Spring 2015 (April-June)

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician April-June 2015 Volume 34, Issue 2

Direct Primary Care Stay current on DPC legislation page 12 Advocacy Day Recap Legislative progress page 14 67th Annual Scientific Assembly Register today and save page 25 2015 Family Physician of the Year Meet the Nominees page 22 2015 Match Results page 19

Connect with MAFP on Twitter and Facebook Visit us online at www.mo-afp.org

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WHERE HEALTH IS PRIMARY. Long-term relationships between doctors and patients build trust and lead to better outcomes.

Family doctors work with their patients throughout their lives.

We want to give all patients access to this kind of continuing care.

Let’s make health primary in America.

Learn more at healthisprimary.org.

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MAFP

executive commission Board Chair - Bill Fish, MD, FAAFP (Lake Ozark) President - Daniel Purdom, MD, FAAFP (Independence) President-elect - Peter J. Koopman, MD, FAAFP (Columbia) Vice President - Kathleen Eubanks-Meng, DO (Blue Springs) Secretary/Treasurer - James Stevermer, MD, FAAFP (Fulton) board of directors District 1

District 2

District 3

District 4

District 5

District 6

District 7

District 8

District 9

District 10

Director: Dana Granberg, MD, FAAFP (Kansas City) Alternate: Jared Dirks, MD (Kansas City) Director: Lisa Mayes, DO (Macon) Alternate: Carrie Peecher, DO (Unionville) Director: David Schneider, MD, FAAFP (St. Louis) Director: Caroline Rudnick, MD (St. Louis) Alternate: Sarah Cole, DO, FAAFP (St. Louis) Director: Jennifer Scheer, MD, FAAFP (Gerald) Alternate: Kristin Weidle, MD (Washington) Director: Lucas Buffaloe, MD (Columbia) Alternate: Afsheen Patel, MD (Jefferson City) Director: Jamie Ulbrich, MD, FAAFP (Marshall) Alternate: David Pulliam, DO, FAAFP (Higginsville) Director: Sudeep Ross, MD (Kansas City) Director: Wael Mourad, MD (Kansas City) Alternate: Ryan Sears, DO (Lee's Summit) Director: Mark Woods, MD (Ozark) Director: John Paulson, DO, PhD, FAAFP (Webb City) Alternate: Charlie Rasmussen, DO, FAAFP (Branson) Director: Patricia Benoist, MD (Houston) Alternate: Vacant Director: Mark Schabbing, MD (Perryville) Alternate: Steven Douglas, MD (East Prarie)

resident directors Betsy Wan, MD (SLU) Kevin Gray, MD (Alternate) (UMKC) student directors Sarah Williams (MU) Jenny Eichhorn (Alternate) (UMKC) aafp delegates Larry Rues, MD, FAAFP (Kansas City) Bruce Preston, MD, FAAFP (West Plains) Darryl Nelson, MD, FAAFP (Alternate) (Lee's Summit) Keith Ratcliff, MD, FAAFP (Alternate) (Washington) mafp staff Executive Director - Kathy Pabst, MBA Member Services/Managing Editor - Sarah Mengwasser Missouri Academy of Family Physicians 722 West High Street Jefferson City, Mo 65101 p 573.635.0830 f 573.635.0148 www.mo-afp.org office@mo-afp.org

MARK YOUR CALENDAR AAFP Annual Chapter Leadership Forum/ National Conference of Constituencies Leaders (formerly ALF/NCSC) April 30-May 2, 2015 Sheraton Kansas City Hotel at Crown Center Kansas City, Mo

AAFP Congress of Delegates September 28-October 3, 2015 Hyatt Regency Denver, Co AAFP Annual Assembly September 29-October 3, 2015 Hyatt Regency Denver, Co

AAFP Family Medicine Congressional Conference May 12-13, 2015 Renaissance Downtown Hotel Washington, D.C. MAFP 67th Annual Scientific Assembly Register

by May June 5-6, 2015 5th to save $5 The Lodge at Old Kinderhook 0!

Camdenton, Mo (Board Meeting)

MAFP 23rd Annual Fall Conference & SAM Working Group November 6-8, 2015 Big Cedar Lodge Ridgedale, Mo (Board Meeting)

AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 30-August 1, 2015 Kansas City Convention Center Kansas City, Mo

INSIDE THIS ISSUE 4

The Future is Looking Bright

5

Help Desk Answers

2 Health is Primary

Resident Case Studies

5 FPIN

7

Everest Foundation Donation

6 ProAssurance

8

Evaluation of Early Pregnancy Bleeding

11 Community Health Center of Central Missouri 18 SLP Inc.

Bill Fish, MD, FAAFP

Wael Mourad, MD

12 Independent MD, A Leader in DPC Michael Wulfers, MD, FAAFP

13 Direct Primary Care Legislation 14 Advocacy Day Recap

Advertisements

20 Southeast Health 21 Results Billing Service 22 MPM-PPIA 23 AAFP National Conference

15 DPC Hearings

29 MHPPS

16 Members in the News

32 Children's Mercy - Kansas City

19 The Match 22 2015 Family Physician of the Year Nominees 25 Register for ASA 26 Indicators of and Screening for Obstructive Sleep Apnea 28 STL & KC Officer Installations 29 Top Ten Award Recipient 31 Annual Business Meeting Notice Donate to MAFP PAC

Missouri Family Physician April-June 2015

3

MAFP Board Chair Report

"

the future is looking bright

T

Bill Fish, MD, FAAFP MAFP Board chair

he board and our membership have been busy in this legislative session working on many recurring issues such as tort reform and some new issues such as Direct Primary Care legislation. I would like to thank our advocacy chairs, Keith Ratcliff and Jamie Ulbrich, our lobbyist Pat Strader, the members of the advocacy commission and especially those physicians who have traveled to Jefferson City to testify on behalf of the MAFP. I also thank our MAFP professional staff who provide organizational support for our advocacy efforts.

I certainly hope by the time you read this we have achieved some type of limit on awards for non-economic damages in medical liability cases.

We simply lose too many physicians to other states in our current climate.

It has been refreshing to see the excitement physicians (and their patients) have displayed during testimony in support of Direct Primary Care. While not a choice for every physician, this practice style offers physicians who have been worn down by administrative headaches in the more traditional practice setting an option for them and for their patients.

I attended the meeting of the St. Louis Chapter of the MAFP in January and had the pleasure of installing their new officers. They are a vibrant group and their members have been active in all aspects of the state organization, being well represented on our advocacy, education and executive commissions.

Based on our director structure on the board, we also have good representation from all other areas of the state. The executive commission strives to have every practice type represented on the board. We have physicians in independent practice, employed physicians, physicians moving to direct primary care, physicians from academia, special constituency members, as well as student and resident members.

4 Missouri Family Physician April-June 2015

It has been refreshing to see the excitement physicians (and their patients) have displayed during testimony in support of Direct Primary Care.�

If you feel your particular issues are going unaddressed or your style of practice is underrepresented, please contact myself, your Executive Director, Kathy Pabst, or any board member to discuss your concerns.

The attendance at Advocacy Day by our members, including students and residents, at the Capitol give me great confidence in our specialty's future in the state.

Enjoy your spring and summer. I look forward to seeing you at our summer scientific meeting where our education commission plans for great CME opportunities in a wonderful environment at Old Kinderhook.

HDAs HelpDesk Answers

do cranberry products reduce the risk of urinary tract infections?

Evidence-Based Answer Cranberry products likely do not prevent urinary tract infections (UTI). Although some small studies and subgroup analyses suggest cranberry products may reduce the risk of UTI for specific subgroups, the combined evidence does not find a convincing benefit (SOR: B, inconsistent results from systematic reviews of randomized, controlled trials).

A

Cochrane systematic review regarding use of cranberry products for UTI prevention was updated in 2012.1 The review included 24 RCTs with a total of 4,473 patients comparing varying dosages of cranberry products (juice, capsules, tablets, concentrate/syrup or combination) taken for at least one month to placebo, antibiotic prophylaxis, water, or no treatment for prevention of UTI (based on symptoms and/or urine culture) in susceptible populations. The majority of trials using placebo or water matched the amount and frequency to that of the cranberry product. Studies evaluating treatment of UTIs with cranberry products and for urinary tract conditions not related to bacterial infection were excluded. The authors felt that the overall study design of the included trials was good; however, they also noted that the trials were small and many failed to use intention-to-treat analysis. The review had moderate heterogeneity (I-squared 53%).

Chelsea Traverse, MD Vicki Jacobsen, MD Sara Oberhelman, MD Mayo Clinic Family Medicine Residency Rochester, MN

Cranberry products did not reduce the risk of recurrent UTI in the overall population (13 trials, N=2462; RR 0.86; 95% CI, 0.71–1.04), women with recurrent UTIs (4 trials, N=594; RR 0.74; 95% CI, 0.42–1.3), the elderly (2 trials, N=413; RR 0.75; 95%CI, 0.39–1.4), patients requiring catheterization (2 trials, N=353; RR 0.95; 95% CI, 0.75–1.2), pregnant women (2 trials, N=732; RR 1.04; 95%CI, 0.93–1.2) or children (2 trials, N=335; RR 0.48; 95% CI, 0.19–1.2).

A second systematic review also published in 2012 using the same inclusion criteria as the Cochrane review (except for antibiotic prophylaxis) included 10 RCTs (all 10 were also included in the Cochrane review) with a total of 1494 patients.2 The initial summary results did not show a difference between cranberry products and controls preventing UTIs (RR 0.68; 95% CI, 0.47–1.0). However, to reduce heterogeneity, a large outlying trial was excluded, resulting in a decrease in heterogeneity from 59% to 43% and a significant reduced risk of UTIs with cranberry products (RR 0.62 95% CI, 0.49¬¬–0.80).

Subgroup meta-analysis found a reduction in UTIs in the general population (9 trials, N=1175; RR 0.62; 95% CI, 0.49–0.80), women (4 trials, N=492; RR 0.49; 95% CI, 0.34–0.73), women with recurrent UTIs (2 trials, N=250; RR 0.53; 95% CI, 0.33–0.83) and children (2 trials, N=84;RR 0.33; 95% CI, 0.16–0.69).

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Resident authors work directly with a physician faculty mentor as "author teams."

Residencies meet RRC requirements, and many programs have developed their faculty into local evidencebased medicine experts!

References 1. Jepson RG, Williams G, and Craig J. Cranberries for Preventing Urinary Tract Infections. Cochrane Database Syst Rev. 2012; (10):CD001321.[STEP 1] 2. Wang CH, Fang CC, Chen NC, et al. CranberryContaining Products for Prevention of Urinary Tract Infections in Susceptible Populations. Arch Intern Med. 2012; 172(13):988–996.[STEP 1] Missouri Family Physician April-June 2015

5

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"

I discovered in SLU an institution that is engaged in impressive research and deeply committed to caring for and teaching the next generation of physicians to assist underserved patients."

- Greg Heffernan, Ph.D., Everest Foundation

everest foundation donation addresses primary care crises

A

$6.6 million gift from the Everest Foundation to Saint Louis University (SLU) will enhance training and educational opportunities for primary care physicians, ultimately bringing care to patients in underserved areas.

We are grateful to the Everest Foundation for providing SLU with additional resources to improve health care for patients from communities in need,” said Fred P. Pestello, Ph.D., president of Saint Louis University. “We appreciate that such a prestigious organization recognizes the excellence of what we do, and we know that their generous gift will allow our SLU School of Medicine to expand our efforts to prepare future physicians to care for each patient with compassion and skill as they address the most pressing health care challenges of today.”

The current shortage of primary care physicians, those in family medicine and general internal medicine is projected to grow, depriving people who live in struggling urban and rural areas of timely medical care.

The Everest Foundation sought a partnership with SLU to address the problem, said Greg Heffernan, Ph.D., director of foundation relations

for Everest Foundation, and the product of Jesuit secondary and higher education. “I contacted Saint Louis University School of Medicine, a very respected Jesuit university in the midst of America’s heartland, as a way of bridging my own education experience under the Jesuits and translating that into our foundation mission in health care. I discovered in SLU an institution that is engaged in impressive research and deeply committed to caring for and teaching the next generation of physicians to assist underserved patients,” Heffernan said. “The Everest Foundation is working on various initiatives to encourage doctors to practice in urban and rural underserved areas, and we particularly are aware of the challenges of not having enough primary care physicians in underserved regions. Primary care physicians are the front line, first contact that most people have to any patient care and their outreach is key to how well a community fares.”

The goal of the Everest Foundation is to make a big impact on medical education. It supports graduate medical education programs at medical schools and hospitals, and is particularly interested

From left: David Schneider, MD, MSPH, FAAFP, chair of family and community medicine at SLU; Greg Heffernan, Ph.D., director of foundation relations for the Everest Foundation; Philip Alderson, MD, dean of SLU School of Medicine; Christine Jacobs, MD, FAAFP, associate professor of family and community medicine at SLU; and Jeffrey Scherrer, Ph.D., associate professor of family and community medicine at SLU, met last summer to discuss how the Everest Foundation and Saint Louis University can work together to address the primary care shortage.

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Missouri Family Physician April-June 2015

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MAFP Member Input

evaluation of early pregnancy bleeding and management of spontaneous miscarriage in primary care

Wael Mourad, MD MAFP District 7 Director Lee's Summit Truman Medical

ABSTRACT Initial evaluation of the pregnant patient with first trimester bleeding begins with as assessment of hemodynamic stability. Knowledge of her medical, gynecologic, and obstetric history is imperative. Physical examination consists of an abdominal and pelvic exam, including the bimanual exam. Diagnostic considerations primarily consist of viable intrauterine pregnancy, early pregnancy failure, and ectopic pregnancy. Laboratory evaluation includes blood type and cross-match, a serum quantitative hCG, and possibly a serum progesterone level.

A Kleihauer-Betke test can be obtained in the setting of heavy hemorrhage. An ultrasonographic evaluation can help confirm the presence and viability of an intrauterine pregnancy, as well as to assist in ruling out an ectopic pregnancy. Counseling at the time of diagnosis of a miscarriage is a crucial portion of management. The primary treatment options include expectant management, medical management, and uterine aspiration. RhoGAM should be administered to the Rh Negative patient. A follow up evaluation, analogous to the postpartum visit, should be performed to follow up on her psychological state, to review options for contraception, results of a diagnostic evaluation if performed, and planning for next pregnancy if desired. A follow up serum quantitative hCG level which demonstrates an 80% drop is sufficient to conclude the miscarriage of a previously determined intrauterine pregnancy as completed.

EVALUATION OF VAGINAL BLEEDING IN PREGNANCY1,2,3 Evaluation of the female patient of reproductive age with vaginal bleeding begins with rapid assessment the ABCs: airway, breathing, and circulation. If the patient is hemodynamically stable, a focused evaluation to further determine the cause of the vaginal bleeding is warranted.

This pertinent history includes the patient’s menstrual history, as well as date and method used to confirm pregnancy if known. Past obstetrical and gynecological history should also be obtained. Knowledge of chronic medical conditions, such as a coagulation disorder, and past surgeries is important for optimal management. The physical evaluation begins with vital signs, both recumbent and standing, to assess for hemodynamic stability and signs of infection. An abdominal examination is performed to assess for peritoneal signs and tenderness, which is important if you are considering an ectopic pregnancy. The uterine fundus can typically palpable externally beyond 12 weeks gestation in the gravida with normal body habitus. A pelvic examination, comprising of speculum and bimanual examinations, is performed to assess for several clinical variables. The speculum examination is used to determine source and severity of bleeding, visualization of products of conceptus, and cervical dilation. Other causes for vaginal

8 Missouri Family Physician April-June 2015

bleeding such as vaginal trauma, cervical cancer, cervical polyps, and cervicitis can be ruled out. The bimanual examination aids in assessment of uterine size, adnexal masses, and cervical motion tenderness. This provides additional information regarding gestational age, evidence to support ectopic pregnancy, and likelihood of pelvic inflammatory disease (PID), respectively. A rapid pregnancy test, which is often a qualitative human chorionic gonadotropin (hCG) test, should be obtained in any female patient of reproductive age presenting with vaginal bleeding or abdominal pain, especially in the setting of amenorrhea or if a pregnancy is possible. A quantitative serum hCG test is usually obtained as well, which should especially be considered if the urine pregnancy test is negative and your suspicion for an ectopic pregnancy his high. In the setting of a positive pregnancy test, an ultrasound of the pelvis is usually ordered. In conjunction with quantitative serum hCG levels, ultrasound data aids in distinguishing between a viable pregnancy, early pregnancy loss, and ectopic pregnancy.

DIAGNOSIS1,2,3 When considering the diagnostic possibilities of early pregnancy vaginal bleeding, it is useful to group them in the categories of viable intrauterine pregnancy, early pregnancy failure, ectopic pregnancy, and molar pregnancy.

Viable Intrauterine Pregnancy with Threatened Spontaneous Miscarriage: A threatened miscarriage is a viable intrauterine pregnancy under 20 weeks gestation in the setting of vaginal bleeding. Half of these pregnant women will progress to term, while the other half will have a pregnancy loss. The prognosis improves to 90-97% that will continue the pregnancy if an ultrasound examination shows a viable intrauterine pregnancy over 7 weeks’ gestation with a heart rate over 90 beats per minute. A subchorionic hematoma will be noted by ultrasonographic examination in 3.1% of first trimester pregnancies, the vast majority of which will resolve by 20 weeks. Observational studies indicated that patients with a subchorionic hematoma were at increased risk for complications such as gestational hypertension, pre-eclampsia, placental abruption, preterm delivery, growth restriction, intrauterine demise, fetal distress, operative assisted vaginal deliveries, cesarean deliveries, neonatal intensive care unit admissions, and perinatal mortality.

Early Pregnancy Failure: The cause of a miscarriage is rarely identified. The most common cause is genetic aberration. This is especially true in an early first trimester miscarriages. Other known causes include the following1,2,3

Member Input MAFP

• Uterine anomalies (i.e. congenital anomalies, adhesions, uterine leiomyoma) • Incompetent cervix • Advanced maternal age • Exposure to diethylstilbestrol • Infection • Drug use (i.e. alcohol, cocaine) • Luteal phase defect with progesterone deficiency.

• Chronic maternal diseases: celiac disease, diabetes mellitus (poorly controlled, chronic hypertension (poorly controlled), other autoimmune diseases (i.e. uncontrolled hypo- and hyperthyroidism, antiphospholipid antibody syndrome).

• Short interconceptual spacing Inevitable Miscarriage: An inevitable miscarriage occurs when vaginal bleeding occurs in the setting of cervical dilation, and products of conceptus have yet to be expelled.

Incomplete Miscarriage: This refers to a miscarriage in which some, but not all, of the products of conceptus have passed.

Septic Miscarriage: A septic miscarriage occurs when a miscarriage has become complicated by intrauterine infection.

Anembryonic Pregnancy: An anembryonic pregnancy, also referred to as a “blighted ovum," is a gestational sac without a developing embryo.

Ectopic Pregnancy1,2,3: An ectopic pregnancy occurs when implantation of the gestational sac occurs in a location other than the intrauterine cavity. Other locations include the fallopian tube, ovary, broad ligament, or peritoneum.

Ectopic pregnancy is an important cause of maternal morbidity and mortality, and for this reason a high index of suspicion is necessary when assessing the patient with first trimester vaginal bleeding. The classical presentation of an ectopic pregnancy can be summarized by the “3 A’s”: amenorrhea, abnormal vaginal bleeding, and lateralizing abdominal pain. If an ectopic pregnancy is suspected, it is prudent for the family physician to involve the obstetrician gynecologist early in the management process.

In addition to the above, other diagnostic considerations include molar pregnancy, friable cervix secondary to cervicitis, endocervical polyps, cervical dysplasia or malignancy, and vaginal bleeding secondary to trauma.

LABORATORY Laboratory evaluation must include a blood type and cross-match, complete blood count, and a serum quantitative hCG level.

Trending the quantitative serum hCG level can be helpful in assessing the viability of a pregnancy. With 99% sensitivity, an increase in the quantitative hCG level of less than 53% in 48 hours confirms an abnormal pregnancy4.

This is to aid in differentiating a viable intrauterine pregnancy from a non-viable pregnancy. Trending the quantitative hCG level is especially necessary in the setting of a vaginal bleeding, a positive pregnancy test, and an

continued on page 10>

Missouri Family Physician April-June 2015

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MAFP Member Input continued... ultrasound examination showing no intrauterine pregnancy. This is to aid in differentiating an ectopic pregnancy from a very early intrauterine pregnancy that is not yet detectable by transvaginal ultrasound. An ectopic pregnancy will not demonstrate the appropriate rise in serum quantitative hCG levels, and will instead classically “plateau," due to a decreased number of syncytiotrophoblast cells. A spontaneous miscarriage would typically demonstrate a drop in serum quantitative hCG levels.

In addition to quantitative serum hCG levels, a serum progesterone level can be obtained to assist in distinguishing a viable pregnancy with vaginal bleeding from a non-viable pregnancy, such as a spontaneous miscarriage or ectopic pregnancy. A level less than 5 ng/mL has a 100% specificity in confirming an abnormal pregnancy, whereas a level greater than 20 ng/ mL is usually associated with a viable intrauterine pregnancy. Levels in the intermediate zone are equivocal, and most ectopic pregnancies fall within this range4.

ULTRASOUND An ultrasound is important to assess if the gestational sac has an intrauterine location, and to check for cardiac activity.

A single quantitative serum hCG level is matched against the sonographic “discriminatory zone” of hCG, which is generalized at 1,500– 2,000 mIU/mL, which when reached is associated with the appearance, on transvaginal ultrasonography, of a normal singleton intrauterine gestation. Therefore, in the setting of a positive pregnancy test, with a quantitative serum hCG above 2,000 mIU/mL, and no ultrasonographic evidence of an intrauterine pregnancy is an ectopic pregnancy must be considered4.

Other sonographic milestones in a normal pregnancy are as follows:1,5,6 • Gestational sac should be visualized at 33.5 days with transvaginal ultrasound in 95% of cases.

• Fetal cardiac activity should be seen at 44.5 days with transvaginal ultrasound in 95% of cases.

• Fetal cardiac activity should be visualized when an embryo is 5mm in crown rump length.

• Fetal cardiac activity should be visualized when the gestation sac is 1.9mm in 99% of cases.

• A normal gestational sac grows 1mm/day.

If an intrauterine pregnancy is identified, but it is too early to detect fetal cardiac activity, the ultrasound can be repeated in two weeks. From the above sonographic milestones, it can be inferred that a viable pregnancy should demonstrate cardiac activity with the follow-up scan7. If cardiac activity is not present, an early pregnancy failure is diagnosed. Other sonographic criteria for early pregnancy failure are as follows8.

• A gestational sac ≥ 25 mm in mean diameter that does not contain a yolk sac or embryo.

• An embryo with a crown rump length ≥ 7 mm that does not have cardiac activity.

COUNSELING3,9 Counseling of your patient should include 3 components: • She should be counseled that her early miscarriage is highly unlikely to be the result of her diet, physical or sexual activity, or non-compliance with prenatal vitamins.

• If this is her first or second miscarriage, her prognosis for successful future pregnancies is generally good. The risk of miscarriage in future pregnancy is estimated to be 14% after one miscarriage and 26% after two miscarriages10.

• She should be informed that miscarriages are very common. One in every 4 women will miscarry at least once in their lives. 15% of all 10 Missouri Family Physician April-June 2015

recognized pregnancies miscarry, and that rate may be as high as one in every two or three pregnancies, both recognized and unrecognized.

TREATMENT2,3,9,11,12 The physician should discuss the available options and evidence to support each option with the patient. Patient preference should guide treatment for spontaneous miscarriage.

Expectant Management: This is commonly referred to as the “wait and see” method. Thus so long as bleeding is not excessive, the patient is hemodynamically stable, and there are no signs of infection, expectant management is a reasonable first line approach. If on sterile speculum exam, products of conceptus can be visualized at the cervical os, spontaneous completion of the miscarriage is very likely without the need for medical or operative intervention. This option is also appropriate for the patient who is averse to any immediate interventions. Patients are typically allowed two weeks for expectant management before intervention is recommended. Average time for completion of a miscarriage is 9 days. Even in the setting where spontaneous passage of products is inevitable, a patient’s request for intervention ought to be respected. Conversely, even if spontaneous passage of products is not inevitable, so long as there exists no extra risks to the patient and she is stable, a request for expectant management should be honored. According to some experts, if the early miscarriage has been managed expectantly for four weeks without passage of products, medical or surgical evacuation should be performed rather than continued expectant management10.

Medical Management: Misoprostol is used as first line therapy. Several regimens can be considered based on the gestational age. A common evidence based regimen is 800 mcg PV, and repeated in 48 hours. An alternative regimen is 600 mcg SL, and repeated in 3 to 12 hours. As with expectant management, medical management ca n be considered if bleeding is not excessive, the patient is hemodynamically stable, and there are no signs of infections. Clinical factors that favor medical management include desire to avoid procedural intervention, an anembryonic pregnancy, as well as a missed miscarriage. The latter two conditions have a lower success rate with expectant management. Analgesics and anti-emetics are prescribed with misoprostol to alleviate common side effects.

With both expectant and medial management of a first trimester pregnancy loss, it is appropriate to inform the patient that the tissue passed will not resemble a baby, or have fetal parts. This depiction in a patient’s mind may be too traumatic, and her choice of management may therefore be altered as a result.

Uterine Aspiration: This is a safe and effective method, in which the patient can be discharged home on the same day. In the patient with persistent or heavy vaginal bleeding, hemodynamic instability, or signs of infection, this is the treatment of choice. Ultrasonography can be used in real time to ensure that all contents of the uterus have been evacuated. It can also monitor for complications such as uterine perforation. If the estimated blood loss exceeds 100 mL, oral methergine for 3 to 5 days can be considered to increase uterine contractions and thereby minimize post-procedure vaginal bleeding. Analgesics are commonly prescribed post-operatively.

Antimicrobial prophylaxis with doxycycline can be considered as well.

Rhesus (Rh) Alloimmunization Prevention13,14,15: RhoGAM is an intra-muscular injection of Anti-D immunoglobulin that is

Member Input continued... MAFP administered for the prevention of isoimmunization. The mechanism by which this occurs is unclear. It should be administered to all mothers with an Rh Negative blood type for certain indications. These include all forms of miscarriage, ectopic pregnancy, elective termination, uterine bleeding of unknown cause, trauma, and invasive procedures such as amniocentesis and external cephalic version. It is also routine administered during the third trimester of pregnancy and postpartum. It is common practice to administer RhoGAM in the setting of an incidental subchorionic hemorrhage, although the need for prophylaxis against isoimmunization for this indication has not been rigorously evaluated. The typical dosage is 300 micrograms. A “micro” dose of 50 micrograms can be considered if the pregnancy related bleeding is in the early first trimester, when the volume of fetal maternal hemorrhage is very small. In the setting of excessive hemorrhage where there is a question if the dosage is sufficient, a Kleihauer-Betke test can be performed to quantify the degree of fetomaternal hemorrhage. This test result can aid in calculating the exact dose of RhoGAM needed to prevent isoimmunization.

FOLLOW-UP EVALUATION1,2,3,12 It is important to determine if the miscarriage has been completed clinically regardless of the management option chosen. Biochemical evidence is important and follow-up hCG levels are used to confirm the completion of a miscarriage. If an intrauterine pregnancy was confirmed, an 80% drop in hCG level is sufficient to assess the miscarriage as completed. If an intra-uterine pregnancy was not confirmed, the hCG levels must be followed until it is negligible.

A work up is not typically indicated after a first miscarriage. It is reasonable to pursue a diagnostic evaluation after a second miscarriage per patient request. A laboratory and/or pathological evaluation should be performed after a third miscarriage to identify potential causes of recurrent

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pregnancy loss. This assessment focuses on screening for genetic factors, antiphospholipid antibody syndrome, assessment of uterine anatomy, and metabolic factors. Testing usually includes peripheral karyotypic analysis of the parents or products of conceptus. Autoimmune and antiphospholipid syndrome (APS) investigation can be accomplished with testing for antinuclear antibodies (ANA), lupus anticoagulant, anticardiolipin antibiodies (ACA), and anti-β2 glycoprotein I antibodies. Testing for sexually transmitted and TORCH (toxoplasma, syphilis, rubella, cytomegalovirus, and herpes) infections is also recommended. Diabetes screening, thyroid disorder screening, and a prolactin level can also be obtained. Imaging of the uterus can be accomplished with sonohysterogram, hysterosalpingogram, and/or hysteroscopy16, 17.

It is reasonable to schedule a postpartum visit 4 to 6 weeks after the completion of a miscarriage. Although the patient did not carry the pregnancy to term, she did have a pregnancy to which her body and organ systems underwent physiological changes. This visit is also an opportune time to reassess for grieving and to provide behavioral health support if warranted. Further reassurance to alleviate the patient’s grief is typically well received. If a diagnostic work up was performed to identify a possible cause of recurrent pregnancy loss, those results can be reviewed at that time. Assessing the patient’s desire for future pregnancy, counseling, and provision of contraception if desired are important components of the postpartum visit. Appropriate screening tests such as Pap smears and immunizations, including Rubella, may also be performed at this visit.

Evidence guiding the optimal interval before attempted subsequent conception is lacking. In clinical practice, many providers recommend waiting at least 3 to 6 months before attempting another pregnancy. The patient should be counseled that folic acid supplementation has been shown to decrease the incidence of neural tube defects, and its need is greater in the first trimester when organogenesis is occurring. For this reason, it is recommended that women of childbearing age take folic acid supplementation because the critical time period of organogenesis may be well under way prior to discovery of the pregnancy. All patients who desire pregnancy should be advised to take prenatal vitamins.

References: 1) ACOG Practice Bulletin #4. “Prevention of Rh D Alloimmunization.” The American College of Obstetricians and Gynecologists. May 1999, reaffirmed 2013.

2) ACOG Practice Bulletin #75. “Management of Alloimmunization During Pregnancy.” The American College of Obstetricians and Gynecologists. August 2006, reaffirmed 2012.

3) Tenore, Josie L. “Ectopic Pregnancy.” Am Fam Physician. 2000 Feb 15;61(4): 1080-1088.

4) Kirkham, Colleen; Harris, Susan and Grzybowski, Stefan. “Evidence-Based Prenatal Care: Part I. General Prenatal Care and Counseling Issues.” Am Fam Physician. 2005 Apr 1;71(7):1307-1316.

5) ACOG Practice Bulletin #101. “Ultrasonography in Pregnancy.” The American College of Obstetricians and Gynecologists. 2009 Feb, reaffirmed 2014.

6) American Institute of Ultrasound in Medicine. “AIUM practice guideline for the performance of obstetric ultrasound examinations.” J Ultrasound Med 2013; 32: 1083–1101. doi:10.7863/ ultra.32.6.1083.

7) Deutchman, Mark and Tubay, Amy Tanner. “First Trimester Bleeding.” Am Fam Physician. 2009 Jun 1;79(11):985-992.

8) Prine L, Macnaughton H. “Office Management of Early Pregnancy Loss.” Am Fam Physician.

2011;84(1):75-82.

9) Griebel, C.P., Halvorsen, J., Goleman, T.B. and Day, A.A. “Management of Spontaneous Abortion.”

Am Fam Physician. 2005 Oct 1;72(7):1243-1250.

10) The Reproductive Health Access Project. First trimester bleeding algorithm. http://www. reproductiveaccess.org/m_m/downloads/First_trimester_bleeding_algorithm.pdf. Accessed October 27, 2014.

11) Cochrane Briefs. “Expectant Management vs. Surgical Treatment for Miscarriage Clinical Question” Am Fam Physician. 2006 Oct 1;74(7):1125-1126.

12) ACOG Practice Bulletin #143. “Medical Management of First-Trimester Abortion.” The American College of Obstetricians and Gynecologists. March 2014.

13) Evaluation and Treatment of Recurrent Pregnancy Loss: A committee opinion. Fertil Steril. 2012; 98:1103-11. American Society for Reproductive Medicine.

14) ACOG Practice Bulletin #94. “Medical Management of Ectopic Pregnancy.”

The American College of Obstetricians and Gynecologists. June 2008.

15) Tulandi T, Al-Fozan HM. Spontaneous abortion: risk factors, etiology, clinical manifestations, and diagnostic evaluation. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA (Accessed on January 6, 2015).

16) Tulandi T, Al-Fozan HM. Spontaneous abortion: management. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA (Accessed January 6, 2015).Ff 17) Johnson, KE. Overview of TORCH infections. In: UpToDate, Post TW (ed), UpToDate, Waltham, MA (Accessed January 30, 2015).

Missouri Family Physician April-June 2015

11

MAFP IndependentMD

IndependentMD, a leader in dpc

"

W

hat’s wrong with you this evening?” asked my wife, Mary, one winter evening about three years ago.

“Why are you so irritable?” I was in the 29th year of medical practice and growing increasingly frustrated. My hospital employers had just implemented the government mandated EMR and I was spending two and three hours each evening finishing documentation and paperwork. “I don’t even feel like a physician any longer,” I replied. “I feel like I’m nothing more than a well paid clerk!”

“Well," said Mary, "don’t just complain to me, do something about it.” Yes, but what could one doctor do about a medical system that had grown increasingly impersonal and bureaucratic?

I had heard about physicians, called concierge doctors, who had dropped out of the system and who had stopped accepting insurance. But wasn’t this type of practice only for the few wealthy individuals who could afford the very expensive fees? How could a practice model such as this ever work in Southeast Missouri? Later that year I went to the national meeting of the AAPS (Association of American Physicians and Surgeons) in San Diego. There I met primary care doctors who were successfully running a cash only practice. So, I kept looking and surfing the internet. I came across an article about two young family physicians in Wichita who had started what they called a direct primary care practice straight out of residency. Since I was going to travel to Wichita that spring for my son’s wedding, I arranged a visit with Dr. Josh Umbehr and Dr. Doug Nunamaker. That visit to their practice, which they named AtlasMD, convinced me that this was a practice model which could work anywhere, even in Southeast Missouri, and a model which could, potentially, revive my love of medicine.

After another year of planning, and with the invaluable help of AtlasMD, I took a leap of faith and, at age 61, left the stability of being a hospital employee to form the first direct primary care practice in Cape Girardeau, IndependentMD. So, what is different about direct primary care (DPC) in general, and IndependentMD in particular?

First of all, I see fewer patients, and can, therefore, give them the time needed to practice medicine the way it should be practiced. Most family physicians have anywhere from 2,0004,000 patients in their practice. I will probably

12 Missouri Family Physician April-June 2015

Michael Wulfers, MD, FAAFP Graduated: University of Missouri, Columbia-1979 Residency: Wake Forest University, Winston Salem, NC-1983 MAFP president: 2008

cap my panel at around 500-600 patients. I do not accept any form of insurance as payment.

Patients pay from $40-79 per month, depending on age (children under age 19 can join for an additional $10 per month). For this they get a yearly preventive exam, unlimited office visits, and 24/7 access to me by cell phone, texting, facetime, or e-mail. Text messaging has been an extremely popular benefit which patients love.

There is no extra charge for any procedures that I perform, such as arthrocentesis, excisions, tympmanometry, cryotherapy, rapid strep testing, urinalysis or EKGs. If they need hospitalization, I will manage their care for no extra charge. Labs that aren’t available in the office are provided at cost through a contract with Quest Laboratories. For example, a lipid profile which would cost a cashpaying patient $75 at the hospital outreach lab 100 feet from my office will cost the patient $4.75 if drawn by my staff. Additionally, I have a small minipharmacy and dispense generic drugs essentially at cost, resulting in huge savings for a large number of my cash paying patients. Finally, when specialty care

Direct Primary Care MAFP

"

I see fewer patients, and can, therefore, give them the time needed to practice medicine the way it should be practiced."

is needed, I’m now free to refer my patients to the best doctor available without regard to that physician’s hospital affiliation.

How can I afford to offer these services for such a reasonable charge, and still make a nice profit? The reason is simple. When you don’t have to deal with the government or the insurance industry, overhead plummets. I have one employee, an LPN, and my wife, the office manager. I don’t need support staff to deal with insurance billing or denials of payment. I don’t need to hire consultants to make sure that I am meeting “meaningful use” requirements. (I do, by the way, use a “non meaningful use” EMR developed by AtlasMD for DPC physicians, and I love it. I would never go back to paper). It is estimated that the overhead for most DPC practices runs about 50% less than that of the typical family practice.

About 15% of my former patients, including a surprisingly large number covered by Medicare, have enrolled in my new practice.

I’m glad to see familiar faces, but I think that I’m heartened the most by the niche that IndependentMD is filling in the community by helping uninsured patients obtain primary care services.

A large number of my new patients either have no health insurance, or poor health insurance. The DPC model at least allows them to get their primary care, labs, and medications for an affordable price. Ideally, DPC should be combined with a “wrap around” catastrophic health insurance policy which would cover expensive items such as hospitalizations and advanced imaging. Adding an HSA (Health Savings Account) is even better, as the monthly premiums paid to the DPC physician should be able to be taken from the HSA. Almost everyone agrees that something needs to be done about the exorbitant cost of medical care in the United States.

The ACA, unfortunately, was designed to increase coverage of the uninsured, but not to lower costs. It is my opinion that we need to introduce market based principles to the medical system in order to stimulate the competition which will eventually bring health care costs down to a reasonable level. Direct primary care is not the only answer, but certainly, can be one of the new ideas utilized in a more market based system. For an innovative and detailed proposal for practical health care reform I encourage you to read the 2014 Physician’s Prescription for Health Care Reform at www.docs4patientcare.org.

Direct Primary Care Legislation HB 769 and SB 478 Direct primary care is an innovative practice model where patients enter into a contractual relationship with a physician and pay a fixed amount that is transparent and agreed upon for primary and preventive care services as spelled out in a “retainer agreement” signed by the patient and the physician. Direct medical care represents an affordable option which can improve access to care, reduce the number of people who now lack such access, cut down on emergency room use for primary care purposes, thereby freeing up emergency room facilities to treat true emergencies, and reduce the need for advanced care for preventable conditions or complications.

HB 769 and SB 478 are based on statutes passed in other states that have debated this issue and found it to be a viable, innovative option for health care for a variety of patients who might be uninsured, underinsured, or those with high deductible health plans. Missouri’s bill clarifies that direct medical care is not insurance and would allow patients to use health savings accounts (HSA) and flexible savings accounts (FSA) to pay their monthly retainer fee, subject to state and federal law. The bill would also allow employers to pay for their employees’ retainer fee through the HSA, FSA or directly to the physician.

The Missouri Academy and Pat Strader, MAFP governmental consultant, have been working diligently with legislators and members in support of this legislation which clearly states that direct primary care is not insurance. Seven states have passed DPC legislation; eight states having pending legislation; and 37 states currently have physicians in DPC practices.

We encourage you to contact your Missouri Representative and Senator to support this important legislation. Visit the MAFP Advocacy page at: http://www.mo-afp.org/advocacy/ to get your legislators’ contact information.

Missouri Family Physician April-June 2015

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MAFP Advocacy Day Recap

"

I was pleased to discover how easy it was to talk to my representative and to find common areas of mutual agreement. I look forward to participating again next year."

- Kurt Bravata, MD

mafp members speak out at advocacy day

'

W

anting to make a difference' sums up the messages delivered to our senators and representatives at this year’s Advocacy Day. Over 40 members (physicians, residents, and medical students) participated in the daylong event that was held in conjunction with White Coat Day. The capitol was a flurry of white coats in and out of offices, the gallery, and hallways of the historic building. This year’s event began on Monday evening with an optional legislative briefing where MAFP priority issues (see inset) were discussed in detail. A brief overview was David Schneider, MD, FAAFP (left) and Kurt Bravata, MD discuss given the next morning before charging important issues at the Capitol during Advocacy Day. off to the capitol. the legislative process in action. Each attendee MAFP governmental consultant, Pat Strader, had the opportunity to report the outcomes of guided members through the MAFP priority their meeting back to the Missouri Academy. legislative issues including tort reform, direct Jamie Ulbrich, MD, FAAFP, advocacy primary care, Medicaid expansion, prescription drug monitoring and others. MAFP staff tended commission co-chair, took the lead and presented to the booth on the 3rd floor rotunda and greeted testimony to the Senate Small Business, legislators, physicians, residents, students and Insurance and Industry Committee on tort reform other visitors. Some students were paired with an that afternoon. The day concluded with lunch and MAFP member to visit their legislators and see a board meeting.

MEMBERS 'MAKING A DIFFERENCE'

1 2

4 14 Missouri Family Physician April-June 2015

5

3

6

DPC Hearings MAFP MAFP Priority Issues Direct Primary Care: SUPPORT HB 769 (Rep. Frederick) SB 478 (Sen. Onder)

impressive turnout in support of direct primary care

Tort Reform Repair: SUPPORT HB 118 (Rep. Burlison) SB 239 (Sen. Brown) Prescription Drug Monitoring Program (PDMP): SUPPORT HB 130 (Rep. Rehder) SB 63 (Sen. Sater) MO HealthNet Reimbursement for Primary Care: SUPPORT HB 551 (Rep Fitzpatrick) SB 151 (Sen. Sater) Health Care Workforce Analysis: SUPPORT HB 112 (Rep. Franklin) APRNS/Collaborative Practice: OPPOSE HB 633 (Rep. Burlison) SB 415 (Sen. Wasson) APRNS/Prescribing of Schedule II Controlled Substances: OPPOSE HB 720 (Rep. Redmon) SB 313 (Sen. Wallingford)

1. KC Residency Program 2. SLU Residency Program 3. Emily Doucette, MD, Peter Koopman, MD, FAAFP and Douglas Crase 4. MAFP board members 5. Bill Fish, MD, FAAFP, Jennifer Scheer, MD, FAAFP, Kristin Weidle, MD, Keith Ratcliff, MD, FAAFP and Jamie Ulbrich, MD, FAAFP 6. Todd Shaffer, MD, MBA, FAAFP, Ed Kraemer, MD and MAFP governmental consultant, Pat Strader

Seven people testified in support of DPC legislation on February 18. Front row L to R: Dan Caldwell, Lori Brown, Jenny Powell, MD, FAAFP, Christy Rush and Mike Stevenson, DO. Back row L to R: Wes Powell and Jacob Stankus.

Lori Brown and Jacob Stankus, both seated next to Representative Frederick, testify in support of direct primary care on February 18. MAFP had a great turnout in support of the bill, with members and their patients traveling from all areas of the state to testify.

Missouri Family Physician April-June 2015

15

MEMBERS IN THE NEWS todd shaffer, md, mba, faafp: chair-elect, cafm

Todd Shaffer, MD, MBA, FAAFP

At the Winter AAFP Working Party Meeting in Phoenix, Todd Shaffer, MD, MBA, FAAFP was elected as chair-elect of Council of Academic Family Medicine (CAFM). CAFM is designed as a task-oriented group that engages in projects representing strategic academic family medicine initiatives. He is currently the President of the Association of Family Medicine Residency Directors (AFMRD) and is the Program Director of the UMKC Family Medicine Residency Program. Dr. Shaffer will assume the chair role in August at the next AAFP Working Party and CAFM meeting.

fmig network announces new regional coordinators The FMIG Network’s 2015 student leaders have been appointed and have started their terms. These seven leaders will serve the Network throughout 2015, in addition to their current leadership roles at their schools’ FMIGs across the country. Krystal Foster, MD, a newly matched resident at Mizzou Family Medicine Residency, will represent the FMIG Network’s Midwest region as Region 2 coordinator.

Krystal Foster, MD

News to share?

The Missouri Family Physician magazine welcomes your input. Please submit newsworthy items for review to: office@mo-afp.org

our condolences Former MAFP President, Dr. W. Wayne Boydston, MD, of Odessa, Missouri, passed away Thursday, February 12, 2015. Dr. Boydston was MAFP president in 1982, chairman of the board in 1983, and was selected as “Doctor of the Year” in 1994 for the state of Missouri.

lichtenberg receives greater st. louis community health award

"

I'm so proud of how the [St. Louis] Academy has evolved." - Kate Lichtenberg, DO, MPH, FAAFP

Kate Lichtenberg, DO, MPH, FAAFP was awarded the Greater St. Louis Community Health Award in January. This award was created by the St. Louis Academy to recognize peers (FPs, FM residents or medical students interested in family medicine) for his or her work as a volunteer, leader, or provider of health services which positively impacts the health of residents in the Greater St. Louis community.

Congratulations, Dr. Lichtenberg, for making a difference in the lives of St. Louisans.

Dr. Lichtenberg is presented her plaque by St. Louis Academy President, Andrea Baxter, MD.

fmig funding initiative - university of mo - columbia Congratulations to Amanda Allmon, MD and Krystal Foster, MD, both of University of Missouri, Columbia, for being selected for the FMIG Funding Initiative. Family Medicine Interest Groups at all U.S. allopathic medical schools and branch campuses are eligible for a $600 grant from the AAFP and the AAFP Foundation to put toward their group's operation in whatever way they see fit. The purpose of the program is to provide crucial funding to FMIGs to work on the front lines at their colleges and enhance student interest in family medicine.

16 Missouri Family Physician April-June 2015

Members In The News MAFP umkc newly elected chief residents & latest scholarship winners

fmig's making a difference Jenny Eichorn, MD and Emily Gray, MD attended the UMKC Family Medicine Education Retreat in November. Mitchell Elting, MD attended the Midwest Family Medicine Conference in Minnesota. Each returned with great insight Jenny Eichorn, MD that will help them increase interest in Family Medicine. Below are their experiences:

CHIEF RESIDENTS

James Kirkpatrick, MD, PhD

James Smith, DO, MBA

Doyle Witt, MD

Congratulations to James Kirkpatrick, MD, PhD, James Smith, DO, MBA, and Doyle Witt, MD -- each of whom will graduate from UMKC Family Medicine Residency Program in June 2016.

SCHOLARSHIP WINNERS

Mitch Bartley, DO Chris Paynter, DO Ben Reine, DO

Congratulations to UMKC Family Medicine Residency's latest scholarship winners.

Each year the Missouri Society of the American College of Osteopathic Family Physicians (MSACOFP) awards up to three (3) $1,000 scholarships to physicians in a family medicine residency in Missouri. The scholarship was established to help identify and develop future leaders for MSACOFP and osteopathic medicine. It rewards residents who demonstrate excellence in osteopathic medicine and intend to practice in Missouri.

Jenny Eichhorn: "I was able to give an honest opinion of what different students at UMKC think about the Family Medicine rotations. It was great to interact with Family Medicine faculty and other School of Medicine faculty, including members of the Council on Curriculum. We were able to Mitchell Elting, MD strategize with the AAFP at the end of the day, making plans to continue to improve interest in Family Medicine at UMKC." Mitchell Elting: "I had the great opportunity to attend the Midwest Family Medicine Conference through receiving a gracious scholarship from a Family Physician to attend the conference. I was able to attend workshops and FMIG leadership events. I brought back many ideas to improve our FMIG and increase interest in Family Medicine."

Emily Gray: "As healthcare becomes more readily available in the United States, the patient population drastically increases, as well as the need for physicians, specifically primary care practitioners. Because the demand of primary care physicians is escalating, it is important that we focus on increasing awareness and desire to pursue careers in fields such as Family Medicine.

The best place to conquer this task is by working with medical students and faculty. I was able to provide information from a student's perspective as to what would be beneficial or detrimental in the Family Medicine rotations. It was a day well spent and hopefully time will reveal our efforts and the success of our goals."

Kate Lichtenberg, Larry Rues, DO, MPH, FAAFP MD, FAAFP

I was able to provide information from a student's perspective as to what would be beneficial or detrimental in the Family Medicine rotations."

- Emily Gray, MD

record setting goals

missouri well represented at aafp

David Barbe, MD, FAAFP

"

Emily Gray, MD

Congratulations to three of our members who will be repesenting Missouri at the AAFP. David Barbe, MD, FAAFP has been endorsed by AAFP for AMA President elect in 2016, Kate Lichtenberg, DO, MPH, FAAFP was appointed to the Commission on Quality and Practice.

And, Larry Rues, MD, FAAFP will serve as the AAFP Delegate for the ANA House of Delegates.

MAFP received 18 applications for the Student Externship program -- a record number!

Winners will be selected soon.

Missouri Family Physician April-June 2015

17

Screening your patients for sleep apnea has never been easier.

Introducing ApneaStrip™ ~ The First Disposable, Inexpensive and Objective Home Screening Device for Sleep Apnea How ApneaStrip™ Can Help You and Your Patients Like many physicians, you likely have patients you suspect are at risk for sleep apnea.

However, without objective evidence, it is sometimes hard to justify the cost of a sleep study or persuade a patient to consult with a sleep specialist.

ApneaStrip™ helps you solve that problem.

ApneaStrip™ is a clinically proven, inexpensive (retail: $29.99) screening device that determines if a patient is at high risk or low risk for sleep apnea. A flashing RED light indicates high risk while a flashing GREEN light indicates low risk. The result can be seen by the patient the very next morning and reported to the doctor by phone.

Helping your patients who may be suffering from sleep apnea starts with ApneaStrip™. Learn more at ApneaStrip.com. Contact us at (888) 757-7367 or info@apneastrip.com.

Available only at St. Louis area

pharmacies.

O

N LY

™

In-Home Sleep Apnea Screening Device

The Match: 2015

MAFP

the match: family medicine match rate ticks upward for sixth straight year

family medicine match rate ticks upward sixth straight year, senior interest slows

"

A couple's match: Gretchen Woodfork, MD and Ryan Stokes, MD, UMKC Family Medicine Residency, happily point to their match.

M

atch Day is the culmination of four challenging years, and, in some ways, is the most exciting day of the medical school experience. Every year at a predetermined time, medical students across the country learn simultaneously which hospital will educate them for the next three to seven years.

On March 20, 3,060 graduating medical students chose a career in family medicine. For the sixth straight year, the family medicine match rate ticked upward.

3,216 family medicine residency positions were offered in 2015, an increase of 84 positions compared to 2014.

While student interest in family medicine grew this year, the number of U.S. seniors choosing family medicine slowed at an unexpected rate of 1,422 - with just six more U.S. seniors matching to the specialty than last year.

Opening my letter officially matching me to University of Missouri - Columbia Family Medicine Residency was an amazing experience with my family and my classmates and their family and friends! The cheers and excitement were palpable!

I can't wait to be a family doc!"

- Krystal Foster, MD

Left: Michelle Hall, MD smiles as she holds up her match letter and her first choice St. Louis University Family Medicine Residency.

Right: L to R: University of Missouri - Columbia Family Medicine Residency's Sarah Kapala, MD, Shari Chang, MD, and Krystal Foster, MD, stop for a picture on Match Day. Missouri Family Physician April-June 2015

19

MAFP Everest Foundation continued...

Pat Patterson Photography

in increasing the number of family medicine and internal The gift will expand the program to teach two more residents medicine physicians in the U.S., Heffernan said. “Our cities annually, which means the family medicine program ultimately and rural areas cry out for more physicians to give patients will grow to educate 18 residents. the attention they need – not only technically superb care that SLU family medicine residents complete their in-hospital a sub, sub-specialist provides but personal, compassionate training at SSM St. Mary’s Health Center and treat patients at and insightful care that a family medicine physician or general Family Care Health Centers’ Carondelet clinic, a community internist brings to the practice of medicine,” said Philip Alderson, health center located in a part of south St. Louis where half the M.D., dean of SLU School of Medicine and vice president for patients live at or below the poverty level. “One of the reasons medical affairs. “Primary care physicians provide a special we chose to build the family medicine residency program the way type of personalized medicine that goes far beyond analyzing we did is to develop a pipeline of physicians who are passionate a patient’s genetic composition to treat a particular problem. about caring for the urban underserved in the City of St. Louis,” They take the time to really get to know a patient and his or her said David Schneider, M.D., FAAFP, chair of the department of world so decisions about medical care are not simply based on family and community medicine at SLU. “It’s so helpful to put technology and sub-specialized knowledge but include factors that can have a huge impact on health, such as a patient’s home life and community. This generous gift from the Everest Foundation presents us with an opportunity to train even more physicians in the disciplines that most closely resonate with this idea.”

In recognition of the gift, SLU named its recently constructed Health Science Education Union, located in the heart of the Medical Center, the “Edwin Everest Education Union.”

The Everest Foundation is funding the Saint Louis University primary care initiative for the next 10 years. The gift is allowing Saint Louis University to: • Add five new primary care residency SoutheastHEALTH serves Southeast Hospital in Cape Girardeau positions – two three-year residents in family a population of 650,000 – » TJC-accredited flagship of SoutheastHEALTH with 96% RNs medicine and three one-year preliminary and nearly 300 beds the largest medical market internal medicine residents » Situated on Mississippi River, city is region’s hub for commerce, between St. Louis and entertainment, the arts, higher education and healthcare •Establish a research fellowship in family Memphis. » Population of 40,000 with average commute of 20 minutes medicine that grants a master of public More than a single health or master of science in public health location, SoutheasHEALTH degree after completing a family medicine Southeast Health Center of Stoddard County in Dexter is a regional system of residency » Expanding medical facility with nearly 50 beds, ED, ICU, care with facilities and telemetry unit and new MOB •Create a visiting fellowship program that opportunities for BC/BE » County population of nearly 30,000: 70% rural may include clinical and/or research training physicians across the » 7 wildlife conservation areas, including Mingo Wildlife Refuge, mentored by faculty for hunting, fishing, nature watching, hiking and camping region, including...

While adding residents most directly addresses the shortage of primary care Southeast Health Center of Ripley County in Doniphan providers, the other initiatives enhance Opportunities » 30-bed facility in Ozark Foothills just north of Arkansas border research and clinical skills of physicians, for BC/BE physicians: » Heart of Current River with large tourism draw which ultimately strengthens the practice of > Minimum salary of 185,000 » County population of 14,000+: All rural medicine. > Signing bonus up to $50,000 Residencies The only urban family medicine residency program in St. Louis, SLU’s three-year program trains 12 residents to practice family medicine in an urban, underserved setting.

20 Missouri Family Physician April-June 2015

> wRVU-based productivity incentives > Student loan repayment up to $200,000 > Relocation assistance, paid CME and much more

For confidential inquiry,

contact Mandie at 573-331-6374 or mpresser@SEhealth.org

Everest Foundation continued... yourself in the shoes of the patients you serve to appreciate their daily challenges, which makes you a more compassionate, understanding and effective doctor.” The Everest Foundation also will add three preliminary (one-year) internal medicine residents.

Family Medicine Research Fellowship SLU will create a family medicine research fellowship program -a post-residency, fourth year of intensive clinical and public health education -- for family physicians. Under the mentorship of a family and community medicine faculty member, the fellow will earn a master of public health or master of science in public health at SLU’s College for Public Health and Social Justice as well as care for patients in one of family and community medicine’s affiliated practice sites.

"

“It’s so helpful to put yourself in the shoes of the patients you serve to appreciate their daily challenges, which makes you a more compassionate, understanding and effective doctor.”

- David Schneider, MD, MSPH, FAAFP

The public health education component provides a deeper understanding of community health – how living in a particular area impacts the personal health of a patient. For instance, people who live in neighborhoods that don’t have quality supermarkets nearby likely will have a more difficult time following a doctor’s recommendation to eat more fruits and vegetables than those who live near many grocery stores. “In the future, primary care physicians will be responsible for the health of neighborhoods and communities. Merging public health education with residency training in primary care best prepares our residents for the future,” said Edwin Trevathan, M.D., MPH, dean of SLU’s College for Public Health and Social Justice. “Public health education will allow future SLU-trained primary care physicians to improve health outcomes by leading communitybased health interventions.”

Beyond improving the quality of patient care, the fellowship will elevate the scholarship of family medicine. It will prepare more family physicians for academic careers, where they not only treat patients but also educate students and residents. They also will be better equipped to conduct research, which ultimately can improve care for many more patients than just those the physician treats. “The fellowship will help address the shortage of family medicine educators and will provide the skills to become a researcher in primary care,” Schneider said. “Research is critical

MAFP

for all patients because doctors need to understand how to provide the best primary care to our patients.”

Visiting Research Fellows Graduates of medical and osteopathic schools and international medical programs who are not enrolled in a residency program will have the opportunity to gain clinical experience and/or conduct medical research for between six and 12 months at SLU. SLU will select visiting research fellows from a pool of candidates provided by the Everest Foundation, pairing them with specific research projects. In some cases, the visiting research fellowship also will include clinical experience treating patients under the supervision of a SLU faculty member.

The structured experience will prepare doctors for a residency, which ultimately will expand the number of physicians who are well equipped to care for patients. Those visiting research scholars who pursue further graduate medical education also agree to commit to caring for patients in urban or rural underserved parts of St. Louis or Illinois and other parts of Missouri for several years. “Because of the grant from the Everest Foundation, SLU will be able to do even more to educate primary care physicians, many of whom settle in St. Louis after they complete their training,” Alderson said. “In this way, we are making a real impact on the quality of health in this region, which recently was named among the top 10 places in the country for medical care, and recognized for its primary care physicians and compassionate approach to patient care.”

The Everest Foundation is a non-profit research organization of professionals from all arenas of medicine that works exclusively with some of America's top schools of medicine. It implements graduate medical education programs and long-term research endowments that create innovative infrastructures and initiatives to transform health care in medically underserved areas, including the developing world.

Established in 1836, Saint Louis University School of Medicine has the distinction of awarding the first medical degree west of the Mississippi River. The school educates physicians and biomedical scientists, conducts medical research, and provides health care on a local, national and international level. Research at the school seeks new cures and treatments in five key areas: infectious disease, liver disease, cancer, heart/lung disease, and aging and brain disorders.

Missouri Family Physician April-June 2015

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MAFP 2015 Family Physician of the Year Nominees

meet your 2015 family physician of the year nominees

C

ongratulations to Missouri's 2015 Family Physician of the Year award Nominees. The winner will be selected by the MAFP Member Services Commission and honored at the Annual Scientific Assemly in June at the Lodge at Old Kinderhook in Camdenton, Missouri. Thank you to everyone who took the time to submit a nomination for this prestigious award.

Julie Burdin, MD, Macon

Arthur Freeland, MD, FAAFP Kirksville

William Haynie, MD, Butler

22 Missouri Family Physician April-June 2015

Michael LeFevre, MD, Columbia

Gene McFadden, MD, FAAFP Waverly

James Miller, DO, FAAFP Butler

Jennifer Powell, MD, FAAFP Osage Beach

Darryl Zinck, MD, St. Louis

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TS SIDEN E R E IN MEDIC DENTS Y U L I T S M L FA EDICA T1 AND M UGUS

Shin Jung

Desire

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Register Today AAFP.ORG/NC

2014 NATIONAL CONFERENCE ATTENDEES

0–A JULY 3 KC, MO

keiran

EMY PRESENT AD ST C A H

THE MIS SO UR I

E

67

annual

th Scientific Assembly CAMDENTON, MISSOURI

june 5-6, 2015

SCHEDULE OF EVENTS

Friday, June 5, 2015

Saturday, June 6, 2015

7:00 - 8:00 am Registration & Breakfast Buffet with

Exhibitors

7:00 - 11:00 am Exhibit Hall Open (Grand Ballroom A)

*All Lectures will be held in Grand Ballroom B

8:00 - 9:00 am Targeted Combined Approaches for the

Treatment of Type 2 Diabetes:

The Role of the Kidney

Mark W. Stolar, MD

7:00 - 8:00 am Registration & Breakfast Buffet with

Exhibitors

7:00 - 11:00 am Exhibit Hall Open (Grand Ballroom A)

*All Lectures will be held in Grand Ballroom B

9:00 - 10:00 am

Skin Anatomy, Mohs History, Mohs Technique, Indications and Reconstruction of Defects Scott Darling, DO

10:00 - 10:45 am

Refreshment Break with Exhibitors (Grand Ballroom A)

10:45 - 11:45 am

Physician Burnout David Voran, MD

11:45 am - 12:45 pm

New Drug Update 2015 Peter Koopman, MD, FAAFP

12:45 - 1:00 pm

8:00 - 9:00 am

GBS in Maternal Child Health Wael Mourad, MD

9:00 - 10:00 am

Improving Long-Term Outcomes in Chronic Heart Failure Paul J. Hauptman, MD

10:00 - 10:45 am Refreshment Break with Exhibitors

(Grand Ballroom A)

10:45 - 11:45 am Modifying Clinic Workflow to Engage

the Patient and Restore the Fun in Daily

Medical Care

David Voran, MD 11:45 am - 1:30 pm

Annual Business Meeting & Legislative Luncheon (Hearth Room)

BOX LUNCH (Grand Ballroom B)

1:30 - 2:30 pm

Literature Update James Stevermer, MD, MSPH, FAAFP

1:00 - 2:00 pm

Substance Use Disorders: Prevent, Detect and Treat Dan Vinson, MD

2:30 - 4:30 pm

Optimizing Fracture Prevention in Patients with Osteoporosis Speaker TBA

2:00 - 3:00 pm

Are You Up To Date in Your Management of Atrial Fibrillation Patients?

Greg Flaker, MD

3:00 - 3:15 pm

BREAK (Grand Ballroom B)

5:15 - 6:15 pm

Social Mixer - Meet and Greet the Future of Family Medicine (Hearth Room) Poster Presentations & Awards - Hors d'oeuvres Reception - All Attendees are Welcome

3:15 - 4:15 pm

Hormone Replacement Therapy Wael Mourad, MD

4:15 - 5:00 pm

Direct Primary Care Michael Wulfers, MD, FAAFP

5:30 - 7:30 pm

Family Fun Picnic (Hearth Room and Patio) Join us for an evening of fun-filled activities including Sparkie dá Clown & Merry Mary

earn up to

13.5 cme credits

6:15 - 8:15 pm Awards & Installation Dinner (Hearth Room) • 2015 MAFP Family Physician of the Year Award • Soaring Eagle Award • Installation of MAFP President & Board Members • AAFP Degree of Fellow Convocation • Tar Wars Poster Contest Award

Sunday, June 7, 2015 9:15 - 11:00 am Commission Meetings with Continental

Breakfast

(Advocacy-Hearth Room & Education and

Member Services-Cypress Board Room)

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MAFP American Academy of Sleep Medicine

indicators of and screening for osa Matthew Scharf, MD, PhD Ilene M. Rosen, MD, MSCE

Case: A 49 year old man with a history of GERD and depression presents for his annual physical. He denies any significant complaints except that he is exhausted which he attributes to increased demands at work. He reports difficulty staying awake at meetings and when working on his computer. He notes a 10 pound weight gain over the past 6 months. On further questioning, he endorses loud snoring and nocturnal gasping for air. Upon awakening, he sometimes finds that his wife has left the bedroom. His medications include omeprazole and escitalopram. His current blood pressure is 148/102, and his body mass index is 31.71 kg/m2. A fasting comprehensive metabolic panel is normal except for a glucose of 104 (normal=70-99). He is started on hydrochlorothiazide and referred to a sleep specialist.

Obstructive sleep apnea (OSA) is a common condition in the United States and worldwide.

Prevalence estimates range from 2-7% in the general population1 but is particularly high in certain cohorts. A prevalence of OSA of over 70% has been reported obese Type II diabetics2 and in patients undergoing bariatric surgery3-4 and with drug-resistant HTN.5 The prevalence of OSA is also high in patients following acute stroke6 and acute coronary syndrome7, as well as in the elderly.8-10 However, the majority of cases of OSA 26 Missouri Family Physician April-June 2015

in the U.S. remain undiagnosed.11-12 OSA is not a benign condition. It is a systemic disorder since the repetitive falls in oxygen affect all organ systems. Untreated OSA can result in serious morbidity and mortality. OSA is associated with hypertension13, impaired glucose control14, congestive heart failure15, coronary heart disease15, mild cognitive impairment or dementia16, depression17, atrial fibrillation18, and stroke.19 OSA, particularly severe OSA, is associated with increased mortality.20 In addition to the health risks, OSA may cause problems with everyday life. Loud snoring may cause the bed partner to sleep in a separate room. Significant sleepiness may interfere with the ability to participate in social activities and perform well at work. Sleepiness is particularly concerning when operating motor vehicles. In fact, OSA has been shown to cause significant impairments in the ability to carry out a simulated driving task21-22 and increases the risk of a motor vehicle crash among drivers by two-fold.23 There are a number of risk factors for OSA including obesity, increasing neck size (greater than 17 inches), male gender, craniofacial features (e.g. retrognathia and macroglossia) and increasing age.24 It is important for providers to ask about common presenting symptoms such as snoring, witnessed apneas, nocturnal gasping,

American Academy of Sleep Medicine MAFP

LITTLE SLEEP, morning dry mouth, feeling unrefreshed on awakening from sleep, and excessive daytime sleepiness (e.g. as measured by the Epworth Sleepiness Scale25). Particular attention should be paid to patients with a history of stroke, refractory hypertension, coronary artery disease as well as to obese type II diabetics and to individuals with depression or new onset atrial fibrillation.

Case Discussion: The patient is obese, has loud snoring and is sleepy to the point that it is interfering with his work. He likely has OSA. This corresponds with his weight gain and sleep problems in the past 6 months, and may contribute to his borderline hyperglycemia and HTN. He requires a sleep study and would likely benefit from treatment.

While a clinical scenario may be strongly suggestive of OSA, the diagnosis of OSA is made by polysomnography. Polysomnography is typically performed in a sleep laboratory and includes electroenceophalographic (EEG), electromyographic, respiratory and electrocardiographic measurements. Portable studies can be done at home as well using devices that provide respiratory and ECG monitoring but not EEG recording. An event is considered obstructive if there is continued respiratory effort observed in the thoracic or abdominal sensors with absent airflow.

Apneas are scored as >90% reduction in breathing, and hypopneas are scored as a >30% reduction in breathing associated with an oxyhemoglobin desaturation of 3%.26 In-laboratory polysomnography can also utilize EEG arousals following a >30% reduction in airflow to score hypopneas. Both apneas and hypopneas last for at least 10 seconds in duration. The number of respiratory events per hour is called the apnea-hypopnea index (AHI). An AHI<5 is considered normal, 5-<15 is considered mild, 15<30 is considered moderate, â&#x2030;Ľ30 is considered severe.

In general, the adverse health consequences of OSA are higher with increasing AHI. Home sleep studies are appropriate for patients with a high pre-test probability of OSA. In-lab polysomnography should be used for individuals with moderate pre-test probability of OSA and may also be indicated in patients for whom there is a concern of another sleep disorder (such as central sleep apnea or a parasomnia) or nocturnal hypoventilation.

As the sensitivity of unattended studies is lower than in-lab studies for OSA, in-lab studies can be considered in patients for whom an unattended study is negative, but a high clinical suspicion for OSA remains.

References for this article can be found on page 30 of this publication.

BIG COST

In the U.S. 3 in 10 working adults sleep 6 hours or less in a 24-hour period.

Short sleep is more common in certain professions.

ALL SHIFTS

NIGHT SHIFTS

Mining and Quarrying

41.6%

Transportation and Warehousing

69.7%

Utilities and Power

38.0%

Health Care and Social Assistance

52.3%

Public Administration

34.3%

Public Administration

44.1%

Manufacturing

34.1%

Manufacturing

41.4%

Transportation and Warehousing

32.7%

Accommodation and Food Service

37.8%

NIGHT SHIFT WORKERS ARE MOST LIKELY TO GET INSUFFICIENT SLEEP.

Sleeping six hours or less per night INCREASES RISK FOR: Obesity by

Stroke by

Diabetes by

Coronary heart disease by

21%

22%

25%

35%

5 Warning Signs You Need Sleep 1

2

You start to doze off when you are driving

You are forgetful or make mistakes

3 You feel fatigued or lack energy

4

5

You are irritable, grouchy or lose your temper easily

You rely on caffeine to get through the day

Make it a priority to get at least 7 hours of nightly sleep.

SLEEP WELL,

BE WELL Sources: Journal Sleep: http://bit.ly/1vnM3uN CDC: http://1.usa.gov/10lLfw2

THIS INFOGRAPHIC WAS SUPPORTED BY THE COOPERATIVE AGREEMENT NUMBER 1U50DP004930-01 FROM THE CENTERS FROM DISEASE CONTROL AND PREVENTION (CDC). ITS CONTENTS ARE SOLELY THE RESPONSIBILITY OF THE AUTHORS AND DO NOT NECESSARILY REPRESENT THE OFFICIAL VIEWS OF THE CDC.

projecthealthysleep.org

Missouri Family Physician April-June 2015

27

MAFP KC and STL Chapter Officer Installations

meet your new 2015 st. louis & kansas city chapter officers

I

n January, the St. Louis chapter held a dinner to honor the newly installed officers. The Kansas City chapters' installation was held in February.

A big welcome and thank you to all members serving the St. Louis and Kansas City chapters. Your hard work and dedication is much appreciated.

Top: Angela Barnett, MD, KCAFP president (left) and Emily Lott, MD, KCAFP vice president.

Center: MAFP Chair, Bill Fish, MD, FAAFP installs Andrea Baxter, MD as the new SLAFP president.

Bottom: Past SLAFP Presidents, L to R: Arturo Montes, MD, FAAFP, Kate Lichtenberg, DO, MPH, FAAFP, Walt Sumner, MD, and David Schneider, MD, FAAFP with new SLAFP President, Andrea Baxter, MD.

meet your local chapters' board officers StL Board Officers President Andrea Baxter, MD Past President F. David Schneider, MD, FAAFP President-Elect Joule Stevenson, MD Vice-President Edina Karahodzic, MD Treasurer Christine Jacobs, MD, FAAFP Secretary Lauren Wiffling, DO Board Members Kara Mayes, MD Emily Doucette, MD Rosa Galvez-Myles, MD Gena Gardiner, MD Tonya Little, MD Tina Bosslet Trost, MD Chris Blanner, MD Mahrukh Khan, MD William Manard, MD

28 Missouri Family Physician April-June 2015

KC Board Officers President Angela Barnett, MD Vice President Emily Lott, MD Secretary/Treasurer TBD Board MEMBERS Mark Martin, MD Donald Potts, MD, FAAFP Ed Kraemer, MD Emily Lott, MD Angela Barnett, MD John Stanley, MD Bradley Chrisjohn, DO Annette Acosta-Dickson, MD

Top Ten Award-Winning Medical School MAFP

top ten award recipient - university of missouri-columbia school of medicine Once again, the University of Missouri-Columbia School of Medicine was one of the AAFP's list of the top ten medical schools in the country for producing family medicine graduates. The winner will receive a 2015 AAFP Top Ten Award next month.

AAFP President, Dr. Robert Wergin, will present these awards during the Society of Teachers of Family Medicine (STFM) Annual Spring Conference on Sunday, April 26th, in Orlando.

2015 Family Medicine Top Ten Awards •University of North Dakota School of Medicine and Health Sciences: 20.8% •University of Kansas School of Medicine: 19.7%

•University of Minnesota Medical School: 18.8% •Brody School of Medicine at East Carolina University: 18.5% •University of Washington School of Medicine: 17.6% •Oregon Health and Science University School of Medicine: 16.9% •Florida State University College of Medicine: 16.2% •University of Missouri – Columbia School of Medicine: 16.0% •University of Wisconsin School of Medicine and Public Health: 15.9% •University of California, Irvine School of Medicine: 15.8% •University of New Mexico School of Medicine: 15.8%

attention residents

Do you need to be published?

Are you interested in submitting your report to be published as a Resident Grand Rounds article in our quarterly Missouri Family Physician magazine?

Contact MAFP staff at (573) 635-0830 or email office@mo-afp.org for more information.

Missouri Health Professional Placement Services (MHPPS) is a non-profit recruiting service dedicated to rural and underserved areas of our great state! We partner with safety-net providers and health care systems throughout Missouri to help health care professionals, like yourself, find a community that best fits your personal and professional needs. Whether it’s a scenic rural setting, dynamic urban location, or somewhere in between, we are committed to focusing on your interests and careers that count!

Find Out More: Joni Adamson 573.636.4222 jadamson@mo-pca.org www.3rnet.org/locations/missouri

Family Medicine Opportunities -

Available throughout MO’s Rural & Urban Areas Loan Repayment Options Competetive Salary & Comprehensive Benefits Contact us Today!

Proud Partners:

MHPPS is located within the MO Primary Care Association Missouri Family Physician April-June 2015

29

MAFP For Your Information OSA Article References: 1. Punjabi NM. Proc Am Thorac Soc. 2008;5(2):136-43. The epidemiology of adult obstructive sleep apnea.

2. Foster GD, Sanders MH, Millman R, Zammit G, Borradaile KE, Newman AB, Wadden TA, Kelley D, Wing RR, Sunyer FX, Darcey V, Kuna ST; Sleep AHEAD Research Group. Diabetes Care.

2009;32(6):1017-9. Obstructive sleep apnea among obese patients with type 2 diabetes.

3. Frey WC, Pilcher J. Obes Surg. 2003;13(5):676-83. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery.

4. Lopez PP1, Stefan B, Schulman CI, Byers PM. Am Surg. 2008;74(9):834-8. Prevalence of sleep apnea in morbidly obese patients who presented for weight loss surgery evaluation: more evidence for routine screening for obstructive sleep apnea before weight loss surgery.

5. Logan AG, Perlikowski SM, Mente A, Tisler A, Tkacova R, Niroumand M, Leung RS, Bradley TD. J Hypertens. 2001;19(12):2271-7. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension.

6. Turkington PM, Bamford J, Wanklyn P, Elliott MW. Stroke. 2002;33(8):2037-42. Prevalence and predictors of upper airway obstruction in the first 24 hours after acute stroke.

7. Yumino D1, Tsurumi Y, Takagi A, Suzuki K, Kasanuki H. Am J Cardiol. 2007;99(1):26-30. Impact of obstructive sleep apnea on clinical and angiographic outcomes following percutaneous coronary intervention in patients with acute coronary syndrome.

8. Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O. Sleep.

1991;14(6):486-95Sleep-disordered breathing in community-dwelling elderly.

9. Ancoli-Israel S, Klauber MR, Butters N, Parker L, Kripke DF. J Am Geriatr Soc. 1991;39(3):258-63.

Dementia in institutionalized elderly: relation to sleep apnea.

10. Aoki K, Matsuo M, Takahashi M, Murakami J, Aoki Y, Aoki N, Mizumoto H, Namikawa A, Hara H, Miyagawa M, Kadotani H, Yamada N. J Sleep Res. 2014;23(5):517-23. Association of sleepdisordered breathing with decreased cognitive function among patients with dementia.

11. Young T1, Evans L, Finn L, Palta M. Sleep. 1997;20(9):705-6. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women.

12. Kapur V1, Strohl KP, Redline S, Iber C, O'Connor G, Nieto J. Sleep Breath. 2002;6(2):49-54.

Underdiagnosis of sleep apnea syndrome in U.S. communities.

13. Marin JM, Agusti A, Villar I, Forner M, Nieto D, Carrizo SJ, Barbé F, Vicente E, Wei Y, Nieto FJ, Jelic S. JAMA. 2012;307(20):2169-76. Association between treated and untreated obstructive sleep apnea and risk of hypertension.

14. Babu AR1, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea. Arch Intern Med. 2005;165(4):44752.

15. Gottlieb DJ, Yenokyan G, Newman AB, O'Connor GT, Punjabi NM, Quan SF, Redline S, Resnick HE, Tong EK, Diener-West M, Shahar E. Circulation. 2010;122(4):352-60. Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study.

16. Yaffe K, Laffan AM, Harrison SL, Redline S, Spira AP, Ensrud KE, Ancoli-Israel S, Stone KL. JAMA 2011;306(6):613-9. Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women.

17. Wheaton AG, Perry GS, Chapman DP, Croft JB. Sleep. 2012;35(4):461-7. Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005-2008.

18. Mehra R, Benjamin EJ, Shahar E, Gottlieb DJ, Nawabit R, Kirchner HL, Sahadevan J, Redline S. Am J Respir Crit Care Med. 2006;173(8):910-6. Sleep Heart Health Study. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study.

19. Redline S1, Yenokyan G, Gottlieb DJ, Shahar E, O'Connor GT, Resnick HE, Diener-West M, Sanders MH, Wolf PA, Geraghty EM, Ali T, Lebowitz M, Punjabi NM. Am J Respir Crit Care Med. 2010;182(2):269-77. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study.

20. Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, Stubbs R, Hla KM. Sleep.

2008;31(8):1071-8. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort.

21. George CF1, Boudreau AC, Smiley A. Am J Respir Crit Care Med. 1996;154(1):175-81. Simulated driving performance in patients with obstructive sleep apnea.

22. Hoekema A1, Stegenga B, Bakker M, Brouwer WH, de Bont LG, Wijkstra PJ, van der Hoeven JH. Sleep Breath. 2007;11(3):129-38. Simulated driving in obstructive sleep apnoea-hypopnoea; effects of oral appliances and continuous positive airway pressure.

23. Tregear S, Reston J, Schoelles K, Phillips B. J Clin Sleep Med. 2009;15;5(6):573-81. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis.

24. Punjabi NM. Proc Am Thorac Soc. 2008;5(2):136-43. The epidemiology of adult obstructive sleep apnea.

25. Murray W Johns. Sleep. 1991; 14 (6): 540-545. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.

26. Berry RB, Brooks R, Gamaldo CE, Harding SM, Marcus CL and Vaughn BV for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.0. www.aasmnet.org, Darien, Illinois: American Academy of Sleep Medicine, 2012.

This article was developed through the National Healthy Sleep Awareness Project, a joint effort of the Centers for Disease Control and Prevention (CDC), American Academy of Sleep Medicine (AASM) and the Sleep Research Society (SRS). Visit www.sleepeducation.org for more information.

This article was supported by the cooperative agreement number 1U50DP004930-01 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

30 Missouri Family Physician April-June 2015

Choosing Wisely® The Choosing Wisely® (www.choosingwisely.org) campaign was created as an initiative of the American Board of Internal Medicine (ABIM) Foundation (www. abimfoundation.org) to improve health care quality.

More than 50 specialty societies have identified commonly used tests or procedures within their specialties that are possibly overused. The American Academy of Family Physicians (AAFP) remains committed to supporting the Choosing Wisely® campaign with the goal of ensuring high-quality, costeffective care to patients.

The AAFP has identified 15 tests and procedures that both doctors and patients should carefully consider and openly discuss before incorporating them into a treatment plan.

Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms: There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.

Sources U.S. Preventive Services Task Force (USPSTF).

Phone: (573) 635‐0830 Tax ID 90‐0162481 www.mo‐afp.org

For Your Information MAFP

What is the MAFP PAC? MAFP PAC is the state political action committee of the Missouri Academy of Family Physicians. MAFP PAC is a special organization set up to collect contributions from a large number of people, pool those funds and make contributions to state election campaigns.

annual business meeting & legislative luncheon Where does my donation go? MAFP PAC will make direct contributions to candidates for the Missouri General Assembly (either State

House of Representatives or State Senate), and statewide offices. Contribution decisions are made in a nonpartisan way based on Missouri Academy of Family Physicians' Annual Business Meeting and Legislative Luncheon candidates’ positions, policies and voting records as they relate to family physicians and our patients. Direct contribution decisions are will be held at the 67th Annual Scientific Assembly on June 6, 2015 at the made by the PAC Committee.

Lodge at Old Kinderhook in Camdenton, Missouri from 11:45 am to 1:30 pm.

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Funds to be used for donations to candidates must be raised separately from membership dues. Voluntary MAFP PAC donations are what will enhance MAFP’s clout in the elections and with elected members of the Legislature.

“Your voice in the political process.”

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Donate online at: www.mo-afp.org or mail the form below to: 722 West High Street, Jefferson City, MO 65101

MAFP PAC is the state Political Action Committee of the Missouri Academy of Family Physicians. MAFP PAC is a special organization set up to collect contributions from a large number of people, pool those funds and make contributions to state election campaigns. The MAFP PAC is a bipartisan group dedicated to helping pro-family medicine candidates win election to public office and educating current legislators on the importance of family medicine. The Missouri Academy of Family Physicians also contracts a lobbyist to help ensure that our members’ positions are supported throughout the state legislative process.

Missouri Family Physician April-June 2015

31

MAFP

Learn more about our Center for Pediatric Genomic Medicine at ChildrensMercy.org/ Genomics

A FASTER, MORE PRECISE PATH TO DIAGNOSIS AND TREATMENT. As many as one in three newborns admitted to a NICU suffers from a genetic disease. The difference between life and death is often a quick diagnosis that expedites treatment. At Children’s Mercy Kansas City, our Center for Pediatric Genomic Medicine is developing genetic testing that’s helping transform the lives of patients around the world.

A FASTER, MORE PRECISE PATH TO DIAGNOSIS AND TREATMENT.

c

We’ve developed the world’s fastest genome sequencing test, so that you can diagnose patients in as few as 50 hours. We’ve also developed a single to detect more than 750to diseases thatsuffers are the result mutation.

As many as one in three test newborns admitted a NICU fromof aa single genetic Beyond the NICU, we’re collaborating with pediatric subspecialists throughout disease. The difference between life and death is often a quick diagnosis that Children’s Mercy in many of our clinics, including Nephrology, Endocrinology, expedites treatment. At Children’s Mercy City,allows our us Center Pediatric Gastroenterology and Kansas Oncology. This to betterfor understand the genetic causes of diseases andtesting minimizes unnecessary testing while delivering Genomic Medicine is developing genetic that’s helping transform the faster and more accurate diagnoses—improving outcomes for children everywhere.

lives of patients around the world.

32

We’ve developed the world’s fastest genome sequencing test, so that you can diagnose patients in as few as 50 hours. We’ve also developed a single test to detect more than 750 diseases that are the result of a single mutation.

Beyond the NICU, we’re collaborating with pediatric subspecialists throughout Children’s Mercy in many of our clinics, including Nephrology, Endocrinology, Gastroenterology and Oncology. This allows us to better understand the genetic causes of diseases and minimizes unnecessary testing while delivering faster and Family morePhysician accurate diagnoses—improving outcomes for children everywhere.

Missouri April-June 2015