravenously in a one-time dose. • Relenza is a nasal spray that’s taken for five days. It shouldn’t be given to people with chronic lung disease because it irritates the airway and can cause exacerbation. • Tamiflu is a pill that’s taken for five days. • Xofluza is a pill that’s taken only for one to two days, but as the most recently approved of the four drugs, it doesn’t yet have extensive clinical documentation. If a patient is at high risk for developing complications from the flu (e.g., if they live in a nursing home, are immunocompromised, or have a cardiorespiratory ailment), the antiviral drugs can be given preventively.

How to Talk to the Vaccine-Hesitant Now, more than ever, you’re likely to meet patients who don’t want to be vaccinated for the flu. Stacia Hays, DNP, a pediatric nurse practitioner in Gainesville, Fla., and an associate professor at Baylor University’s Louise Herrington School of Nursing in Waco, Texas, shares her strategy: “My job as a provider is to support the patient, to arm them with the facts, and let them make their decision. If they don’t want to get the flu shot, they don’t have to, but I’ll continue to have conversations with them. “An experience I often share with vaccine-hesitant patients and families is that of a 15-year-old who wasn’t vaccinated for the flu. She contracted influenza and her symptoms were so severe she required a lung bypass machine. She barely survived. She now suffers from chronic lung damage. I don’t tell that story to scare the patient or make them change their mind about vaccination. But I want them to have a real picture of the dangers and the downsides — for themselves and for their children — so they can make an informed choice.”

Complications: Bronchitis and Pneumonia Three out of five people who get the flu develop acute bronchitis, says Dr. Schachter. People who have asthma or another chronic lung disease, or who are routinely exposed to air pollution or cigarette smoke, are at particular risk. In a typical case of the flu, the fever, sore throat, and body aches start to go away after three days. If, after three days or so, the patient develops a burning chest pain and their coughing becomes more severe, they may have acute viral bronchitis. If the patient produces green mucus or their fever is 101oF or higher, they might also have a bacterial infection and may need to take antibiotics. If a patient experiences serious shortness of breath, they may have developed viral pneumonia and should go to the emergency room. This is particularly important for young children and the elderly, who are most vulnerable to pneumonia. C

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REFERENCE 1. Centers for Disease Control and Prevention. Influenza Vaccination: A Summary for Clinicians. Accessed Jan. 12, 2022. https://www.cdc.gov/flu/professionals/vaccination/vaxsummary.htm

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BY CARRIE ADKINS-ALI

MINUTES WITH ... Kristene Diggins, DNP, FAANP, MBA, CNE, NEA-BC, a clinical investigator provider with CVS Minute Clinic and an adjunct DNP faculty member for Purdue Global University What led you to convenient care? Kristene Diggins: I was drawn to convenient care in 2006 when I worked overseas as a volunteer NP. I worked in an autonomous setting where I cared for patients with malaria, tuberculosis, and other tropical ailments. My support system was completely virtual. I enjoyed working directly in the community, where I felt people’s needs most acutely. When my husband and I decided to move back to the United States, I searched for opportunities that would allow me to work directly in a community, with the virtual support of collaborating physicians and other professionals readily available. I found CVS MinuteClinic through a Google search. Back then, CVS had only a few clinics in a handful of states, but they happened to have a clinic in Charlotte, North Carolina, where we were moving. The rest is history! What inspires you at work? Outside of work? KD: I am inspired to teach, mentor, and support others in health-care professions like nursing. I have worked as an adjunct NP faculty member at Liberty University and the University of Phoenix for many years, and I am invigorated by the relationships I build while mentoring. My faith is probably my greatest inspiration, leading me to believe in the best in people and always see hope in difficult situations. Consequently, I enjoy volunteering in our local free community clinic and serving as a mentor. My family is my anchor. My husband and I have been married for 30 years, and we have two grown sons. One son is in medical school, and the other is a biomedical engineer. I’m very inspired by their love of learning. What is your favorite challenge in the clinic? KD: I love the challenge of helping a customer or patient who’s upset. I appreciate that the health-care system and its attendant inconveniences can create a sense of frustration in patients before they even reach our clinic’s doors. The challenge for me is to de-escalate their mindset and help them have an experience that renews their belief in the existence of clinicians who care. What excites you about the future of the industry? KD: The future of this industry is evolving rapidly. Just when I think I understand where we’re going, we take a turn that is broader than I anticipated. I think the future of the industry is to keep meeting patients where they are in their communities. While the services and the focus of the care we provide may change, we’ll continually adapt to best serve the needs of our patients, whether that means primary care, acute care, or health promotion. We will care for the community one patient at a time. Is there a book that you think all convenient care clinicians should read? KD: There are many great books out there on care-delivery models that would help each clinician in the industry maximize the unique value they bring to their communities. I recommend Convenient Care Clinics: The Essential Guide to Retail Clinics for Clinicians, Managers, and Educators (1st Edition), by Joshua Riff, MD, MBA, FACEP; Sandra Ryan, MSN, RN, CPNP, FCPP, FAANP; Tine Hansen-Turton, MGA, JD, FCPP, FAAN; and Caroline Ridgway, JD. C

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