Spring 2017 (April-June)

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician April-June 2017 Volume 36, Issue 2

'SHOW ME SHAFFER' Todd D. Shaffer announces run for 2017 AAFP Board of Directors Page 16

SPRING ISSUE FOCUS:

ACHIEVING HEALTH EQUITY

executive commission Board Chair - Peter Koopman, MD, FAAFP (Columbia) President - Kathleen Eubanks-Meng, DO (Blue Springs) President-Elect - Mark Schabbing, MD (Perryville) Vice President - Sudeep Ross, MD (Kansas City) Secretary/Treasurer - James Stevermer, MD, FAAFP (Fulton) board of directors District 1 Director: John Burroughs, MD (Kansas City)

Alternate: Jared Dirks, MD (Kansas City) District 2 Director: Lisa Mayes, DO (Macon)

Alternate: Vacant District 3 Director: Vacant

Director: Sarah Cole, DO, FAAFP (St. Louis)

Alternate: Kara Mayes, MD (St. Louis) District 4 Director: Jennifer Scheer, MD, FAAFP (Gerald)

Alternate: Kristin Weidle, MD (Washington) District 5 Director: Lucas Buffaloe, MD (Columbia)

Alternate: Vacant District 6 Director: Jamie Ulbrich, MD, FAAFP (Marshall)

Alternate: David Pulliam, DO, FAAFP (Higginsville) District 7 Director: Wael Mourad, MD, FAAFP (Kansas City)

Director: Afsheen Patel, MD (Kansas City)

Alternate: Ryan Sears, DO (Lee's Summit) District 8 Director: Mark Woods, MD (Ozark)

Alternate: Charlie Rasmussen, DO, FAAFP (Branson) District 9 Director: Patricia Benoist, MD, FAAFP (Houston)

Alternate: Vacant District 10 Director: Deanne Siemer, MD (Jackson)

Alternate: Vicki Roberts, MD, FAAFP (Cape Girardeau) Director At Large Emily Doucette, MD (St. Louis) resident directors

MARK YOUR CALENDAR AAFP Annual Chapter Leadership Forum/National Conference of Constituency Leaders April 27-29, 2017 Sheraton Kansas City Hotel at Crown Center, Kansas City, MO

AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 27-29, 2017 Kansas City Convention Center, Kansas City, MO

AAFP Family Medicine Congressional Conference May 22-23, 2017 Washington Court Hotel, Washington, DC

AAFP Congress of Delegates September 11-13, 2017 Grand Hyatt, San Antonio, TX

MAFP 69th Annual Scientific Assembly (ASA) June 9-11, 2017 The Lodge at Old Kinderhook, Camdenton, MO MAFP Board of Directors Meeting June 11, 2017 The Lodge at Old Kinderhook, Camdenton, MO

AAFP Family Medicine Experience (FMX) September 12-16, 2017 Grand Hyatt, San Antonio, TX MAFP 25th Annual Fall Conference & KSA Working Group November 10-11, 2017 Big Cedar Lodge, Ridgedale, MO

ANNUAL BUSINESS MEETING & LEGISLATIVE LUNCHEON NOTICE The Missouri Academy of Family Physicians' Annual Business Meeting & Legislative Luncheon will be held at the 69th Annual Scientific Assembly on Saturday, June 10, 2017 at The Lodge at Old Kinderhook in Camdenton, MO from 11:45 am to 1:30 pm.

Kanika Turner, MD (SLU) Alicia Brooks, MD (Alternate) (SLU) student directors

INSIDE THIS ISSUE

Emily Gray (UMKC) John Heafner, MSPH (Alternate) (SLU)

Pg.

aafp delegates Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate mafp staff Executive Director - Kathy Pabst, MBA, CAE Communications and Education Manager - Sarah Mengwasser Membership and Programs Coordinator - Becki Hughes 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 The information contained in Missouri Family Physician is for information purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

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Executive Director's Column Chair's Report Resident Grand Rounds Help Desk Answers DHSS: Health Disparities in Rural MO Advocacy Day Recap MAFP Key Issues Legislative Update Q&A with Dr. Shaffer Munger; Barbe Lead National Groups Members in the News Family Physician of the Year Nominees Annual Scientific Assembly Schedule of Events and Registration Form KC & STL Chapter Updates AAFP News Cancer Health Disparities Match Day Multi-State Recap

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EXECUTIVE DIRECTOR'S COLUMN

Equity, not equality

h

ere we are getting ready to wrap up the 99th General Assembly Legislative Session, but this magazine is being prepared several weeks prior to the gavel dropping to close this session. Your Academy is actively protecting family physicians and their patients through our advocacy efforts at the capitol, but also through collaborating with other statewide groups such as the Missouri Diabetes Shared Learning Network, Tobacco Free Missouri, Missouri Health Care Workforce Coalition, Distracted Drivers Work Group, Mother and Child Health Coalition, Missouri Advisory Committee on Childhood Immunizations, and the list goes on. The MAFP staff and members are there, actively promoting quality health care for all.

The common dominator with each of these groups and others is that they all focus on improving patient health and wellbeing. Whether it is a choice between what to eat, which bills to pay, medicine to take, breaking an addiction, or any other health care decision, family physicians are there with the patients guiding them for a better quality of life.

Yet, not everyone is able to make the best choice; whether it is because of their environment, personal characteristics, mental wellness, or other disparities that impact their life’s choices. I state “life’s” choices because sometimes the choice is made for our patients because of life, and is out of their control. How do they obtain equity in life’s basic necessities? Articles in this edition of the magazine focus on disparities and inequities of Missourians, and the challenges and cost of these inequities.

What more can we do as an individual, organization, community, and state?

You are in the trenches helping Missourians make a better life for themselves...seeing patients in your

clinic, volunteering at community medical clinics, serving on mission trips, providing emergency care at school events, and we won’t go into the administrative responsibilities and expectations, but the list goes on and on.

Experts provide us with insight into the impact of disparities and inequalities through data and its analysis. But what does it mean, and how do we use it to improve patient care? Andrew Hunter, Bureau Chief, Bureau of Health Care Analysis and Data Dissemination, with the Missouri Department of Health and Senior Services, wrote an article found on page 10 which analyzes data impacting Missouri’s rural population. Peter Koopman, MD, FAAFP, MAFP Board Chair, shares his perspective on the slow matriculation of family medicine, the invisible benefits of maintaining good health, and the hopeful positive outcomes of receiving preventive care.

Kathy Pabst, MBA, CAE, Executive Director

"

Yet, not everyone is able to make the best choice; whether it is because of their environment, personal characteristics, mental wellness, or other disparities that impact their life’s choices."

Lastly, Lannis Hall, MPH, MD, Siteman Cancer Center at Barnes-Jewish St. Peters Hospital, writes an article on cancer health disparities and the progress necessary to reduce them. Her research is shared in an article in this magazine on page 24.

Yet, these articles don’t touch the magnitude of the problem…but we get it, we live it. Family physicians are at the forefront of this challenge always hoping and working towards better outcomes for their patients.

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CHAIR'S REPORT

Over the hills and far away

i Peter Koopman, MD, FAAFP

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recently became more involved in medical student education at Mizzou. As an Associate Clerkship Director for the University of Missouri Medical School's Family Medicine Clerkship, I have taken over the task of recruiting, retaining, and evaluating community family medicine preceptors. During this transition, I have learned some of our specialty’s history. Mizzou’s program is one of the oldest (actually second oldest) of required family medicine third-year clerkships in U.S. medical schools. Family medicine was recognized by the American Board of Medical Specialties as the 20th medical specialty in 1969 (the first since the 1940s). By the early 1970s, the University of Missouri had both a department and a required clerkship. This was an unusually fast uptake in Missouri. This rapid adoption in Missouri occurred for many reasons. Some had to do with local, powerful advocates (The AAFP offices remain close by in the Kansas City area, in part, also for this reason); but also by active leaders at the university who, prior to the specialty becoming named, had formed a division of Community Health and Medical Practice in the early 1960s. In contrast to this rapid adoption, when I graduated from the University of Pittsburgh Medical School in 1992 (20 years later) there was a skeletal department of family medicine, and no required clerkship.

Reflecting on this slow adoption of family medicine led me to consider the article by Atul Gawande in The New Yorker from July 29th 2013 called Slow Ideas (www.newyorker.com/ magazine/2013/07/29/slow-ideas) in which he described the difference between the adoptions of anesthetic techniques to surgery versus aseptic techniques. Both were implemented in the late 1800s, but it took anesthesia seven years (way before the internet age) for it to be widely adopted by all British and American surgeons; yet more than 40 years for true aseptic techniques to be similarly adopted. Both techniques were equivalent in cost, both were of benefit to the patient, but one idea spread widely and quickly, while the other took more than a generation. Gawande postulates on reasons, and I agree, that the likely primary reason is that anesthesia was immediately visible to help the patient and made the surgeons life easier; where as aseptic technique combatted invisible germs, and when worked well, was preventative, unseen, and made the surgeons life harder (hand washing, changing gowns, original antiseptic

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carboxylic acid burned hands).

I believe similar to aseptic technique, family medicine is a slow idea. When we do our job well, nothing happens. Patients do not get sick.

They improve their health and stay well or better manage their chronic disease. They stay out of the hospital. Patients do not see that advantage as easily as they see what happens after a knee replacement. The “idea” of family medicine has been more defined in the last 40 years (AAFP definition - (www.aafp.org/about/policies/all/ family-medicine-definition.html) but not yet fully accepted by our patients or our colleagues. This is happening slowly.

"

In the future we will have a system in the U.S. that accepts that the idea that family medicine is essentially important and needs to be widely adopted. The result, as proven in many other countries, will be that American healthcare will become better, cheaper and more equitable.

I have hope."

I have hope. In the future we will have a system in the U.S. that accepts the idea that family medicine is essentially important and needs to be widely adopted. We will adopt policies to support this idea. All medical schools will emphasize and support this idea. The population and health care systems will understand and respect the importance of this idea as they do aseptic technique. The result, as proven in many other countries, will be that American healthcare will become better, cheaper, and more equitable. I have hope.

Through our exceptional health care services, we reveal the healing presence of God.

SSM Health St. Mary’s Hospital in Jefferson City has exciting opportunities for family medicine physicians looking in Mid-Missouri. We have multiple clinics to choose from including Jefferson City and a network of rural health clinics throughout Mid-Missouri.

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SSM Health has been providing health care services since 1874 Outpatient only Four-day work week Great colleagues who are active in the community and enjoy collaborating Beautiful new hospital opened in November of 2014 Competitive salary, extensive benefits, starting bonus, relocation package, and other incentives available Jefferson City provides a growing economy, exceptional school districts, strong public safety, brief commute times, and a stable employer as the state’s capital Recently named the “Most beautiful small town in America”

To be considered for any of our openings,

please send your CV to Todd.Vandewalker@ssmhealth.com.

If you have any questions, please call 573-681-3384 (office) or 573-999-7477 (cell).

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RESIDENT GRAND ROUNDS

Special delivery: An update on OB best practices Objectives • Discuss several influential obstetric studies, systematic reviews, and meta-analyses that have been published over the last year (2016-2017).

• Point out literature strengths and limitations, as well as areas needing further investigation.

• Highlight practice-changing recommendations based on this new research.

Antenatal Betamethasone for Women at Risk for Late Preterm Delivery New England Journal of Medicine – Published April 7, 2016 (reference #2) Andrea Schuster, MD University of Missouri Family Medicine Residency

• Previous practice: Antenatal glucocorticoids were administered to all women at risk for delivery in the early preterm period (<34 weeks gestation), due to clear evidence of improved neonatal respiratory outcomes. This recommendation was not extended to those at risk for late preterm delivery (34 0/7 weeks to 36 6/7 weeks gestation), due to a lack of sufficient data showing benefit and it was thought that infant survival was within 1% of term infants at >34 weeks gestation. However, further study made it clear that late preterm infants have more complications as neonates and in childhood than infants born at term.

• Study objective: To evaluate whether betamethasone administered in the late preterm period decreases neonatal complications.

• Methods • RCT conducted at 17 university-based clinical center between Oct 2010 – Feb 2015 • Inclusion criteria • Singleton pregnancy • 34.0-36.5 weeks gestation • High probability of delivery in late preterm period • Exclusion criteria

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RESIDENT GRAND ROUNDS

• Received glucocorticoids earlier in pregnancy • Expected to deliver in <12 hours • Chorioamnionitis • Dilation ≥8 cm • Nonreassuring fetal status • Uncertain gestational age • Double blind randomization in 1:1 ratio to receive two injections, 24 hours apart, of either 12 mg IM betamethasone or placebo. Only ~60% of participants in either study group received both doses of the study drug (betamethasone or placebo) due to difficulty predicting time of delivery.

• Outcomes • Outcomes data extracted from maternal and neonatal charts; Reviewers blinded.

• Primary outcome: Composite endpoint of need for respiratory support within 72 hours after delivery • CPAP or HFNC for >2 consecutive hours • Supplemental O2 with FiO2 ≥30% for >4 continuous hours • ECMO • Mechanical ventilation • Stillbirth • Neonatal death within 72 hours of delivery • Results • Neonates whose mothers received betamethasone were less likely to require respiratory support than those whose mothers received placebo (11.6% vs. 14.4%, RR 0.80, 95% CI 0.66-0.97, P= 0.02). NNT = 35 women.

• Lower rate of severe respiratory complications in betamethasone group (8.1% vs. 12.1%, RR 0.67, 95% CI 0.53-0.84, P<0.001). NNT = 25 women.

• Lower rates in infants in the betamethasone group of transient tachypnea of the newborn, bronchopulmonary dysplasia, resuscitation at birth, surfactant use, and ≥3 day stay in NICU. • Higher incidence of neonatal hypoglycemia in betamethasone group (24.0% vs. 15.0%, RR 1.60, 95% CI 1.37-1.87, P<0.001).

• There were no stillbirths or neonatal deaths within 72 hours of delivery.

• Conclusions • Administering antenatal betamethasone to women at risk of late preterm delivery significantly decreased adverse respiratory outcomes in neonates.

• Betamethasone administration did significantly increase the rate of neonatal hypoglycemia, but not other maternal or neonatal complications.

• No significant differences between groups in gestational age at delivery, incidence of SGA infants, length of hospital stay, rate of neonatal sepsis, necrotizing enterocolitis, intraventricular hemorrhage, hyperbilirubinemia, or hypothermia.

• Practice Changer: “A single course of betamethasone is recommended for pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids.”

– ACOG • Give 12 mg IM betamethasone x2, dosed 24 hours apart (preferred), or 6 mg IM dexamethasone x4, dosed 12 hours apart.

• Even if ability to administer the second dose is unlikely due to timing of delivery, the first dose should still be given.

• There is no benefit to accelerated dosing (giving the second dose sooner than 12 hours after the first dose).

• The greatest benefit occurs when delivery is within two to seven days of the initial dose.

• Neonatal blood glucose should be monitored closely in late preterm infants after in utero betamethasone exposure due to increased risk of neonatal hypoglycemia.

continued on page 26...

MO-AFP.ORG 7

HDAs HelpDesk Answers

Are beta-blockers effective for the treatment of infantile hemangiomas?

EVIDENCE-BASED ANSWER

Treatment of infantile hemangiomas (IH) with oral propranolol (3 mg/kg per day) for 6 months results in complete or near complete resolution in 60% of babies compared with spontaneous resolution in 4% (SOR: B, large RCT).

Propranolol results in at least some improvement in more than 97% of treated infants. Oral propranolol may be more effective than oral steroids and serious adverse events (AEs) are rare (SOR: B, systematic reviews of mostly observational studies).

A

EVIDENCE SUMMARY

Carin E. Reust, MD, MSPH, University of Missouri Columbia

Courtney C. Crider, MD, University of Missouri Columbia

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2015 multicenter, double-blind RCT (N=456) compared 4 different oral propranolol regimens (1 mg/kg per day for 3 or 6 months, and 3 mg/kg per day for 3 or 6 months) with placebo in children, age 1 to 5 months, who had non–life threatening, proliferating IH.¹ The primary endpoint was treatment success, defined as complete or nearly complete resolution of IH assessed by blinded evaluations of standardized photographs over 24 months. Overall, 29% of patients dropped out (65% in placebo group), mostly due to treatment failure.

At 6 months, a planned interim analysis of the first 188 patients showed a treatment success rate of 8% with placebo, 38% with propranolol 1 mg/kg per day, and 63% with propranolol 3 mg/kg per day.

Propranolol dosing for the remainder of the study was 3 mg/kg per day. Final efficacy analysis for all patients showed higher rates of treatment success at 6 months with propranolol 3 mg/kg per day compared with placebo (60% vs 4%; P<.001; NNT=2), with 88% of patients improved by 5 weeks. AEs such as nasopharyngitis, diarrhea, fever, cough, and vomiting occurred in 76% of the placebo group and in 96% of the propranolol group. No difference was noted in serious AEs (worsening of hemangioma, bronchiolitis, bronchitis, apathy, gastroesophageal reflux disease) between the placebo (5.5%) and propranolol (5.9%) groups. Known serious AEs of propranolol therapy (hypotension, bradycardia, hypoglycemia, or bronchospasm) occurred in 2 patients in each group.¹ A 2013 systematic review of 41 trials including retrospective case series, 1 prospective clinical trial, and 1 RCT (N=1,264) looked at the efficacy and safety of oral propranolol in treating IH in children.² Patients’ mean age was 6.6 months (range 3 days–10 years) and 28% had received prior treatment, mainly oral prednisone. Mean propranolol dose was 2.1 mg/ kg per day (range 1–4 mg/kg per day) and average treatment time was 6.4 months. Response was defined as any IH improvement, judged by visual changes in color and size from clinic visits or serial photographs. Mean response rate to propranolol

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was 98% (range 82%–100%), with a 17% relapse rate, defined as increase in size or color, or both. A total of 371 AEs were reported in 39 trials (n=1,189), most commonly sleep changes, acrocyanosis, and gastrointestinal or respiratory issues. Ten symptomatic serious AEs (hypotension, hypoglycemia, bradycardia) were reported.² A 2013 systematic review and meta-analysis (33 studies: retrospective case series and prospective clinical studies) examined the efficacy of systemic steroids and oral propranolol for IH.³ The response rate was variably defined as the change in IH appearance over time based on pigmentation, size, involution, regression, volume, or visual analog scale. Follow-up ranged from 2 weeks to 12 months.

Significant heterogeneity (I²= 68%–95%) was present among studies due to variable IH location and type, medication dosing or duration, and specific measurement of response in each study. No studies directly compared steroids with propranolol.

The response rate was 71% for steroids (10 studies, n=1,416; most common dose 2–3 mg/kg per day) and 97.3% for propranolol (23 studies, n=692; most common dose 2 mg/kg per day). AEs occurred in 17.6% of steroid patients (n=2,697) and 13.7% of propranolol patients (n=699).³

Interested in more HelpDesk Answers?

Get the answers to your clinical questions with a complementary 3 month electronic subscription to

Evidence-Based Practice!

To sign up for your free 3 month subscription, visit www.fpin.org/comp-ebp.

References: 1. Léauté-Labrèze C, Hoeger P, Mazereeuw-Hautier J, et al.

A randomized, controlled trial of oral propranolol in infantile hemangioma. N Engl J Med. 2015; 372(8):735–746.

[STEP 2] 2. Marqueling AL, Vikash O, Frieden IJ, et al. Propranolol and infantile hemangiomas four years later: a systematic review. Pediatr Dermatol.

2013; 30(2):182–191.

[STEP 2] 3. Izadpanah A, Izadpanah A, Kanevsky J, et al. Propranolol versus corticosteroids in the treatment of infantile hemangioma: a systematic review and meta-analysis.

Plast Reconstr Surg. 2013; 131(3):601–613. [STEP 2]

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MO-AFP.ORG 9

Health disparities in Missouri's rural population

T Andrew Hunter, Missouri Department of Health and Senior Services

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he Missouri Department of Health and Senior Services (DHSS) captures and analyzes data from several state surveillance systems. Some examples of the major systems include vital records (births and deaths), hospital and emergency room discharge data and the Missouri Cancer Registry, among others. The Bureau of Health Care Analysis and Data Dissemination (BHCADD) is charged with managing and maintaining some of the data systems mentioned above, as well as disseminating findings to local, state and national stakeholders. One of the most important ways data is disseminated is through the Missouri Public Health Information Systems (MOPHIMS) website, which houses the Missouri Information for Community Assessment (MICA) query tool. (https://webapp01.dhss.mo.gov/ MOPHIMS/MOPHIMSHome). MICA is an online tool that allows the public to access aggregated Missouri resident data on many of the health surveillance systems.

Another way BHCADD disseminates public health findings is through the development of reports, including Health in Rural Missouri.

This report is produced every other year in collaboration with the Office of Primary Care and Rural Health (also situated in DHSS). Presented here are some highlights and excerpts, with updated statistics, from the most recent version of Health in Rural Missouri.

The state of Missouri has a population of just over 6 million. About 63% of the population lives within the 14 counties defined in the report as urban. The remaining 37% of Missouriâ&#x20AC;&#x2122;s population resides in the remaining 101 rural

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counties. An analysis of key health indicators reveals significant disparities between Missouriâ&#x20AC;&#x2122;s rural and urban populations. This can be demonstrated by examining known social determinants of health. For example, poverty rates are higher in rural areas while rates of higher education are significantly lower. Health status indicators such as life expectancy show rural Missouri residents live shorter lives than their urban counterparts (76.8 versus 77.8 years).

Maternal and child health indicators also reveal disparities, such as a higher teen pregnancy rate for rural areas as well as a slightly higher infant mortality rate.

One area that may be of particular interest to family physicians is disparities associated with chronic lower respiratory diseases (CLRDs). The category of CLRD includes chronic obstructive pulmonary disease (COPD), emphysema, asthma, bronchiectasis, non-acute bronchitis and other forms of chronic airway obstruction. In the past decade, CLRD has surpassed stroke and now ranks as the third leading cause of death for both rural and urban Missourians, behind only heart disease and cancer. Over the 2010-2014 time period, the rural CLRD death rate of 60.48 (age adjusted per 100,000 population) is 32% higher than the urban rate of 45.69. Further analysis shows that the urban-rural rate difference is statistically significant. Geographically, 34 counties have CLRD death rates that are statistically significantly higher than the state average. All but two of the 34 counties are rural.

The largest concentration of these counties is located in the southeast corner of the state.

DHSS

CLRD Mortality Rates by County 2010-2014

LEGEND

Statistically lower than state Note statistically significant Statistically higher than state Unreliable (<20 cases)

Rural CLRD death rates are significantly higher than urban rates for both males and females. In addition, males have significantly higher CLRD death rates than females in both rural and urban areas. However, the gender disparity in rural areas is much greater than in urban areas, with rural males having a 32% higher death rate than rural females. In contrast, the urban male death rate is only 16% higher than the urban female rate.

Death Rates for CLRD Missouri, 2010-2014

Male Female

Urban

Rural

Age-adjusted rates per 100,000 residents

More statistics on CLRD are available through the use of emergency room (ER) data. One of the major sub-categories for CLRD is COPD (and bronchiectasis). The rural COPD ER visit rate is statistically significantly higher than the urban rate (7.08 versus 4.64 age-adjusted per 1,000 population). Rural COPD ER visit rates are significantly higher than urban rates for both males and females. In contrast to CLRD mortality where men had higher rates, for COPD ER visits, rural and urban female residents are discharged at significantly higher rates than their male counterparts. These findings for Missouri are supported by the Centers for Disease Control and Prevention (CDC), which reports that COPD prevalence is higher among women than men. A report by the National Center for Health Statistics suggests that “increased COPD morbidity among

women is believed to reflect increased smoking rates among women beginning in the 1940s....

Although death rates from COPD remained lower among women overall, death rates did not change for women from 1999 through 2007, while they decreased for men.” Taken together, the findings from morbidity and mortality data reveal a marked shift in the relative burden of COPD towards women.

Emergency Room Visit Rates for COPD Missouri, 2010-2014

Rural Urban

Male

Female

Age-adjusted rates per 1,000 residents

Cigarette smoking remains the primary risk factor for developing COPD. Missouri’s adult smoking rate continues to rank near the highest quarter of all U.S. states. Using 2014 Behavioral Risk Factor Surveillance System (BRFSS) results, rural Missouri’s current adult smoking rate is 6.4 points higher than the urban rate (25.1% versus 18.7%). Preventive care addressing tobacco usage and healthy habits could decrease COPD and CLRD morbidity and mortality rates in both urban and rural geographies.

For more information on urban/rural disparities, please view the full Health in Rural in Missouri report (http://health.mo.gov/living/families/ ruralhealth/publications.php). For additional questions on rural/urban health disparities or for information about other health statistics that are available through the DHSS website please visit the new MOPHIMS website (https://webapp01. dhss.mo.gov/MOPHIMS/MOPHIMSHome) or contact Andrew Hunter or Whitney Coffey (Andrew. hunter@health.mo.gov or whitney.coffey@health. mo.gov).

Akinbami, L.J. and Liu, X. (June 2011). Chronic Obstructive Pulmonary Disease Among Adults Aged 18 and Over in the United States, 1998-2009. NCHS Data Brief, 63. Hyattsville, MD: National Center for Health Statistics. Accessed March 13, 2017, from http://www. cdc.gov/nchs/data/databriefs/db63.pdf.

MO-AFP.ORG 11

ADVOCACY DAY '17

Family physicians promote quality patient care at the state house

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1. UMKC resident, Jacob Shepherd, MD, MAFP President, Kathleen Eubanks-Meng, DO, and Rep. Jeanie Lauer.

2. MAFP Executive Director, Kathy Pabst visits with David Schneider, MD, FAAFP, and residents.

3. John Heafner, John Flo, students from SLU, and Emily Doucette, MD. 4. Kathy Pabst and Jennifer Powell, MD, FAAFP. 5. Todd Shaffer, MD, MBA, FAAFP and Chadwick Byle, MD, a resident from UMKC.

F

amily physicians, residents and students descended on the Capitol in Jefferson City to discuss with our legislative leaders their perspective on legislation making its way through the chambers. Nearly 40 members visited their elected officials on March 1, but not without proper preparation. A quick overview was held at breakfast that morning, and a detailed legislative briefing was conducted the evening before.

Keith Ratcliff, MD, FAAFP, and Emily Doucette, MD, MAFP Advocacy Commission Co-chairs, presented an overview of how a bill becomes a law (kind of like School House Rock, some of you will remember this).

But seriously, the pathway for a bill to become law is long, arduous, and can be quite challenging. Yet, with the guidance of MAFP’s Governmental Consultant, Pat Strader, the attendees understood methods to educate our legislators to better comprehend the impact of legislation on physicians and their patients, as well as the collaboration with other organizations which strengthen our position.

This year’s issues were similar to last year’s, but

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with a few twists and turns. New bills were also included in the mix.

Pat shared her expertise and navigated members through the MAFP priority legislative issues including the continuing effort to encourage legislators to enact an effective prescription drug monitoring program; concerns with legislation that would increase the scope of practice for APRNs while removing significant provisions now required to be contained in a collaborative practice agreement; access to quality health care, patient protection, and other important family medicine issues. MAFP staff, Sarah Mengwasser and Becki Hughes, set up the MAFP booth on the 3rd floor rotunda and greeted legislators, physicians, residents, students and other visitors.

Some residents and students were paired with MAFP members to visit their legislators and see the legislative process in action. Each attendee had the opportunity to report the outcomes of their meeting back to the Missouri Academy and make suggestions for the next Advocacy Day. The day wrapped up with lunch and a board meeting.

MAFP KEY ISSUES

A breakdown of key MAFP issues MAFP SUPPORTS THE DEVELOPMENT OF AN EFFECTIVE STATE PDMP

SUPPORT HCS HB 90 & 68 and SCS SBs 314 & 340 – • Missouri continues to be the only state without a PDMP. PDMPs with local jurisdiction will continue to increase, but may not have the interoperability to effectively report data.

• “…family physicians are working hard to balance the need for adequate pain management with the constant awareness that addiction to opioids is a national health crisis.” (Wanda Filer, MD, FAAFP, AAFP President).

• A PDMP is a clinical tool that can empower physicians to effectively treat and care for their patients.

• More babies are being born with Neonatal Abstinence Syndrome. (HIDI Health Statistics, January, 2017) • Last year, those with heart disease and cancer decreased, while accidents rose significantly on the rankings not due to motor vehicle accidents, but due to drug overdoses.

• The MAFP supports a PDMP that monitors the prescribing and dispensing of all Schedule II through Schedule IV controlled substances, requires dispensers to electronically submit specified information to the department within 24 hours of dispensation, and does not require a pharmacist or prescriber to obtain information about a patient from the database.

• The MAFP is concerned that expanding prescriptive authority of Schedule II medications to other mid-level providers increases the access and availability of addictive opioids.

(HB 823)

MAFP SUPPORTS COLLABORATIVE PRACTICE WITH OUR APRN COLLEAGUES

• MAFP believes the physician-led team approach delivers the best and most cost effective care to Missourians and that APRNs are dedicated, skilled members of the health care team.

• The current collaborative agreement process has served Missouri patients well and MAFP believes it should be maintained in its present form.

• OPPOSE SB 42 and HB 165 – Repealing most provisions of the current APRN collaborative practice agreements, as well as creating a new category of APRN licensure with increased scope of practice.

• OPPOSE HB 244 – By expanding the geographic proximity requirement and increasing the number of collaborative agreements a physician may enter into with an APRN from 3 to 5, the team-based approach to medicine is drastically weakened because effective collaboration is much more difficult.

PATIENTS DESERVE ACCESS TO QUALITY HEALTH CARE • The MAFP believes that all Missourians, regardless of social, economic or political status, race, religion, gender, or sexual orientation should have access to essential health care services and supports measures that increase Medicaid coverage to Missourians who lack affordable health care.

• Hundreds of thousands of low income, working Missourians are still without access to primary care. Most are working adults who do not qualify for Medicaid and are unable to afford plans offered on the health insurance exchange.

• Increased eligibility and transformation of Medicaid services is the most immediate way to provide access to primary care and preventive services, particularly to vulnerable populations.

• If hormonal contraceptive therapy is available over-thecounter, it should be without unnecessary barriers. Pharmacist prescriptive authority for this medication adds a barrier to accessing hormonal contraceptive therapy (oppose that provision of HB 233 and HB 373).

• SUPPORT HB 544 – In order to increase access to primary care for working adults and their families, additional MoHealthNet reimbursement would be made to physicians who provide services after hours.

•OPPOSE HB 601, HB 789, SB 407 – Patient Safety and Radiologic Imaging Act would create an access to care issue in rural areas if clinic STAFF are not allowed to offer in-clinic x-rays.

PROTECT OUR PATIENTS

• SUPPORT HB 312, HB 284, HB 293, HB 378, and SB 253 – Amend texting while driving for all drivers, regardless of age; and prohibiting certain younger drivers from using any electronic wireless communication device (hands-free or not) while operating a vehicle.

• OPPOSE HCS HB 535, HCS HB 576, and HCS HB 588 – Changes to the motorcycle helmet requirements.

• SUPPORT HB 66 – Expands the newborn screening requirements to include spinal muscular atrophy (SMA) and Hunter syndrome.

OTHER IMPORTANT LEGISLATION

• SUPPORT SB 52 – Suicide awareness and prevention services in higher education, includes Show-Me Compassionate Medical Education Act to study medical student suicide.

• SUPPORT HB 569 – Show-Me Compassionate Medical Education Act to study medical student suicide.

• SUPPORT HB 479 – Eliminate “covenants not to compete” from future Missouri contracts between business entities and includes employment contracts between physicians and 501(c) (3) hospitals.

• OPPOSE SB 263 and HB 209 – Allows chiropractors to become Medicaid providers. MoHealthNet is already underfunded with low reimbursement rates. Adding another set of providers, without adding appropriate funding, would only make the situation worse by taking away dollars for primary and preventive care.

• SUPPORT HB 153 and SB 200 – Increasing the standard for admission of expert testimony.

• SUPPORT SB 31 and HB 95 – Evidence may be introduced of the actual cost, rather than the value, of the medical care rendered.

MO-AFP.ORG 13

LEGISLATIVE UPDATE

Legislative update

A

Pat Strader, MAFP Governmental Consultant

s we enter the last six weeks of this legislation session, we will focus on MAFP priority issues – those we support and ones we oppose.

Here are a few highlights of what’s been happening at the Capitol: • The Senate confirmed a number of Governor Eric Greiten’s appointments to head various State Departments. Among them was Dr. Randall Williams as the state’s new Director of the Department of Health and Senior Services. Dr. Williams comes to Missouri from North Carolina where he served as the State Health Director and Deputy Secretary for Health Services. Reports indicate that Dr. Williams led the fight against the opioid crises in North Carolina and efforts to combat the Zika Virus.

• MO HealthNet Overhaul – House and Senate Leadership, as well as the current administration, has been focused on moving legislation that would control Medicaid costs. Several of these measures include seeking a Medicaid global waiver from the Federal government so that Missouri could design its own program; instituting managed care statewide; and changing requirements for drugs a Medicaid patient may receive. While it appears the legislators are backing down from the current limit of five prescriptions per patient, other issues such as copays are still on the table.

• The Legislature has until May 5 to pass the budget for Fiscal Year 2018 that begins July 1. The Budget and Appropriations Committees continue to grind away as they work toward this deadline. Lower than expected revenues have

led budget leaders to look at some unpopular cuts such as ending tax credits for elderly and disabled renters to avoid long-term cuts to inhome care for Medicaid rather than relying on one-time tobacco money.

• Concerning particular legislative measures, MAFP is fully engaged in bills relating to: tort reform issues such as collateral source and expert witness testimony; APRNs scope of practice and removal of important provisions now required in current collaborative practice agreements; legislation that would require certification of anyone performing x-rays (even plain film and chest x-rays) without becoming a certified radiologist technician of some level; reviewing Athletic Trainers’ proposed changes to their scope of practice; and creating a new process for licensing of current unlicensed professions (commonly referred to as the Sunrise Act), including a process for those professionals currently licensed that are seeking to substantially increase their scope of practice, just to name a few.

And finally, I would like to thank those physicians, residents and students that traveled to Jefferson City for the 2017 Advocacy Day, and to those members who have testified on legislation this session important to MAFP. Having seen what a difference it makes when physicians provide testimony by sharing their knowledge and stories, plus the ability to answer questions from committee members in precise detail, I am hopeful that MAFP can work toward developing a more robust testimony pool for future sessions.

It is never too late to get involved If you were unable to attend this year’s Advocacy Day, we still need your help! The MAFP always needs physicians to present testimony at hearings and information on important issues.

By the time you receive this magazine, this year’s session is almost over, but we are always planning ahead. Requests for testimony and opinions are made in the weekly legislative updates from our Governmental Consultant, Pat Strader.

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Don’t worry...if you haven’t presented testimony before, Pat will guide you through the process and help prepare you. There is nothing more important than a family physician sharing his or her story about their patients and how the proposed bill will impact them.

Contact MAFP Executive Director, Kathy Pabst, to inquire about how you can be involved in advocacy efforts at (573) 635-0830 or kpabst@mo-afp.org.

We are dedicated to rural and underserved areas of our great state! MHPPS partners 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 se�ng, dynamic urban loca�on, or somewhere in between, we are commi�ed to focusing on your interests and careers that count!

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'SHOW ME SHAFFER' Todd D. Shaffer, MD, MBA, FAAFP in the run for AAFP Board of Directors

"

Serve before you leadâ&#x20AC;? is something I have been teaching for years to my students, residents and fellow family physicians. I have had many opportunities with the AAFP and other family medicine organizations to serve and finally lead. It is now my time to step forward to lead and inspire others on a national basis for the true meaning of family medicine â&#x20AC;&#x201C; caring for all with no limitations on who or what we see."

- Shaffer

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MISSOURI FAMILY PHYSICIAN

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Q.

Q&AWITH DR. SHAFFER

Why do you want to serve on the AAFP Board of Directors?

As long as I have been a leader, I have served many organizations and I have wanted to make a difference.

With my communication and management skills, I am confident I can represent family physicians ranging from practice management topics to delivery of high quality care and continuing education. I have always wanted to sacrifice and to contribute to my specialty for the support and betterment of our members while making a positive impact in our patients, families and communities we serve. I am confident that as a representative of all family physicians, I can articulate to the needs of our practicing physicians, patients, to the public, government, and payers.

Q.

What makes you stand out from the other candidates?

Above all, my servant leader heart. My focus is on family physicians and I will value and consider your perspective on the myriad of issues we face on a daily basis. I have developed my skills through a formal leadership training through a Physician MBA program. I practice my leadership skills daily as a former program director of an innovative residency program for 15 years. My past involvement in state and national organizations has provided me with the experience needed to advocate for family medicine.

During my presidency at the Missouri Academy of Family Physicians, the organization experienced growth in members during the downturn in the economy when most state academies were losing members. All of this prepared me for more leadership opportunities by advancing through leadership roles of the Association of Family Medicine Resident Directors (AFMRD) and Council of Academic Family Medicine (CAFM). During those eight years involved with leadership of multiple issues, we improved residencies and the improved quality of output of our nation’s family medicine residency programs.

These opportunities have allowed me to serve family physicians in our nation’s Capitol by advocating for health care at the Family Medicine Advocacy Summit (formerly the Family Medicine Congressional Conference) both representing Missouri and the AFMRD on multiple visits.

Strong leadership skills are essential when the rapidly changing technology in health care. I am deeply involved with innovation in EHRs and their use for population management and reducing the burden for physicians using it. I have spoken nationally at several EHR conferences on how to leverage the EHR you have to help you provide more efficient care to your population you serve.

Q.

What are your priority issues if you are elected?

• Physician happiness and fulfillment (payment, burnout, satisfaction) • Advocate for GME Reform (national training system valuing and paying for primary care) • Education of physicians for future healthcare needs of the population • National set of ideals for family medicine physicians

Q.

What challenges do you anticipate family physicians will face in the next five years and how would you address them?

This is a challenge because both legislative and regulatory issues are changing, non-stop while we are expected to keep up. AAFP provides a multitude of resources on these many topics that will impact our future.

• MACRA is here and as an organization, the AAFP is already supporting members with resources and advocacy.

I hope to continue that advocacy for what it means to all family physicians and work on ways it can be simplified for every family physician employed or in solo practice. We must value work at the patient level and have data that supports that well beyond healthcare insurance outcome measurements. I will continue to strive to have meaningful outcomes for all of us to achieve for our communities and for the health of our practices no matter what type of practice our members may be in.

• Physician Payment Reform - We know we must have payment reform in this country to value care that provides continuous person-centered care with high quality outcomes defined by the patient and the system. We need to reward outcomes and not procedural aspects of medicine. Complexity and care management of the many things we take care of need to be valued in the context of the total patient experience in health care.

• Repeal and Replace - This is a moving target with the new administration. Although we might not know where this may go in the coming years, we must advocate for insurance coverage for our patients we care for and meet the ideals of what we expect in the country for our population’s healthcare. Although it is very complex, we must strive to get our patients affordable high quality healthcare from a regular source of primary care. Moving to this concept will require efforts and compromises to meet the goals we have for the next generation to come.

• Continued Increase in Healthcare Expenditures Although this seems inevitable, we must control cost. One of the effective ways to do that is to have a strong primary care workforce. We must continue to strive for a larger and well-trained primary care physician workforce. Advocacy at all levels…from medical school admissions, through the education system, to the market, including governmental interventions, to prepare our society for the future of an effective and efficient healthcare team.

Q.

If you had to describe yourself in one word, what would it be and why?

Contributor - My goal and motto for leadership is to always give of time, talent, resources, and to encourage others to expand their leadership and commitments. I have always wanted to make things better when I leave them than when I found them. My top five Strength Finder qualities include being strategic, an achiever, responsible, a learner, and a WOO which makes me perfect for this calling of representing family physicians. continued on page 35...

MO-AFP.ORG 17

MUNGER; BARBE LEAD NATIONAL GROUPS

Missouri roots extending from state to national levels Michael Munger, MD, FAAFP, AAFP President, September '17

m

ichael Munger has been in the active practice of family medicine for 30 years. A graduate of University of Missouri Kansas City Combined BA/MD Medical Program and Baptist Family Medicine Residency in Kansas City, he began practice in Kansas City, Missouri in a group family medicine private practice. In 2001, he moved his practice to Overland Park, Kansas to the Saint Lukeâ&#x20AC;&#x2122;s Medical Group. He continues there in practice, also serving as Vice President of Medical Affairs for Primary Care.

Although in full-time practice for his entire career, Mike had the privilege to serve as a part-time Affiliate staff for the Baptist Family Medicine program, fueling one of his passions, teaching. He also has experience in medical organizations, having served as Chairman of both a Physician-Hospital Michael Munger, MD, FAAFP Organization and Physician Organization. As Vice President for Medical Affairs for the Saint Lukeâ&#x20AC;&#x2122;s Medical group, his responsibility included leading the transformation process for the 14 sites to PCMH NCQA Level 3 certification, accomplished in October 2013.

Active in organized family medicine from early in his practice, Mike served as President of the Kansas City Academy of Family Physicians in 1992, President of the Missouri Academy of Family Physicians in 1999, and as President of the Kansas Academy of Family Physicians in 2009. He served at the American Academy of Family Physicians as a member of the Scientific Program Committee, including a year as chair in 1995, and on the Commission on Education, chairing it in 2011. He also served on the Commission on Health of the Public and Science. He has served as a Delegate to the Congress of Delegates from Missouri in 1998-2000, and as a Kansas Delegate from 2011 to 2013. He was elected to the AAFP Board of Directors in 2013 and served a three-year term. In September 2016, Mike was elected President-Elect of the AAFP and will become President in September 2017.

Q & A with AMA President-Elect, David O. Barbe, MD, FAAFP David Barbe is vice president of regional operations for Mercy Clinic in Springfield, Missouri, with responsibility for five hospitals, 90 clinics and more than 200 physicians and advanced practitioners. He also maintains a David Barbe, MD, FAAFP family practice in his hometown of Mountain Grove, Missouri. Dr. Barbe feels strongly that organized medicine is critical to ensuring that the physician perspective is included in conversations about the policies that will affect us and the products we will use.

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Whether we are advocating for federal and state laws which will benefit our patients, assisting IT companies as they develop EHRs, or working with medical schools to prepare our future colleagues, participating in groups like the AMA, the Missouri Academy of Family Physicians and the Missouri State Medical Association is how we shape the future of our profession. As one physician, you can have little impact; but by joining forces with tens of thousands, even hundreds of thousands of other physicians, we can be a strong voice for our patients and our profession.

Q. Why did you choose to serve on the board and run for national office?

A. In my experience, family physicians have a strong desire to serve the people of their communities, and I am no exception. Years ago,

MUNGER; BARBE LEAD NATIONAL GROUPS my wife and I returned to our small hometown of Mountain Grove, Missouri, hoping to improve health care in that rural community. As the years have passed, I have been blessed with opportunities to extend my service to the state and national levels to improve not just the health of my own patients but to improve the health and health care system for all patients and physicians. Above all, I want to serve others, both as a physician and as a leader within our profession.

Q. What unique qualities do you have as you serve as president-elect, and then president?

A. I think my colleagues at the AMA would say I am a good listener, and good at building consensus. As chairman of AMA’s Board of Trustees from 2013– 2014, I worked hard to ensure that all parties and all perspectives were heard before bringing the group to a decision. In an organization of physicians with many differing opinions, leadership is often finding the right balance between the ideal and the practical.

Q. What are your priority issues to address during your tenure?

A. There are a number of critical advocacy challenges the AMA will be working on in the coming year – the most notable being the anticipated changes to the Affordable Care Act. The AMA has long advocated for affordable health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice and universal access for patients. Those same principles will guide our advocacy efforts regarding any health system reform proposals or changes to the Affordable Care Act. We also will continue our work with the Centers for Medicare and Medicaid Services (CMS) to ensure that the new regulations implementing the Medicare Access and CHIP Reauthorization Act (MACRA) are workable for physicians. The AMA was instrumental in convincing CMS to provide relief for small and rural practices in the MACRA (now known as the Quality Payment Program) Final Rule by increasing the low-volume threshold so more clinicians are exempt, reducing reporting requirements, and offering technical assistance.

Other key areas of advocacy include: opposing health insurance mergers that reduce competition and threaten patient access and choice; working to end the opioid epidemic that is destroying so many lives and communities; and fighting for transparency in drug pricing.

In addition to advocacy, the AMA has adopted an ambitious plan to help shape the future of health care in three areas of strategic focus: improving

health outcomes; accelerating change in medical education; and promoting physician satisfaction and practice sustainability.

Improving Health Outcomes – In partnership with other key organizations such as the Centers for Disease Control and Prevention, the American Diabetes Association and the American Heart Association, we are working to prevent Type 2 diabetes and heart disease. These and other chronic conditions adversely affect the lives of one in two American adults. Our efforts are focused on identifying and addressing the precursors of these diseases—prediabetes and hypertension—before they progress into more serious illness.

Accelerating Change in Medical Education – Innovative technology, team-based care and changing patient expectations are hallmarks of modern medicine, yet the traditional, century-old medical school curriculum does not address these topics. Recognizing this, the AMA convened a consortium of 32 leading medical schools to rewrite the medical school curriculum to meet the needs of 21st century patients. Last November, we released a new Health Systems Science textbook, an emerging area of study that explores how physicians deliver care and how patients experience it – a science we expect will soon be widely taught.

Physician Satisfaction and Practice Sustainability – I am passionate about finding ways to restore the joy to the practice of medicine.

Too many of our colleagues are becoming burned out by administrative hassles, technology that does not improve efficiency, and perpetual second guessing by outside groups.

An AMA/Dartmouth study released last fall found that for every hour a physician spends with a patient, he or she spends two hours entering data into the Electronic Health Record (EHR) and additional paperwork. That’s how bad it has become.

External influences like these are damaging the physician’s spirit, and our colleagues are leaving the profession at an alarming rate.

I look forward to leading the AMA’s work on multiple fronts to address the factors that lead to physician dissatisfaction. In addition to our aggressive advocacy to make government policies and regulations more physician friendly, we are also providing tools physicians can use in their everyday practice, such as the STEPSforward™ practice transformation series. These online, interactive modules have been designed by physicians and address common practice challenges such as transitioning to value-based care, implementing team-based care, and

continued on page 22 ...

MO-AFP.ORG 19

MEMBERS the

IN NEWS NEWS TO SHARE?

Campbell featured on Fox2now STL

The Missouri Family Physician magazine welcomes your input.

Please submit newsworthy items for review to: office@mo-afp.org

Singer and 70's teen heart throb, David Cassidy recently announced he is battling dementia. Dr. John Campbell from Mercy Clinic of Geriatric and Family Medicine joined Fox2now to talk about Cassidy and his recent diagnosis of dementia, a chronic disorder which impairs the mental processes such as memory, decision making and personality. Campbell shared his knowledge of the disease and what one can do to decrease their likelihood of receiving a dementia diagnosis.

Potts, Physician of the Day for 35 years

Donald Potts, MD, was recognized by the Missouri legislature for serving as Physician of the Day for 35 years. Thank you, Dr. Potts, for your service to family medicine and the state of Missouri!

FCM Excellence in Teaching Award recipients

In Memorium

The University of Missouri - Columbia 2017 School Of Medicine Curriculum Board Education Day was held Thursday, February 9, 2017. Congratulations to the following FCM Excellence in Teaching Award recipients: Curriculum Board Award for Faculty Excellence in Teaching: Citation of Merit Elizabeth Garrett, MD, MSPH Outstanding Clinical Faculty Educator: Margaret Day, MD, MSPH

Garrett

Day

Buck

Ellingsworth

Thomas A. Johnson passed away January 18, 2017. Dr. Johnson was President of the St. Louis chapter in '84.

Outstanding Community Faculty Preceptor: Denise Buck, MD, St. Louis Outstanding Course Director: Elizabeth Garrett, MD, MSPH Outstanding Resident Teaching: Chase Ellingsworth, MD

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Doug P. Parashak passed away March 15, 2017.

Dr. Parashak was President of the St. Louis chapter in '91.

Dr. Beth Rosemergey named UMKC Family Medicine Residency program director Dr. Beth Rosemergey has been appointed by the Dean of UMKC School of Medicine in the role of program director. This appointment began March 20, 2017.

“I am honored to be the program director for this outstanding Family Medicine Residency. I am standing on the shoulders of many wise and committed faculty in a program steeped in tradition while charting a course for the future of Family Medicine. I look forward to working Rosemergey with our talented residents as we continue to grow and achieve excellence in resident education while delivering quality patientcentered care to all of the patients we serve. The best of what it means to be Family Medicine is right here in our community!” said Dr. Rosemergey.

Dr. Rosemergey is a Kansas City University of Medicine and Biosciences College of Osteopathic Medicine Alumni (1988). UMKC Family Medicine has trained residency graduates for 35 years.

SLU residents receive federal grant; focus on implementing underserved community curriculum

Cockrell wins AFMRD scholarship

Cockrell, MD

Cherry Cockrell, MD, PGY2, Mercy FMR, has been selected by the Association of Family Medicine Residency Directors (AFMRD) as one of ten residents to receive a scholarship to attend the 2017 Family Medicine Advocacy Summit (FMAS) in Washington, D.C. on May 21-23, 2017.

Verry; Campbell, now faculty at Mercy Dr. Christian Verry graduated from University of Missouri and completed his residency in Denver, CO. He completed his fellowship in sports medicine, and now supervises the program’s orthopedic Verry and sports medicine curriculum.

Dr. John Campbell graduated from Washington University and completed residency at Mercy Family Medicine. He then completed a fellowship in geriatrics, and now supervises the program’s geriatric Campbell curriculum.

In 2011, the Saint Louis University Family Medicine Residency received a federal grant from Health Resources and Services Administration to implement a Longitudinal Underserved Community Curriculum (LUCC). This curriculum prepares residents for community-oriented primary care, and has now become part of the permanent curriculum of the residency. As part of the LUCC program, during their PGY2 year, residents participate in 12 one-day immersion Community Health Seminars addressing health issues in community context. One of these seminars is focused on State Health Policy.

On January 23rd and 24th, Dr. Christine Jacobs and PGY2 Residents, Drs. Alicia Brooks, Michael Donovan, Michelle Hall, Jared Henrichs, and Joseph Moleski, attended a Legislative Advocacy Day at the State Capital in Jefferson City, MO, hosted by the Missouri Primary Care Association (MPCA). Dr. Jacobs and the residents attended a dinner meeting with MPCA executives discussing primary care healthcare issues in Missouri. Dr. Jacobs and the residents visited the State Capitol where they met individually with legislators including Representative Donna Baringer, Representative Tracy McCreery, and Senator Jamilah Nasheed.

Mercy PGY2's give back

During the holiday season, Mercy's second year class decided they wanted to give back. A hospital hospitality house, located across the street from the clinic, is always searching for volunteers. The PGY2s rallied together to plan, pay for, and cook a meal for all the tenants staying at the home.

MO-AFP.ORG 21

MUNGER; BARBE LEAD NATIONAL GROUPS continued from page 19 ...

and regulations more physician friendly, we are also providing tools physicians can use in their everyday practice, such as the STEPSforward™ practice transformation series. These online, interactive modules have been designed by physicians and address common practice challenges such as transitioning to value-based care, implementing team-based care, and choosing EHR software.

system, I see the full spectrum of problems physicians face in delivering care, and I am responsible for making their practice environment better. I look forward to doing that on a much greater scale.

Q. How have your past experiences prepared you for this position?

A. My thirty-three years’ experience as a family physician has given me a good understanding of the challenges our patients and our physician colleagues face in navigating the dysfunctional health care system. I served two terms on the AMA Council on Medical Service that develops policy recommendations for the AMA on the social and economic factors that drive health care. I worked extensively on issues related to health care system reform, insurance market reform, and coverage of the uninsured. These issues continue to be important in the lives of individual patients, physicians’ practices, and are a huge topic of conversation in our national politics. The AMA will be heavily involved in those issues.

My business experience will help guide me in the new position. In my current “day job” as a physician executive in a large, integrated health

Q. What challenges do you anticipate family physicians will face in the next five years and how would you address them?

A. I am extremely optimistic about the future of our specialty. We bring tremendous value to the health care system by truly knowing our patients, often through many stages of their lives.

We can offer them benefits other specialties cannot: individualized care, continuity of care, and a primary care health care home.

Research shows that people are healthier when they have access to a primary care physician.

The more primary care physicians there are in a particular area, the healthier the population.

There are challenges, of course. Family physicians, like all physicians, must adapt to changes in care delivery and payment models. We cannot keep doing things the same way. We have to be more efficient, and we have to continue to demonstrate our value to the health care team.

I look forward to working with the Missouri AFP and other interested organizations to help shape the future of our specialty, and our profession.

Meet the 2017 Family Physician of the Year nominees

James Felts, MD Rolla, MO

David Kapp, MD, FAAFP Perryville, MO

Nominations are in for the 2017 Family Physician of the Year. James Felts, MD, Rolla; David Kapp, MD, FAAFP, Perryville; Bruce Preston, MD, FAAFP, West Plains; and Jeffrey Sharp, MD, FAAFP, Sedalia, were nominated and are currently being evaluated by MAFP's Member Services and Executive Commissions.

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Bruce Preston, MD, FAAFP West Plains, MO

Jeffrey Sharp, MD, FAAFP Sedalia, MO

Annually, the Missouri Academy solicits nominations for an outstanding, caring family physician in Missouri, nominated by you, the patient, a family member, friend, or colleague. This prestigious award will be presented at our Annual Scientific Assembly in June. Best of luck to all!

TMF QUALITY INNOVATION NETWORK

MO-AFP.ORG 23

69 th

annual SCIENTIFIC

ASSEMBLY

"70 Years of Strong Medicine for Missouri"

JUNE 9-10, 2017

SCHEDULE OF EVENTS Friday, June 9, 2017 7:00 - 8:00 am

7:00 - 11:00 am

8:00 - 9:00 am

Registration and Breakfast Buffet with Exhibitors

Exhibit Hall Open (Grand Ballroom A) *All lectures will be held in Grand Ballroom B AAFP Board Update Ada Stewart, MD, FAAFP, AAFP Board Member

9:00 - 10:00 am

Updates on Dysuria for the Clinical Provider Amy Williams, MD

10:00 - 10:45 am

Refreshment Break with Exhibitors (Grand Ballroom A) Sponsored by Direct Primary Care Clinics

10:45 - 11:45 am

Recent Enhancements in ABFM's Family Medicine Certification Joseph Tollison, MD, Senior Advisor to the President, American Board of Family Medicine

12:00 - 1:00 pm

Luncheon Speaker: Pediatrics in Pictures: Exploring Everyday Conditions; An Alternative Learning Experience Mark Suenram, MD

1:00 - 1:15 pm

Break

1:15 - 2:15 pm

The Role of Patient Self Management of Chronic Conditions David Voran, MD

2:15 - 3:15 pm

Venous Disease Updates Scott Darling, DO, FAAFP

3:15 - 4:15 pm

Assessment and Treatment of Borreliosis Charles Crist, MD, PC

5:15 - 6:15 pm

Reception (Creek View Conference Center)

6:15 - 8:15 pm

Awards and Installation Dinner (Creek View Conference Center) • 2017 Family Physician of the Year Award • Soaring Eagle Award • Installation of President & Board Members • AAFP Degree of Fellow Convocation • Tar Wars Poster Contest Award

Saturday, June 10, 2017 7:00 - 8:00 am Registration and 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

9:00 - 10:00 am

Overcoming the Barriers to Individualized Management of Overactive Bladder in the Primary Care Setting Theodore W. Johnson, II, MD, MPH PeerView Institute for Medical Education Telehealth Update: Where It’s Been and Where It’s Headed David Voran, MD

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

(Grand Ballroom A)

10:45 - 11:45 am Addressing Child Obesity in Primary Care

Amy Williams, MD

Annual Business Meeting and Legislative Luncheon (Creek View Conference Center)

1:30 - 1:45 pm

Break

1:45 - 2:45 pm

Issues in High Altitude Medicine Mark Suenram, MD

2:45 - 3:45 pm

Pediatric Chest Pain, Syncope, and Palpitations: One Pediatric Cardiologist's Perspective Peter C. Dyke II, MD

3:45 - 4:45 pm

Resident and Student Poster Presentations

5:30 - 7:30 pm

Family Fun Fiesta Join us for an evening of fun-filled family activities (Creek View Conference Center)

11:45 am - 1:30 pm

Sunday, June 11, 2017 9:15 - 11:00 am

11:00 am - 1:30 pm

Commission Meetings with Continental Breakfast Advocacy - Grand Ballroom A Member Services - Red Oak Education - Cypress Room Board Meeting with Working Lunch (Grand Ballroom A)

CUT AND MAIL TO MAFP

69th Annual Scientific Assembly June 9-10, 2017 The Lodge at Old Kinderhook Camdenton, Missouri

REGISTRATION FORM Register by (May 9) and be entered to win a FREE two-nights' stay at the Lodge at Old Kinderhook

Name:

MD DO FAAFP Other

AAFP ID#: Address:

REGISTRATION One-Day Only* MAFP Member

$200

□Friday □Saturday

New Physician

$175

Life Member

State

Zip:

Phone:

Fax:

Email:

$

□Friday □Saturday

$325

$

$100

□Friday □Saturday

$175

$

$0

□Friday □Saturday

$0

$

AAFP Member

$210

□Friday □Saturday

$400

$

Non-Member Physician

$225

□Friday □Saturday

$450

$

Non-Physician Attendee

$125

□Friday □Saturday

$200

$

$25

xxxxxxxx

$25

$

-$50

$

-$50

$

Resident or Student (Non-Missouri member)

Special dietary or physical accommodations required? If so, please list:

MEMBERSHIP ANNIVERSARY?

Please complete this section if you received a letter notifying you of a Membership Anniversary.

□ Yes, I received my Membership Anniversary letter and will attend the Awards & Installation Dinner on Friday evening, June 9.

□ One complimentary guest will accompany me to the dinner.

FOUR WAYS TO REGISTER: Online with credit card at www.mo-afp.org • Fax this form to (573) 635-0148 • Call us at (573) 635-0830 • Mail this form with payment to: MAFP, 722 West High Street, Jefferson City, MO 65101-1526 REGISTRATION CANCELLATIONS must be in writing and received by MAFP no later than May 9, 2017. MAFP policy requires a $50 administrative fee be deducted from each refund processed. Questions? Call (573) 635-0830 or email: office@mo-afp.org.

Amount

$375

(within 7 yrs of residency completion)

City:

Full

Syllabus Materials

(Printed $25) Free if you download on-line version (available closer to conference)

Free for Life Members

Will you be conferred at the Fellow Convocation?

If yes please deduct $50 from your total. You are allowed one guest (complimentary).

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Early-Bird Discount (until 5/9/2017) *Does not apply to 1-day registration FHFM Donation (Tax Deductible) Tax ID 43-1480324

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RSVP & GUEST OPTIONS Event

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Saturday Lunch: Annual Business Meeting & Legislative Luncheon

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Saturday Dinner: Family Fun Fiesta

□Yes

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Family Fun Fiesta (Child age 5-12)

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Total (RSVP & Guest Options) $

CME sessions, meals, breaks, and electronic syllabus are included in the registration fee.

All functions in the Exhibit Hall are for registrants only. By registering for this conference, I authorize MAFP to use photographs of me with or without my name for any lawful purpose, including print or online marketing.

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□ Enclosed is my check made payable to: Missouri Academy of Family Physicians Please charge my: □ MasterCard □ Visa □ Discover □ American Express

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RESIDENT GRAND ROUNDS continued from page 7 ...

Delayed Umbilical Cord Clamping After Birth

ACOG Committee Opinion No. 684 – Published January 2017 (reference #3) • Previous studies and recommendations supported delayed cord clamping (DCC) when possible in preterm infants due to a known reduction in the rate of intraventricular hemorrhage, but cited insufficient evidence to recommend for or against DCC in term infants. There was concern that DCC would delay necessary resuscitation efforts, increase risk of maternal postpartum hemorrhage, and increase rates of neonatal hyperbilirubinemia requiring phototherapy due to excessive placental transfusion.

• A 2012 systematic review of 15 studies involving 738 preterm infants (24-36 weeks gestation at birth) showed that delayed cord clamping (30-180 seconds) decreased the number of infants that required transfusion for anemia (RR 0.61, CI 0.46-0.81), and decreased the incidence of intraventricular hemorrhage (RR 0.59, CI 0.41-0.85) and necrotizing enterocolitis (RR 0.62, CI 0.43-0.90). One small study even showed improved motor function in infants born at <32 weeks at 18-22 months corrected age.

• A 2013 Cochrane review of 15 clinical trials involving 3911 term infants (>37 weeks gestation at birth) showed that early cord clamping (less than one minute after birth) decreased hemoglobin levels at birth and at 24-48 hours of life (mean difference -2.17 g/dL and -1.49 g/dL, respectively), increased the risk of iron deficiency anemia at 3-5 months of age (RR 2.65, CI 1.046.73), and even and modestly lowered scores in social and fine motor function at 4 years of age in one study. However, early cord clamping did decrease the rates of neonatal jaundice requiring phototherapy (RR 0.62, CI o.41-0.96).

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RESIDENT GRAND ROUNDS

• A review of five trials, involving 2200 women showed that DCC led to no increased risk of postpartum hemorrhage, no decrease in maternal hemoglobin level, and no increased need for maternal blood transfusion.

• Conclusions • In term infants, DCC increases hemoglobin levels and improves iron stores for first several months of life. Higher iron stores may translate to improved neurodevelopmental outcomes; however, more study in this area is needed.

• In preterm infants, DCC improves RBC volume, decreases need for blood transfusion, and lowers incidence of necrotizing enterocolitis and intraventricular hemorrhage.

• DCC does not increase risk of postpartum hemorrhage, lower maternal postpartum hemoglobin levels, or increase the need for maternal blood transfusion.

• Practice Changer: Delay umbilical cord clamping in vigorous term AND preterm infants for at least 30-60 seconds after birth. – ACOG, NRP. • WHO recommends delaying cord clamping to no earlier than one minute after birth.

• Royal College of Obstetricians & Gynaecologists recommends delaying cord clamping to two minutes after birth.

• American College of Nurse-Midwives recommends delaying cord clamping for two to five minutes after birth.

• When DCC is performed, systems should be in place for monitoring and treatment of neonatal jaundice in term infants, due to slightly increased incidence of jaundice requiring phototherapy.

• Technique for delayed cord clamping • Place newborn immediately on the maternal abdomen after delivery for skin-to-skin.

• Initiate standard early care measures while waiting to clamp the cord (i.e. drying, stimulation, covering infant with dry linens).

• Suction secretions only if they are copious or obstructing the airway.

• When meconium is present, it is ok to delay cord clamping if the infant is vigorous.

• Continue standard management of the third stage of labor (e.g. oxytocin infusion).

• There is insufficient evidence to support umbilical cord milking.

• Immediate umbilical cord clamping should be considered in cases of maternal hemorrhage, hemodynamic instability, abnormal placentation (e.g. placenta previa or abruption), or need for immediate fetal resuscitation.

References: 1. Antenatal Corticosteroid Therapy for Fetal Maturation. Committee Opinion No. 677. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 128:e187094.

2. C. Gyamfi-Bannerman, E.A. et al. Antenatal Betamethasone for Women at Risk for Late Preterm Delivery. New England Journal of Medicine. 2016; 374: 1311-20.

3. Delayed Umbilical Cord Clamping After Birth. Committee Opinion No. 684. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 129: e5-10.

4. McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal anad neonatal outcomes. Cochraine Database of Systematic Reviews 2013, Issue 7. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub3.

5. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birht on maternal and infant outcomes. Cochraine Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub3.

6. Timing of umbilical cord clamping after birth. Committee Opinion No. 543. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120(6):1522-6.

ATTENTION RESIDENTS: NEED TO BE PUBLISHED? Submit your report to be published as a ResidentGrand Rounds article in our quarterly Missouri Family Physician magazine. Contact MAFP: office@mo-afp.org

MO-AFP.ORG 27

KC & STL Chapter Updates

Lott; Jacobs assume president positions

t

he Kansas City and St. Louis Chapters hosted their installation dinners (St. Louis in January, and Kansas City in February) where the new presidents took the oath of office and new board members were installed. Emily Lott, MD, is president of the Kansas City Chapter, and Christine Jacobs, MD, FAAFP, assumes the role of president for the St. Louis Chapter. Congratulations to all, and thank you for your time and dedication.

Emily Lott, MD is sworn in as Kansas City Chapter President by Mark Martin, MD, FAAFP.

Kansas City Chapter Board of Directors

President: Emily Lott, MD Vice-President: Jason Goergen, DO Board Members: Annette Acosta-Dickson, MD, FAAFP Anne Arey, MD, FAAFP Angela Barnett, MD Rachel Hailey, MD Ed Kraemer, MD Mark Martin, MD, FAAFP Donald Potts, MD, FAAFP Beth Rosemergey, MD, FAAFP *Two vacancies are currently being filled.

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Lott

Jacobs

Christine Jacobs, MD, FAAFP, is sworn in as St. Louis Chapter President by Peter Koopman, MD, FAAFP.

St. Louis Chapter Board of Directors

President: Christine Jacobs, MD, FAAFP President-Elect: Lauren Wilfling, DO Vice President: Chris Blanner, MD Treasurer: Kara Mayes, MD Secretary: TinaRose Trost, MD Board Members: William Manard, MD, FAAFP Katy Liu, MD Johnetta Craig, MD, MBA Dawn Davis, MD Emily Doucette, MD Kevin King, MD Tonya Little, MD Daniel Herleth, MD Matthew Breeden, MD

AAFP NEWS

New Center for Diversity and Health Equity to be established within AAFP

O

ne of the top four strategic objectives in the AAFP Strategic Plan reads, “take a

leadership role in addressing diversity and social determinants of health as they impact individuals, families and communities across the lifespan and to strive for health equity.” To implement this Board established

priority, a new Center for Diversity and Health Equity is being formed.

“Our new Center for Diversity and Health Equity will position the AAFP to exert greater leadership on these important topics as they impact individual and population health,” said Bellinda Schoof, Director, Health of the Public and Science Division. “The creation of the new Center is also consistent with the work of the Commission on Health of the Public and Science and its subcommittee on health equity as well as recent discussions at the AAFP Congress of Delegates and National Conference of Constituency Leaders.”

“We are committed to developing this new Center, which addresses an important need for our members, their patients and communities.” said Julie Wood, MD, Senior Vice President for Health of the Public and Interprofessional Activities. “This led to some refocusing of our current Health of the Public activities to implement strategies that entail a comprehensive approach.”

“As we recruit staff with specific expertise and skills for the new Center, we will be looking for individuals with a proven track record in social epidemiology, policy, health equity, and collaboration with community organizations who can support our members in promoting evidencebased community and policy changes needed to address social determinants of health,” Dr. Wood continued.

Initial activities of the new Center will include an assessment to identify AAFP member needs and education as well as a review of current and needed AAFP policy.

Additionally, the Center will address workforce diversity, research regarding health equity, and advocacy for a broader set of policies and collaborations that will position the AAFP to better address the social determinants of health.

Establishment of the Center is part of a realignment of staffing within the division. Some positions have been repurposed, but the full scope of existing work within the division will continue.

Are you moving? Changed your name? Or just need to update your email, phone number, or employer information?

We want to know! Stay connected with the AAFP and the MAFP no matter where you are. Update your contact information online at www.aafp.org/ to ensure you receive timely AAFP and MAFP news and updates.

AAFP PerformanceNavigator®

Cardiometabolic Conditions: Diabetes, Hypertension, and Dyslipidemia Satisfy your Family Medicine Certification's Performance Improvement and SelfAssessment activities—all in one program. Earn up to 105 AAFP Prescribed credits.

Improve care among your patient panel with cardiometabolic conditions: diabetes, hypertension, and dyslipidemia.

Make changes to your practice in a collaborative environment. Hear from expert, real-world faculty how to improve care for your at-risk patients.

Learn how to improve cardiometabolic outcomes among your at-risk patient panel.

Benefit from talking through solutions and challenges with fellow family physicians.

Participate in peer-to-peer learning, practice reflection, and addressing practice barriers. Create an action plan to guide practice performance interventions. Register at: www.aafp.org/stlouis or call (800) 274-2237.

Who can participate in the PerformanceNavigator Workshop?

The PerformanceNavigator Workshop: Cardiometabolic Conditions is designed for physicians who have a continuous patient panel. Physicians who work in environments where they do not see at least 20 patients regularly will not fully benefit from the course as they are unable to receive the 60 credits for the Family Medicine Certification Performance Improvement modules.

AAFP Performance Navigator Workshop April 27-29 St. Louis, MO AAFP members: $1,895 Nonmembers: $2,295 PerformanceNavigator is a three-step process: STEP 1: Assess your practice (course prep) STEP 2: Attend three-day collaborative workshop STEP 3: Reassess your practice Earn up to 105 AAFP Prescribed credits MO-AFP.ORG 29

CANCER HEALTH DISPARITIES

Cancer health disparities are improving, but more progress is necessary

I Lannis Hall, MD, MPH Lannis Hall is the Director of Radiation Oncology, Siteman Cancer Center, Barnes-Jewish Hospital, St. Peters, Assistant Professor of Clinical Radiation Oncology, and Clinical Trials Outreach Leader at Washington University School of Medicine

30

n the United States, cancer is the second leading cause of death after cardiovascular disease. Approximately 590,000 deaths are projected in 2017, with prostate, breast, colorectal and lung cancer responsible for close to 50 percent of lives lost. On a more positive note, the cancer mortality rate has decreased by 23 percent in the last 25 years, translating into the avoidance of 1,711,000 cancer deaths.

This improvement is primarily due to a reduction in tobacco use and advances in prevention, screening and treatment. Unfortunately, all ethnic and racial groups are not faring equally. Compared to White Americans, African American men and women have a higher incidence rate for most cancers and a 30 percent higher cancer mortality rate.

Over the last two decades, the definition of disparity has undergone an evolution. Initially, a disparity referred to a difference in incidence, health outcomes and access to health care for different populations. More recently, social determinates of health such as poverty level, education and geographical residence have been included in the disparities equation. Many health organizations have moved beyond the definition of disparity to include health equity, which is defined various ways, but by Healthy People 2020 as the attainment of the highest level of health for all people. The goals for Healthy People 2020 are to achieve health equity, eliminate disparities and improve the health of all groups.

In 1999, to better understand health care disparities, Congress requested that the Institute of Medicine (IOM) evaluate whether racial disparities exist in health care delivery, and to identify the sources of the potential unequal treatment. The IOM evaluated the data and controlled for access-related factors like insurance coverage and accessible health care services.

The committee reported that across all disease sites, whether evaluating HIV/AIDS, diabetes, mental health, cardiovascular interventions or cancer care, minorities were more likely to have less desirable services such as amputation or

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castration rather than testosterone-lowering medications, and less likely to receive clinically necessary services like cardiac catheterizations.

Finally, this report recommended a multi-step approach directed at 1) supporting community health care workers and multidisciplinary and preventive care teams; 2) developing legal, policy and regulatory strategies that enhance access; and 3) improving cultural and linguistic diversity between the patient and caregivers.

This review will focus narrowly on epidemiology and cancer outcomes of three solid tumors: prostate, breast and colorectal cancer. These three cancers have large disparities in health outcomes, despite screening tools that can positively impact survival for all ethnic and racial groups.

Prostate Cancer Prostate cancer is the most common cancer diagnosed in men, with 180,000 expected new cases in 2017. Prostate cancer is also the second leading cause of cancer death after lung cancer.

African American men have the highest incidence of prostate cancer and the highest mortality of any ethnic and racial group. One in six African American men will develop prostate cancer and one in 23 will die from the disease. This mortality rate is 2.4 times higher than any other ethnic and racial group. The reason for this disparity remains unclear; however, data consistently has indicated an earlier age at onset of disease, more aggressive disease at diagnosis, greater risk of adverse pathologic features at the time of radical prostatectomy and a higher rate of recurrence.

Before the widespread use of prostate specific antigen (PSA), metastatic prostate cancers constituted 25 percent of newly diagnosed cases in White men, and 50 percent in African American men. These advanced-stage cancers remain incurable even today, with a five-year survival of only 30 percent regardless of race. Since the widespread use of PSA screening, less than five percent of men with newly diagnosed prostate cancer have metastatic disease.

Unfortunately, PSA is an imperfect screening

CANCER HEALTH DISPARITIES

tool. While an elevated PSA level may indicate prostate cancer, an abnormal blood test may occur for reasons unrelated to the disease, such as BPH and prostatitis, and can also lead to the detection of prostate cancers that are unlikely to be lifethreatening.

Two large clinical trials, one European and one American, enrolled over 250,000 men to assess the effectiveness of PSA screening to reduce prostate cancer mortality. The results of these two studies were conflicting; the European study reported a 20 percent survival advantage for the men screened with PSA, and the American study indicated no survival advantage. Despite complaints about flaws in the American study, another concern for both studies was the inadequate participation of African American men to assess the impact of screening in a high-risk population.

"

Primary care physicians are essential in reducing cancer disparities by supporting cancer screening, behavioral modification, timely initiation, and completion of cancer treatment and clinical trial participation."

The conflicting study results and the lack of participation of African American men have led to controversy in screening for prostate cancer in the United States. One concern is that men who may benefit the most from PSA screening are routinely denied access. The US Preventive Services Task

Force recommends no screening regardless of risk while most other medical organizations recommend at least a discussion regarding the risks and benefits of screening. The American Cancer Society recommends that the screening discussion begin at the age of 45 for African American men and younger for men with a strong family history.

Unfortunately, recent data indicate a decrease in screening in all men, regardless of age, race and ethnicity. A recent study reported that only 30 percent of primary care providers discuss the risks and benefits of PSA screening with their patients. For African American men, the confusion around screening could upend real progress in reducing disparities in this disease. The mortality rate for prostate cancer has dropped for all men in the last 25 years and African American men have enjoyed a 40 percent reduction in mortality since the widespread adoption of PSA testing. The importance of a discussion regarding the risks and benefits of screening and treatment is key to an educated decision and, hopefully, continued progress in ending disparities for this disease.

Breast Cancer Breast cancer is the most common cancer diagnosed in women with an expected 240,000 new cases in 2017. Breast cancer is the second leading cause of cancer death in women after lung cancer. African American women have an earlier age of onset of disease than White women, 58 as compared to 62, and 30 percent of breast cancers are diagnosed before the age of 50.

Breast cancer in younger African American women can be particularly aggressive due to an increased diagnosis of an aggressive subtype called triplenegative breast cancer, which has a higher risk of recurrence and death.

Breast cancer screening guidelines have changed over the past several years to reduce unnecessary biopsies. There are now five different screening guidelines leading to confusion among women and providers. Two of the guidelines, the American Cancer Society and the US continued on page 32 ...

MO-AFP.ORG 31

CANCER HEALTH DISPARITIES continued from page 31 ...

Preventive Services Task Force, recommend mammography screening begin at the age of 45 and 50 respectively, whereas the previous recommendation was at the age of 40. These new guidelines have the potential to miss breast cancer at an early stage.

If the US Preventive Services Task Force guidelines are strictly followed, a full 30 percent of African American women could potentially develop a breast cancer without ever having a referral for a mammogram. Similar to prostate cancer, the clinical studies that supported the new breast cancer screening guidelines, suffer from inadequate representation of African American women to assess the impact of delayed screening in this population. Equally important has been the rising incidence of new breast cancer cases in African American women. In Missouri, African American women are now diagnosed with breast cancer more frequently than White women. The increase in incidence is thought to be due to higher rates of obesity, which disproportionately affects African American women. Over 82 percent of African American women are now considered overweight or obese, and this is a risk factor for developing breast cancer later in life.

The disparity in breast cancer survival between African American women and White women continues to widen. In the early 1990s, the disparity in survival between African American women and White women was 17 percent; in 2000 the survival disparity was 35 percent and most recently in 2012, 42 percent. The most significant reason for this disparity has been advanced stage at diagnosis. Only 52 percent of African American women present with localized disease. Health care providers are instrumental in reducing disparities in breast cancer by recommending routine exercise and a healthy weight, a well-balanced diet with 5-7 fruits and vegetables and mammography screening to maximize survival benefit.

Colon and Rectum Cancer Colorectal cancer is the third most common cancer diagnosed in men and women with an estimated 134,000 new cases in 2017. Colorectal cancer is the third leading cause of cancer death with an expected 49,000 lives lost this year. African American men and women have an earlier onset of disease and more advanced stage at diagnosis.

Compared to White Americans, colorectal cancer mortality rates are 41 percent higher in African American women and 52 percent higher in African American men. The majority of the disparity in 32

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survival is due to advanced stage at diagnosis. Only 37 percent of African American men and women present with localized disease. Although screening rates have improved, African American screening rates are still not optimal and some experts recommend that screening begin at the age of 45 rather than 50 due to earlier age at diagnosis.

Survival differences between African Americans and White Americans are also impacted by treatment variation, comorbidities and socioeconomic status.

Multiple studies have documented lower rates of surgical treatment and receipt of adjuvant chemotherapy in African Americans.

Several modifiable factors can increase the risk of colon cancer. These include obesity, physical inactivity, long-term smoking, high consumption of red or processed meats and very low intakes of fruits, vegetables and fiber. Disparities in income, education and housing have influenced the ability to adopt healthy behaviors that can reduce risk.

Primary care physicians are essential in reducing disparities by advising timely screening, facilitating repeat surveillance, supporting tobacco cessation and promoting a healthy diet and exercise.

This review focused on the most obvious causes for disparity in survival between African Americans and White Americans, including 1) lack of optimal screening, 2) stage at diagnosis, and 3) modifiable risk factors such as physical activity, weight management and diet. Other factors that contribute to disparities in survival were not discussed in detail. These include 1) differences in treatment and higher rates of non-guideline directed care; 2) socioeconomic factors like poverty status, education level and housing; 3) insurance status and access to health care services, and 4) pharmacogenomics and biologic variation in drug response. In order to understand the impact of all these variables on cancer survival, participation in clinical studies is essential. The importance of broad participation in clinical studies by all racial and ethnic groups ensures that treatment strategies are effective across all populations.

African Americans represent 13 percent of the population but only five percent of the clinical study participants. Several studies indicate that men and women who participate in clinical studies live longer, possibly because of access to new treatments and closer follow-up by the doctors, nurses and research team. Primary care physicians are essential in reducing cancer disparities by supporting cancer screening, behavioral modification, timely initiation, and completion of cancer treatment and clinical trial participation.

MATCH DAY

Match Day 2017: Largest in history

"

This is the eighth straight year that the family medicine match rate climbed year-over-year."

Tyler Gouge, MD and Misty Todd, MD, graduates of University of Missouri - Columbia (MU), both matched to MU FMR.

I

nterest in family medicine continued its upward trend for the eighth consecutive year, according to the 2017 National Residency Matching Program®. This year, the total number of medical students choosing family medicine was 3,237, up 132 from the 3,105 last year. The number of U.S. allopathic medical school graduates choosing family medicine was 1,530, up 49 from 2016.

In the 2017 NRMP Match: • Family medicine* offered 11.7% and filled 11.7% of the total positions • The fill rate for U.S. Seniors in family medicine was 45.3% *Includes family medicine-categorical, plus combined programs: emergency medicine-family medicine, family medicine-preventive medicine, medicine-family medicine, and psychiatry-family medicine.

Compared with 2016, family medicine residency programs in the 2017 NRMP Match: • Matched 132 more students and graduates (3,237 vs. 3,105) • Matched 49 more U.S. Seniors (1,530 vs. 1,481) • Had a similar overall fill rate (95.8% vs. 95.2%) • Had a similar fill rate for U.S. Seniors (45.3% vs. 44.4%) • Offered 11.7% of all positions in the Match (11.7% in 2016) • Matched 8.8% of all U.S. Seniors in the Match (8.7% in 2016)

MO-AFP.ORG 33

MULTI-STATE

Multi-State forum draws leaders to Dallas

L-R: President-Elect, Mark Schabbing, MD, MAFP Executive Director, Kathy Pabst, MBA, CAE, Todd Shaffer, MD, MBA, FAAFP, and Sudeep Ross, MD, MBBS, MBA.

O

nce again, family physician leaders gathered for a two-day meeting in Dallas where they shared best practices in their states and learned about issues common among the thirteen states represented.

Mark Schabbing, MD, President-Elect, Sudeep Ross, MD, MBBS, MBA, Vice President, Todd Shaffer, MD, MBA, FAAFP, and MAFP Executive Director, Kathy Pabst, represented your Academy at this gathering.

Telemedicine is rapidly changing with demand and technology, and this topic kicked off the conference.

A regular at this meeting, Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement, and Policy, provided an update on a moving target…repeal and replace the Affordable Care Act. MACRA is always a timely topic - and how family physicians can maximize reimbursement was presented. Again, looking to the future, an update on direct primary care regulatory and legislative actions provided attendees direction for this new practice model. Each chapter also provided an update on state legislative issues and best practices.

Mark Schabbing, MD, MAFP President-Elect attended this conference for a second time. Chapter leadership

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from the heartland and southwestern states came together to share information. Schabbing values the opportunity to discuss situations where we made headway in our respective state legislatures, new ideas of where we were improving state participation with membership, and how we are bringing information to our members. Dr. Schabbing stated, “This was

an excellent time to meet and exchange ideas of what was working in our state, and to bring fresh ideas back home. National leadership was present to give an update on what we might be expecting with the new presidential agenda. I can say the meeting was a success again this past year.”

Missouri will have the opportunity to lead next year’s meeting to plan and organize the meeting topics, speakers, and logistics. Please feel free to forward ideas for topics and speakers to our Executive Director, Kathy Pabst at kpabst@mo-afp.org.

Q&A WITH DR. SHAFFER

Q&AWITH DR. SHAFFER Q.

How has your past experience prepared you for the AAFP Board of Directors?

I have always been involved in the many groups at my local, state, and national levels. This involvement has allowed me to “serve” others…my family, my community, my colleagues, and most importantly, my patients.

On a personal level, my involvement in Boy Scouts taught me to lead at an early age and involvement throughout my career further developed my ability to encourage, trust, and help others. Coaching children (my son’s baseball team) is like herding cats…but, teaching them teamwork helped them focus on the larger picture of winning, yet doing better the next time if we lose.

As a professor, education is the foundation for growth. I have served as faculty for 22 years and 15 years as a Program Director of one of the largest and most comprehensive programs in the country. My passion for education is reflected in my current service on the AAFP’s Commission on Continuing and Professional Development, previous service to the AAFP Commission of Insurance and Finance and as a member of the MAFP’s Education Commission for 18 years. These opportunities continually teach me leadership skills to better serve you.

My involvement and transition through officer positions of my state chapter expanded my vision and range to a state-wide level. It brought together individual family physicians to create one voice in our state’s Capitol. This is also true on a national level as I served as the Association of Family Medicine Residency Directors as president and board member for seven years and with my service to the Council for Academic Family Medicine. Representing my state at the Congress of Delegates for the past couple of years has continued my interest and passion for the administrative side of guiding our specialty to the needs of its members.

69 th

"

continued from page 17 ...

The culmination of my education, experience, and passion has led me to where I am today… wanting to take the next step of serving you as a board member on a team of family physicians, and contributing to the American Academy of Family Physicians."

Communicating our message is critical to educating the public and legislators about our agenda. Through executive leadership in AFMRD and CAFM, I participated as an advisor to the Family Medicine for America’s Health and the Health is Primary national marketing campaigns.

Through this, we are able to prove the value family medicine has for our country's healthcare needs.

The culmination of my education, experience, and passion has led me to where I am today… wanting to take the next step of serving you as a board member on a team of family physicians, and contributing to the American Academy of Family Physicians.

Your Humble Servant, Todd D Shaffer, MD, MBA, FAAFP

annual SCIENTIFIC

ASSEMBLY

JUNE 9-10, 2017

ANNUAL BUSINESS MEETING & LEGISLATIVE LUNCHEON NOTICE The Missouri Academy of Family Physicians' Annual Business Meeting & Legislative Luncheon will be held at the 69th Annual Scientific Assembly on Saturday, June 10, 2017 at The Lodge at Old Kinderhook in Camdenton, MO from 11:45 am to 1:30 pm.

MO-AFP.ORG 35

ANNUAL SCIENTIFIC ASSEMBLY

2017

DATE in

THE

E EARN CM NETWORK RELAX

SAVE

2017

JUNE 9-10

THE LODGE AT OLD KINDERHOOK

ANNUAL FALL CONFERENCE

NOVEMBER 10-11

BIG CEDAR LODGE

2017

Missouri Academy of Family Physicians 722 West High Street Jefferson City, Missouri 65101 Website: mo-afp.org Email: office@mo-afp.org Phone: 573.635.0830