Winter (January-March 2016)

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician January-March 2016 Volume 35, Issue 1

O

Congress of Delegates New Officers, Resolutions and Reports Page 10 Annual Fall Conference A Recap of Events Page 14 Capitol Commentary Join MAFP for Advocacy Day Page 17

Connect with MAFP on Facebook, Instagram and Twitter.

Visit us online at www.mo-afp.org

CME Revenue Sharing Earn CME and Give Back to Your Chapter Page 33

SEE THE FOREST AND THE TREES

WHERE HEALTH IS PRIMARY. Increased collaboration between primary care and public health is key to addressing the biggest health challenges facing our country today.

Family doctors are working to bridge the gap between personal and public health.

Let’s make health primary in America.

Learn more at healthisprimary.org.

Brought to you by America’s Family Physicians

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#MakeHealthPrimary

executive commission Board Chair - Daniel Purdom, MD, FAAFP (Liberty) President - Peter Koopman, MD, FAAFP (Columbia) President-Elect - Kathleen Eubanks-Meng, DO (Blue Springs) Vice President - Mark Schabbing, MD (Perryville) 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: Sarah Cole, DO, FAAFP (St. Louis)

Director: Caroline Rudnick, MD (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: Afsheen Patel, MD (Jefferson City) District 6 Director: Jamie Ulbrich, MD, FAAFP (Marshall)

Alternate: David Pulliam, DO, FAAFP (Higginsville) District 7 Director: Sudeep Ross, MD, MBA (Kansas City)

Director: Wael Mourad, 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: Vacant

Alternate: Vacant Director At Large Emily Doucette, MD (St. Louis) resident directors Kevin Gray, MD (UMKC) Kanika Turner, MD (Alternate) (SLU) student directors Jenny Eichhorn (UMKC) Emily Gray (Alternate) (UMKC) aafp delegates David Schneider, MD, FAAFP, Delegate Todd Shaffer, MD, MBA, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate mafp staff Executive Director - Kathy Pabst, MBA Communications and Education Manager - Sarah Mengwasser Membership and Programs Assistant - Lauren Eichelberger 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 3

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MARK YOUR CALENDAR MAFP Advocacy Day February 15-16, 2016 Capitol Plaza Hotel Jefferson City, MO Multi-State Forum February 27-28, 2016 Grand Hyatt DFW Dallas, TX AAFP Annual Chapter Leadership Forum/National Conference of Constituencies Leaders May 5-7, 2016 Sheraton Kansas City Hotel at Crown Center Kansas City, MO AAFP Family Medicine Congressional Conference April 18-19, 2016 Washington Court Hotel Washington, DC

AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 28-30, 2016 Kansas City Convention Center Kansas City, MO AAFP Congress of Delegates September 19-21, 2016 Hyatt Regency Orlando, FL AAFP Family Medicine Experience (FMX) September 20-24, 2016 Hyatt Regency Orlando, FL MAFP 24th Annual Fall Conference & SAM Working Group November 4-6, 2016 Big Cedar Lodge Ridgedale, MO

MAFP 68th Annual Scientific Assembly (ASA) June 3-4, 2016 The Lodge at Old Kinderhook Camdenton, MO

INSIDE THIS ISSUE Pg. 2 Health is Primary 4 President's Report 6 Resident Grand Rounds 8 Help Desk Answers 10 Congress of Delegates 14 Annual Fall Conference 17 Capitol Commentary 24 Team Based Practice Management 26 Members in the News 28 Simulation Program 30 Adult Vaccination Practice Module 31 Summer Externship 32 Value Modifier Program 33 CME Revenue Sharing 34 Missouri Recovery Network 35 Opioid Abuse

Advertisements Pg. 2 Health is Primary 8 FPIN 9 Cox Health 13 MHPPS 16 Children's Mercy 19 U.S. Army 23 SEMO Drug Pharmacy 29 NORCAL Mutual 30 Marley Drug 31 MPM/PPIA 34 Midwest Dairy 35 Direct Primary Care Clinics 36 Southeast Health

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PRESIDENT'S REPORT

Communication Breakdown

I Peter Koopman MD, FAAFP

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was struck in these last few months by how much stress is created in my professional life by poor communication. At times, my patients cannot communicate well which makes it difficult to be patient-centered and adequately serve their needs. Also, at times, I am unable to communicate my understanding of events to my patients effectively. Doctor and patient communication issues contribute in a major way to medical errors, inappropriate testing - both too much and too little, patient dissatisfaction, as well as physician dissatisfaction. I believe that a continued focus on improving doctor/patient communication would help to reach the AAFP stated triple aim of improved patient satisfaction, improved patient outcomes, and lower healthcare costs. I also believe it would improve the fourth aim stated by some of improved physician satisfaction.

I admit I struggle with how to communicate with patients optimally. I have been through health literacy training. I understand teach back. I try to avoid medical jargon. As a block director in the first year medical school curriculum for patient interviewing at Mizzou, I teach and facilitate the teaching of these concepts and skills to our future workforce. Yet I remain uncertain I have all the right skills in my private clinical work or teach the skills optimally in my academic work.

Medical communication is hard. When your agenda is different or in conflict with your patient, the message is hard to convey. When your patient is ill or in pain, they often cannot hear a message you are sending. When decisions have life and death consequences, the ability to see clearly is challenging. Many medical decisions are murky in terms of right answers, and patient-centeredness speaks to autonomy and allowing shared decision making; but conveying that murky information in a digestible way is a struggle. It is hard to tell someone bad news and deliver it effectively.

In addition to this inherent difficulty in medical communication, the system under which we work

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values our ability to be efficient and see more patients, and does not support nuanced and prolonged conversations. We also, at times, fight a battle against unrealistic expectations of complete cure or answers to all symptoms which the medical community has promoted and is the patient’s desire.

In summary, communication does break down for many reasons. Yet, I believe family medicine’s

"

I believe that a continued focus on improving doctor/ patient communication would help to reach the AAFP stated triple aim of improved patient satisfaction, improved patient outcomes, and lower healthcare costs."

values of patient-centeredness, a focus on the whole patient, and relationship-based care contribute strongly to less communication breakdown. We can continue to improve, and I know I will continue to reflect and try to do better for my patients and students. I have hope that our healthcare system is moving away from fee for service and recognizing the value of primary care.

This shift in payment and focus may allow some of the more nuanced conversations to be more valued. I remain proud to be a family physician and can, through the mist, see a future with less struggles in communication breakdown if we remain committed to our values.

Missouri family physicians Be the voice of

Participate in Advocacy Day at the state Capitol. Bring a colleague, medical student or resident and join fellow Missouri Academy members to promote the importance of family medicine and primary care to our state legislators. This is your opportunity to educate your State Representative and Senator on issues affecting you, your profession, and your patients.

Lodging: Capitol Plaza Hotel has provided a group rate of $90 single/double for Monday evening, February 15.

Call the hotel direct at (573) 635-1234 to make your reservation and be sure to mention the “Missouri Academy of Family Physicians” to receive the discounted rate. A limited number of complimentary sleeping rooms are available on a first come, first served basis for those attending the Monday evening legislative briefing.

Contact the MAFP Office for availability and to reserve one of these rooms.

February 15-16, 2016 • Capitol Plaza Hotel • Jefferson City, Missouri Monday, February 15, 2016 – 6:30 – 8:30 p.m.

Detailed legislative briefing at Capitol Plaza Hotel Tuesday, February 16, 2016 – 8:00 a.m. – 1:30 p.m.

Legislative briefing and breakfast at Capitol Plaza Hotel Visit your legislators’ offices (appointments will be scheduled for you by MAFP staff) Buffet Luncheon at Capitol Plaza Hotel – 11:30 a.m. – 1:30 p.m.

Board of Directors Meeting (working lunch) 1:30 – 5:00 p.m.

For more information, contact the MAFP office at (573) 635-0830 or office@mo-afp.org

RESIDENT GRAND ROUNDS

Hepatitis C for the Primary Care Physician CASE SCENARIO Case Scenario: A 74 year old woman with chronic Hepatitis C infection presents for fatigue. She wonders if her fatigue could be due to Hepatitis C. She would consider treatment for Hepatitis C, but is wary of potential side effects of those medications.

Alicia LuddenSchlatter, MD Department of Family and Community Medicine University of Missouri Health Care

ABSTRACT Hepatitis C Virus (HCV) is a major cause of liver disease, cirrhosis, liver transplant, and hepatocellular carcinoma. The USPSTF and CDC recommend screening all individuals born between 1945 through 1965, and individuals at high risk for infection. Treatment of chronic Hepatitis C infection greatly reduces the risk of hepatocellular carcinoma, liver transplantation, and liverrelated mortality, as well as extrahepatic complications. Interferon and ribavirin were previously the cornerstones of treatment, but many newer therapies have recently been approved which provide superior cure rates with fewer adverse effects. This article addresses recommendations for screening, diagnosis of chronic hepatitis C infection, treatment options, and special considerations for pregnant and pediatric populations.

DISEASE BURDEN HCV is a major cause of chronic liver disease and cirrhosis. Over 185 million people are infected worldwide, causing over 350,000 deaths annually. In the United States, over 2.7 billion people are chronically infected, and the disease burden is expected to increase due to the large number of people infected in the 1960s and 1970s.

Hepatitis C-related end-stage liver disease is the most common indication for liver transplants among adults in the United States, and studies suggest that HCV infection is a major cause increasing incidence of hepatocellular carcinoma. In addition, chronic HCV infection is associated with decreased quality of life, including chronic fatigue, anxiety, depression, post-traumatic stress disorder, and poor quality of life scores, although the relationship is not necessarily causational and many confounding factors likely contribute.

Transmission HCV is transmitted primarily through blood exposure. Intravenous drug use is the most important risk factor, accounting for 60% of acute infections in the U.S. Other mechanisms of transmission include vertical transmission from mother to infant, organ transplant or blood transfusion prior to 1992, and unprotected sex in HIV infected men who have sex with men. Vaginal intercourse among monogamous couples is unlikely to result in transmission, but sexual contact that increases the possibility of blood-to-blood contact (e.g., anal sex, sex during menses, sexual paraphernalia, and intercourse with partners with open lesions) increases this risk.

For health care workers, the risk of HCV infection after a needle or sharps exposure to HCV-positive blood is 1.8%, with a range of 0-10%. There are no CDC recommendations to restrict a healthcare worker who is known to be infected with HCV, other than standard body fluid precautions.

There is no postexposure prophylaxis to decrease risk of infection after a potential exposure, and there is no available Hepatitis C vaccine.

Pathophysiology The HCV genome is single-stranded RNA. It has a high mutagenic potential for several reasons. The virus has both core and envelope proteins, both of which have high mutation potential. The viral RNA polymerase does not proofread, resulting in random nucleotide changes.

There are 6 known genotypes of HCV, and the prevalence of various genotypes varies geographically.

Types 1, 2, and 3 are the most common in the U.S., comprising 97% of HCV infections. However, there are over 50 subtypes within genotypes. Furthermore, divergence of HCV isolates within genotypes,

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RESIDENT GRAND ROUNDS

subtypes, or even within the same host may differ in sequence homology by only a few percent. These slight genetic differences lead to variation between “quasispecies” and complicate medical efforts to create genomically-targeted therapy.

Immunity to HCV does not commonly develop after acute infection. Not only is there great genetic diversity amongst viral strains, but neutralizing antibodies to HCV tend to be short-lived. Therefore, HCV infection does not produce lasting immunity against reinfection even to the same virus isolate.

Natural History After exposure to the virus, there is an incubation period of 30-60 days. The infection spontaneously resolves in 20-50% of patients, but progresses to a chronic infection in 50-80% of patients. Of those individuals with chronic disease, 20% will develop cirrhosis, end-stage liver disease, and/or hepatocellular carcinoma [Figure 1].

Figure 1:

Acute HCV infection refers to signs and symptoms that occur within six months of the presumed exposure. Clinical manifestations may include jaundice or non-specific symptoms, or the patient may be asymptomatic. For both acute and chronic hepatitis C infection, labs may reveal waxing and waning elevated liver enzymes.

Chronic HCV infection is associated with increased risk of B-cell lymphoma and cyroglobulinemia.

There are many extrahepatic manifestations of HCV [Table 1].

Table 1: Extrahepatic Manifestations of HCV Infection: • Arthritis • Porphyria cutanea tarda • Leukocytoclastic vasculitis • Lichen planus • Raynaud phenomenon • Sicca syndrome • Idiopathic thromocytopenic purpura • Membranoproliferative glomerulonephritis • Membranous nephropathy • Hypo/hyperthyroidism • Diabetes mellitus • Essential mixed cryoglobulinemia • Monoclonal gammopathy • Non-hodgkin lymphoma continued on pages 18-22 >

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HDAs HelpDesk Answers

Do High-Intensity Workouts Result in Better Depression Treatment than Medications?

Evidence-Based Answer High-intensity exercise is not more effective than pharmacologic therapy for depression (SOR: A, systematic review of RCTs). Exercise treatment alone produces a modest, short-term improvement in depressive symptoms (SOR: A, systematic review of RCTs). The addition of exercise therapy to antidepressant treatment does not appear to improve depression beyond the effect of antidepressant treatment alone (SOR: B, single RCT).

Jack Wells, Jr., MD, MHA and R. Spencer Kirkland, BS University of Missouri School of Medicine Columbia, Missouri

A

2013 Cochrane review of 4 RCTs included 298 adult patients with depression randomized to exercise versus pharmacologic therapy.1 Diagnostic methods varied among the four trials and severity of depression was not reported.

Three trials reported “hard” intensity of exercise as defined by the American College of Sports Medicine guidelines and one trial reported moderate/hard intensity. The intervention duration was reported as 16 weeks in three of the trials and was not reported in one trial. Because the scales used to measure depressive symptoms varied among trials, standardized mean difference (SMD) in depression symptoms was used.

No significant difference was noted between the two interventions in the primary outcome of a reduction in depressive symptoms (SMD –0.11; 95% CI, –0.34 to 0.11). (Note: an SMD of 0.2 is considered small, 0.6 moderate, 1.2 large, and 2.0 very large.) None of the studies assessed long-term outcomes beyond the exercise or pharmacologic period.1

In a 2011 systematic review of 13 RCTs, 687 patients (age >18 years) diagnosed with depression were randomized to an exercise or a nonexercise control group.2 Depression was diagnosed by a trained health worker or based on a diagnostic system such as the International Classification of Diseases, Hamilton Rating Scale for Depression (HAM-D), or Beck Depression Inventory (BDI). Improvement in depressive symptoms was measured at the end of the intervention. Exercise produced a moderate reduction in depressive symptoms (SMD –0.40; 95% CI, –0.66 to –0.14). The efficacy of exercise was significant in studies of <10 weeks’ duration (5 trials, n=131; SMD –1.0; 95% CI, –1.4 to –0.66), but was not significant in studies >10 weeks long (7 trials, n=453; SMD –0.12; 95% CI, −0.30 to 0.05). No long-term reduction was noted in depressive symptoms beyond the end of the exercise intervention (5 trials, n=350; SMD=0.01; 95% CI, −0.28 to 0.26).2 In a 1999 RCT, 156 patients (>50 years) with depression were randomized to high-intensity exercise (supervised walking or jogging for 30 minutes three times per week), sertraline alone (50–200 mg daily), or a third group that combined sertraline and high intensity exercise.3 This trial was reviewed in a meta-analysis above and examined separately here due to the combined exercise/sertraline group.

Outcomes were assessed by a clinician blinded to group assignment. After 16 weeks of treatment, multivariate analysis of variance showed no significant differences among the groups on the HAM-D or BDI scores. Analysis of HAM-D scores measured at various intervals throughout the trial showed that the response rate differed among the three treatment groups (ANOVA P=.02; results showed graphically in paper), with the fastest initial response (within the first four weeks) seen in the sertraline-alone group.3

1. Cooney GM, et al. Cochrane Database Syst Rev. 2013; (9):CD004366. [STEP 1] 2. Krogh J, et al. J Clin Psychiatry.

2011; 72(4):529–538. [STEP 1] 3. Blumenthal JA, et al.

Arch Intern Med. 1999; 159(19):2349–2356. [STEP 2].

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PRESIDENT'S REPORT

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PRESIDENT'S REPORT

Missouri Family Physician October-December MO-AFP.ORG 2015 99

CONGRESS OF DELEGATES

Congress of Delegates: A Recap of

A Todd Shaffer, MD FAAFP, Delegate

David Schneider, MD, FAAFP Delegate

Keith Ratcliff, MD, FAAFP Alternate Delegate

Kate Lichtenberg, DO, MPH, FAAFP Alternate Delegate

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s with past AAFP Congress of Delegates meetings, there were several interesting and divisive topics presented for discussion and consideration. This year’s interesting debate included marijuana reform, practice efficiency, social determinates of health, and a request for training residents in certain areas of family medicine. Other discussion focused around demonstrating quality outcomes and making PCMH accreditation by organizations such as NCQA more meaningful and tying them to measures that are considered representative of what it means to be a medical home.

Similar debate and discussion sessions focused around marijuana. Ironic this year is that the meeting was also in Denver, Colorado -- a state that, in the past few years, expanded the ability to purchase marijuana legally. New York State Academy introduced a resolution to legalize marijuana for personal use, tax it, and

"

cannot be completed on marijuana itself. There was an agreement among the group at the reference committee that to reclassify marijuana to Schedule II rather than Schedule I would open up opportunities for federally-funded research.

Delegates did eventually adopt a substitute measure that called for the AAFP to support the decriminalization of the possession of marijuana for personal use and would encourage the National Institute of Health to conduct appropriate research for its health effects.

The Congress also voted that AAFP include education on human trafficking in residency and in CME programming as we often see victims of trafficking and almost never pick up on it.

Support for health care in rural areas of this country was also a major focus of discussion as more rural hospitals close and practitioners leave rural practice.

Another area of discussion was about certain

Overall this was a great Congress of Delegates.

I enjoyed participating and working through the reference committees and hearing testimony from colleagues. I look forward to resolutions being further adopted by the AAFP Board and some of the ones that were referred for further discussion." Todd Shaffer, MD, FAAFP

the funds support substance abuse treatment.

Another resolution from the Minnesota Academy called for reclassification of marijuana to allow research to be conducted on its potential benefits for patients. Colorado alternate delegate Brian Bacak, MD, of Denver spoke up that his state had legalized personalized use of marijuana in 2012 and medical use of marijuana in 2000.

He told the reference community that legalized marijuana has not been simple in Colorado.

“A common idea is that if you legalize marijuana then criminal activity will disappear. But that is not what has happened” in his state. He urged the AAFP to be careful in seemingly endorsing the public health problems of marijuana. With the current classification of marijuana, research

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Delegate pharmaceutical companies that acquired drugs that had been previously inexpensive and raising the price extremely. An example is Turing Pharmaceuticals that acquired the drug pyrimethamine (Daraprim) and immediately increased its price from $13.50 to $750 per tablet. Several delegates spoke on the AAFP moving forward with a resolution to urge Congress and other peripheral agencies to investigate current policies that result in pharmaceutical price increases as it can create barriers to accessing generic medications.

The reference committee also heard several resolutions dealing with adult contraceptives including two methods to ensure public and private health plan coverage of long-acting

CONGRESS OF DELEGATES

Officers, Resolutions and Reports... reversible contraceptives. Concerns focused on placement of these devices immediately postpartum in the hospital prior to discharge as well as physician payment for placement of such services separate from the global fee. You might know, that if you place an implantable device prior to discharge or even on the same day of discharge from the hospital, it will be included in the global fee and will not be reimbursed for the placement or for the medication. Testimony demonstrated that many patients who are most at risk for an unplanned pregnancy may not return to

L to R: Peter Koopman, MD, Todd Schaffer, MD, Kate Lichtenberg, DO, David Schneider, MD, Kathy Pabst, Executive Director, Keith Ratcliff, MD and Patrick Harr, MD at the Annual Meeting of the AAFP Congress of Delegates in Denver, Colorado on September 27-30, 2015.

have it placed at a later time. Also discussed was prescribing contraceptives to patients on Medicare disability. Patients currently who have Medicare through disability do not have access for coverage of typical contraception. Their disability could put their health at significant risk if they become pregnant. The Congress of Delegates did pass a resolution to support Medicare coverage through all FDA approved methods and to have CMS cover these contraceptives for all women of reproductive age.

Telemedicine was a center of conversation as the Mississippi delegation presented a resolution that insisted telemedicine and mobile health be utilized only as part of an established patientphysician relationship that includes recent face-to-face encounters. Alex McDonald, MD, of California testified that nothing can take the place of the physical examination yet medicine will be practiced that way in 50 years as we know it now.

The topic was referred on to the AAFP Board for further discussion.

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Several other topics included the tackling the social determinates of health. New York had a resolution for the AAFP to consider recommendations on how gentrification impacts health outcomes. The resolution called for AAFP to investigate how neighborhoods where food is no longer affordable to low-income families become food deserts on an economic basis. The reference committee offered a substitute resolution, which was adopted, that asked the AAFP to partner with public health, policy centers, and research organizations to investigate the impacts on health outcomes and use the information to possibly create recommendations to help improve the health of these normal populations.

Another major resolution adopted by the Congress of Delegates included the reduction of the negative effects of income, education, and nutrition inequality be aligned with the AAFP strategic goals for collaboration with public health agencies to achieve this objective.

Discriminatory policy as a public health concern was another resolution topic presented for consideration. Multiple delegates of color took turns testifying to personal stories and those related to their patients of discrimination and in some cases serious abuse at the hands of police officers. Ultimately, delegates adopted two resolutions and referred two to the AAFP board.

The first clause adopted by AAFP would create a policy statement recognizing that any use of force beyond that reasonably necessary to accomplish a lawful police purpose poses a serious ongoing public health issue that disproportionally effects minority communities. Also adopted was the second clause asking the AAFP to support transparency and accountability in everyday interactions between the police and the public. As we have seen in our state of Missouri last summer, and more recently on the University of Missouri â&#x20AC;&#x201C; Columbia campus, race relations is an important topic that our academies must voice and how this affects our patients and our communities.

There were several other resolutions that dealt with further Suboxone training, the AAFP to require residency programs to train residents for pain medication treatment, and for required training in disability evaluations, but these did not make it out of reference committee.

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CONGRESS OF DELEGATES

AAFP President Takes Office; New AAFP Leaders Elected

"

Our time is now. America is hungry for answers to a broken U.S. health care system."

Missouri Chapter Delegates: Dave Schneider, MD, FAAFP Todd Shaffer, MD, MBA, FAAFP Missouri Chapter Alternate Delegates: Keith Ratcliff, MD, FAAFP Kate Lichtenberg, DO, MPH, FAAFP

N

Wanda Filer, MD, MBA AAFP President

ewly installed AAFP President Wanda Filer, MD, MBA, of York, PA, stood on stage in front of a packed theater at the Congress of Delegates to officially open the Academy's 2015 Family Medicine Experience. Filer began her inaugural address by saying to her family physician colleagues, "Our time is now. America is hungry for answers to a broken U.S. health care system." The AAFP Congress of Delegates elected John Meigs, Jr., MD, of Brent, AL, to be the AAFP's president-elect.

Others elected or chosen by acclamation for the following positions include: Speaker of the Congress - Javette Orgain, MD, MPH, of Chicago, IL; Vice Speaker - Alan Schwartzstein, MD, of Oregon, WI; Directors - John Bender, MD, MBA, of Fort Collins, CO; Gary LeRoy, MD, of Dayton, OH; and Carl Olden, MD, of Yakima, WA; New Physician Board Member - MarieElizabeth Ramas, MD, of Mount Shasta, CA; Resident Board Member - Richard Bruno, MD, MPH, of Baltimore, MD; and Student Board Member - Tiffany Ho, MPH, of Baltimore, MD.

All pictured on page 10

MISSOURI PRIORITY RESOLUTIONS No. 201

Title Action of Congress Patient Education Videos for Familydoctor.org Referred to the Board of Directors

209

Hospice: An Integral Part of Family Medicine

Substitute Adopted

301

Support Placement and Coverage of Long-Acting Reversible Contraceptives (LARC) in the Early Postpartum Period

Substitute Adopted

305

Issues Related to and Educate Physicians Medicare Advantage Plans

Adopted

306 Electronic Health Records Designation as Medical Devices

and Regulated by the FDA

408 Explore Ways to Assist Members in Addressing Driving

Safety of Older Adults

Referred to the Board of Directors

409

Communicate Concerns about Electronic Cigarettes with Retail Clinics and Urge Them to Cease the Sale of These Products

Substitute Adopted

501

Expanded Use of Naloxone

Substitute Adopted

513

Advocate for the Central Role of Primary Care in Performing Annual Wellness Visits

Substitute Adopted

604

Medical Education Support for Practice in Rural and Underserved Areas

Substitute Adopted as amended on the floor

Substitute Adopted

609 Standardizing Visiting Medical Student Elective Not Adopted Medical History Forms

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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 setting, dynamic urban location, or somewhere in between, we are committed to focusing on your interests and careers that count!

Find Out More: Contact Us Today!

Joni Adamson Manager of Recruitment 573.636.4222 jadamson@mo-pca.org www.3rnet.org/missouri

   

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Ask us about complimentary career planning luncheon presentations for FMIG and Residency Programs on topics such as: CV Writing; Compensation Packages; Job Search Strategies; Interviewing; Job Selection; Loan Repayment Incentive Programs; Finance Basics; Contract Negotiation, and/or Job Transition.

Pride, Passion, Purpose: Careers That Count!

Proud Partners Of:

MHPPS is non-profit and located within the MO Primary Care Association 13

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2015

ANNUAL FALL CONFERENCE

ANNUAL FALL CONFERENCE; A GREAT TURNOUT IN 2015

T

he 2015 Annual Fall Conference, held at Big Cedar Lodge in Ridgedale, Missouri on November 6-7 was a success with increased attendance in both attendees and exhibitors. The SAM Working Group, held on Sunday of the conference drew in a large crowd as well. Friday evening, the Family Health Foundation of Missouri held it's first-ever Wine Tasting event, hosted by the Missouri Wine and Grape Program and sponsored by Missouri Health Professional Placement Services.

All proceeds from the Wine Tasting went to support foundation programs such as Tar Wars, externships and student scholarships. Members, their spouses, Cadey Harrel, MD, left, and Kara Mayes, MD chat during a morning break.

Dr. Harrel spoke to the members on the topic of Breastfeeding in her session colleagues and friends joined together on Saturday afternoon. to learn about Missouri wines and the history behind them. Saturday's Legislative Luncheon brought a full house as the Academy welcomed Representatives Diane Franklin and Keith Frederick, DO to speak to members on current issues. Pat Strader, MAFP Legislative Consultant was honored for her hard work and support during the legislative session; focusing especially on her work pertaining to House Bill 769, Direct Primary Care which passed due to the support of you, our members. A special thank you to all of our members, attendees and speakers for your dedication and commitment to the Academy, and to our exhibitors; without you, AFC would not be possible.

Members enjoying the Wine Tasting on Friday evening. Bottom right: Pat Strader receives framed House Bill 769 from Dr. Purdom, MAFP Chair, in honor of her hard work and dedication to the Academy.

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ANNUAL FALL CONFERENCE

"

It [AFC] was a fantastic show for us and we look forward to next year!" -Exhibitor

50/50 Raffle

WINNER Tha nk

Yo u !

Dr. William Rosen was the winner of the Family Health Foundation's 50/50 Raffle this year.

Dr. Rosen kindly donated all of the proceeds back to the foundation.

2015 EXHIBITORS & SPONSORS • AMGEN • Anthem • Astellas Pharma • Barnes-Jewish Hospital • Children’s Mercy Hospital • Citizens Memorial Hospital • CoxHealth • Crealta Pharmaceuticals • Direct Primary Care Clinics, LLC. • Docs Who Care • Freeman Health System • Fresenius Medical Care 15

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• GeneTrait Laboratories • Genzyme • HealthLink • Marley Drug • MDsuite • Merck & Co., Inc. • Mercy Hospital • Missouri Army National Guard • Missouri Beef Industry Council • Missouri Care • MoDocs • MO Health Professional Placement Services

• MPM/PPIA • Novo Nordisk • Pfizer • Sanofi Pasteur • SEMO Drug • SoutheastHEALTH • St. Louis Children’s Hospital • St. Louis University Hospital • Stanley’s Pharmacy • United Allergy Services • U.S. Army Health Care MO-AFP.ORG 15

PRESIDENT'S REPORT

WHEN YOUR PATIENT NEEDS A SPECIALIST, WE HAVE MORE THAN 600.

Transforming pediatric medicine every day.

To refer a patient, call 1-800-GO-MERCY 1 (800) 466-3729

As a physician, you’re committed to your patient’s successful outcome.

At Children’s Mercy Kansas City, we are, too. Here, you’ll find more than 600 pediatric specialists eager to use their in-depth experience to transform patient health.

From subspecialists to nurses, radiologists and lab techs to child life specialists — there’s a professional in every position specifically trained to treat children.

You don’t have to look far from home to find the best care for your pediatric patients. We have the region’s only pediatric trauma center and the only Level IV NICU between Denver and St. Louis. Our transplant center serves young lives in need of a heart, liver or kidney. Every service we offer, from disease-specific clinics to innovative treatment options, ensures better outcomes for more than 500,000 patients every year.

Improving the pediatric health of the region with nationally recognized care.

It’s not just an outcome we pursue —but a transformation we lead.

For more information, visit childrensmercy.org/transform 16

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CAPITOL COMMENTARY

Capitol Commentary

T

he Second Regular Session of Missouri’s 98th General Assembly convened at noon on Wednesday, January 6. Pre-filing of legislation began on December 1, 2015, and by the end of March, about 2,000 measures will have been introduced. You will be hearing a lot about the Annual MAFP Advocacy Day at the Capitol scheduled for Tuesday, February 16, with a dinner/review on Monday evening February 15. I urge you to attend this important and fun event.

Bill Review and Process Bills are given an initial review then prioritized into Tiers I, II and III. Measures that we consider Levels I and II are placed on the MAFP website to give members a quick way to review the most important bills. MAFP’s position on some of these bills might simply be “monitor” or “neutral." A bill can move up or down in priority depending on subsequent versions or amendments adopted to the bill. Of course, all bills filed in the legislative session can be accessed on the House and Senate websites. The Advocacy Commission reviews legislation to determine how the bills will affect physicians and their patients.

Positions are formulated based on our research and available data, and by assessing feedback received from members. Many measures are repeat bills that were filed in previous sessions, so our background on those bills can be more extensive.

Reviewing a Bill Each bill has a page on either the House or Senate website. The bill summary and bill text are available for each one. Throughout the process as different versions are adopted, they will also show up on the bill’s page. Amendments and fiscal notes can also be viewed. It is important to note when reading a bill that language included within [brackets] is being removed from the law; language shown in BOLD type is new language being added to the law.

Keep Updated with Friday Reports As MAFP’s legislative consultant, I prepare a “Friday legislative report” for members to give you the latest updates on major legislation. It will also include any significant events that might have occurred during that week. If a bill you want to know about is not the subject of that week’s report, I am always available to visit with you and provide the information.

Legislative Alerts Missouri has a large legislature – 34 Senators and 163 State Representatives. That’s why it is 17

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important for you to become familiar with the people that represent your district at the Capitol. MAFP’s key contact program strives to match up our members with each and every Senator and Representative, but we still have slots that need to be filled. Occasionally, you will receive a request or an “Alert” asking you to contact your Senator or State Representative about a particular bill. We will provide a description, brief talking points and the contact information. An email or phone call to their offices works well. You will need to identify yourself as a “constituent” and provide your address and contact information.

Legislative Priorities As we do each and every session, MAFP will be promoting the importance of primary care for Missouri’s citizens and we will continue to advocate for enhanced reimbursement for primary care. Many issues will be on the agenda – the state’s plan to expand managed care statewide for the current Medicaid population; exploring Medicaid expansion/ transformation; physician licensure; implementing a prescription drug monitoring program; APRN scope of practice and other scope issues; safety-related measures such as opposing the repeal of the mandatory motorcycle helmet law, and addressing texting while driving – just to name a few. MAFP would like for you to consider “testifying” during the upcoming session. If there is a particular subject or issue that is important to you, let us know so we may add you to our list of available physicians. Also indicate a day that would work best for you. Hearings are held Mondays through Thursdays, with each Committee assigned a specific day and time.

Pat Strader MAFP Legislative Consultant Feel free to contact me any time with questions or comments. You may also contact the MAFP staff or reach me through the Academy office.

2016 - An Election Year Election year sessions always bring surprises. All members of the House of Representatives and onehalf of the Senate (odd-numbered districts) will be up for election or re-election this year. Missouri will also elect a new Governor, Lieutenant Governor, Secretary of State, State Treasurer, and Attorney General. The only statewide office not up for election this year is the State Auditor.

Ballot Issues 2016 may see many issues on the ballot. The process has begun for “certifying” the ballots, followed by groups supporting the measure collecting the appropriate number of signatures. We will outline some of those in a future edition of the magazine.

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RESIDENT GRAND ROUNDS continued from page 6 >

Screening and Diagnosis Assessment The USPSTF and CDC recommend periodic HCV screening for all adults at high risk of infection, and one-time screening for all adults born between 1945 and 1965. This specific age range is based on data over a ten-year period which showed that three-fourths of patients in the U.S. living with HCV infection were born between 1945 and 1965. The American Association for the Study of Liver Disease recommends annual screening for intravenous drug users and men who are HIV positive and have unprotected sex with men.

The USPSTF recommends screening via a test for anti-HCV antibodies (sensitivity 95%, specificity 99%, positive likelihood ratio 95, negative likelihood ratio 0.05). The number needed to screen is less than 20 persons, and even in low-prevalence populations, anti-HCV antibody testing remains highly accurate.

If a patient screens positive for anti-HCV antibodies, a qualitative blood test for HCV RNA must be ordered to determine if the patient is currently infected. Patients who are positive for viral RNA in the blood are either acutely or chronically infected. If a patient is positive for anti-HCV antibodies but negative for HCV RNA, they likely have been exposed in the past but are negative for current HCV infection [Figure 2]. An interpretation of HCV assays is found in [Table 2].

Figure 2:

Table 2: Interpretation of HCV Assays: Anti-HCV Positive

HCV RNA Interpretation Positive Acute or chronic HCV depending on the clinical context

Positive

Negative

Resolution of HCV; Acute HCV during period of low-level viremia

Negative Positive Early acute HCV infection; chronic HCV in setting of immunosuppressed

state; false positive HCV RNA test Negative

Negative

Absence of HCV infection

The initial screen relies on the presence of antibodies, which may take three months to develop.

Therefore, if a patient is negative for anti-HCV antibodies but has a potential exposure in the previous six months, it is recommended to measure HCV RNA every four to eight weeks for at least six months, or repeat anti-HCV antibody testing in twelve weeks.

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RESIDENT GRAND ROUNDS

Assessment of Chronic HCV Infection If a patient is found to be positive for chronic HCV infection, two labs are important to obtain prior to starting treatment. First, quantitative HCV RNA is needed to determine a baseline viral load. During treatment, the viral load will be repeated to monitor response to therapy. Secondly, testing for HCV genotype is recommended to help guide therapy.

In patients with chronic HCV infection, the degree of liver fibrosis is predictive of disease progression and clinical outcomes. The gold standard to assess fibrosis progression is a liver biopsy with histologic assessment of the degree of fibrosis. The Metavir Scoring System is a commonly used assessment which assigns a grade of fibrosis from zero (no fibrosis) to four (cirrhosis or advanced liver scarring) [Table 3]. Acceptable, noninvasive alternatives include panels of serum biomarkers and an ultrasoundbased test know as vibration-controlled transient liver elastography.

Table 3: Metavir Scoring System for the Assessment of Liver Fibrosis and Cirrhosis: Level of fibrosis Score No fibrosis 0 Minimal scarring 1 Positive scarring with extension beyond area containing blood vessels 2 Bridging fibrosis with connection to other areas of fibrosis 3 Cirrhosis or advanced liver scarring 4

All patients with chronic HCV infection should be screened for Hepatitis B and HIV. Not only would individuals infected with HCV have risk factors for other blood-borne diseases, but concurrent Hepatitis B and HIV infections both may accelerate the progression of liver fibrosis. Patients with severe fibrosis also require surveillance to monitor hepatitis function, monitor for liver cancer, and screen for esophageal varices.

Treatment Traditionally, treatment of chronic HCV infection was recommended for patients with a Metavir score of 2 or greater. However, increasing knowledge of disease outcomes and advances in therapy have changed the thresholds for treatment.

According to the Infectious Disease Society of America, “Evidence clearly supports treatment in all HCV-infected 19

MISSOURI FAMILY PHYSICIAN

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RESIDENT GRAND ROUNDS

persons, except those with limited life expectancy (less than 12 months) due to non-liver related comorbid conditions.”

Treatment effectiveness is monitored via repeated measurements of HCV RNA in the patient’s serum. A Sustained Viral Response (SVR) is defined as an absence of HCV RNA on PCR testing 12-24 weeks after stopping antiviral medications. Achievement of a SVR is associated with a 99% chance of remaining negative for viral RNA in long-term follow-up, and is considered tantamount to a cure.

Patients who achieve SVR will still have HCV antibodies, but have no detectable HCV RNA in their serum or liver tissue. Furthermore, patients with SVR have improved transaminases and improvement of fibrosis and cirrhosis. SVR is associated with a more than 70% reduction in the risk of hepatocellular carcinoma and a 90% reduction in the risk of liver-related mortality and liver transplantation. SVR is also associated with improvement in extrahepatic manifestations such as cryoglobulinemic vasculitis and remission of associated lymphoproliferative disorders such as non-Hodgkin lymphoma. In addition, patients with SVR have improved quality of life, including physical, emotional, and social health.

Criteria for treatment are typically age 18 or older and willingness to adhere to treatment. Due to the many benefits of therapy and improved side effect profile of newer medications, the IDSA now recommends that clinicians should treat HCV-infected patients “preferably early in the course of their chronic HCV infection, before the development of severe liver disease and other complications.”

Patients treated early in the disease course may have better response to treatment and achieving SVR removes the risk of further transmission to other individuals. However, given finite resources, the IDSA suggests prioritizing immediate treatment to individuals at high risk for liver-related complications [Table 4].

Table 4:

HCV Treatment Priority Groups: Highest Priority for Treatment Owing to Highest Risk for Severe Complications • Advanced fibrosis (Metavir F3) or compensated cirrhosis (Metavir F4) • Organ transplant • Type 2 or 3 essential mixed cryoglobulinemia with end-organ manifestations (eg, vasculitis) • Proteinuria, nephrotic syndrome, or membranoproliferative glomerulonephritis High Priority for Treatment Owing to High Risk for Complications • Fibrosis (Metavir F2) • HIV-1 coinfection • Hepatitis B virus (HBV) coinfection • Other coexistent liver disease (eg, NASH) • Debilitating fatigue • Type 2 Diabetes mellitus (insulin resistant) • Porphyria cutanea tarda Persons At Elevated Risk of HCV Transmission and in Whom HCV Treatment May Yield Transmission Reduction Benefits • Men who have sex with men (MSM) with high-risk sexual practices • Active injection drug users • Incarcerated persons • Persons on long-term hemodialysis • HCV-infected women of child-bearing potential wishing to get pregnant • HCV-infected health care workers who perform exposure-prone procedures

There are many predictors of treatment response. Viral genotype is the strongest predictor of SVR; SVR rates are highest for genotypes 2 and 3 and lowest for genotype 1. Other predictors for SVR include certain host interleukin polymorphisms and statin use. Factors associates with decreased rates of SVR include higher baseline viral loads, advanced fibrosis and cirrhosis, older age, insulin resistance, and African American ethnicity.

Many treatment options for chronic HCV infection now exist. HCV therapy is complex and rapidly changing, and therefore medications should be prescribed by an experienced provider. Pegylated interferon and Ribavirin were previously the mainstays of treatment. Unfortunately, both of these regimens were associated with serious adverse effects. In recent years, new interferon-free regimens 20

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have been approved which show superiority, are better tolerated, and are becoming the standard of care. These newer agents, such as Olysio, Solvaldi, Harvoni, and others target specific proteins encoded by the viral genome [Figure 3, Table 5].

Figure 3: HCV POLYPROTEIN STRUCTURE AND TARGETS:

Table 5: Newer Agents for Treatment of Chronic HCV Infection: Trade Name Generic Agent(s) Protein Sequence Target Olysio Simeprevir NS3 Solvaldi Sofosbuvir NS5B Harvoni Ledipasvir NS5A Sofsbuvir NS5B Viekira Pak Ombitasvir NS5A Paritaprevir NS3/4A Ritonavir HIV-1 Protease Inhibitor Dasabuvir NS5B

These medications are prescribed in particular combinations based on the viral genotype. Most courses of treatment are 12-24 weeks. Medications are generally well tolerated; adverse effects may include anemia, fatigue, flulike symptoms, headache, and nausea. These new regimens are expensive, typically costing upwards of $8,500-$155,000.

All individuals with HCV infection should be vaccinated against hepatitis A and B. Providers should inquire as to current alcohol use and encourage cessation (although history of alcohol use does not preclude individuals from receiving treatment). Patients and families should be educated regarding preventing transmission [Table 6].

Table 6:

Reducing the Risk of HCV Transmission • Avoid needle sharing • If multiple sexual partners, advise condoms • For monogamous couples, condoms not routinely recommended due to low risk of transmission • Avoid household blood contacts: avoid sharing razors, toothbrush, and nail clippers • In health care settings, utilize standard precautions for blood-borne diseases

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Pregnant Women HCV seroprevalence rates are 0.6-6.6% in pregnant women worldwide, and approximately 2/3rds of these women have detectable HCV RNA in their serum. Vertical HCV transmission from mother to child is approximately 10% in HCV RNA positive mothers. Vertical transmission essentially only occurs if the woman is viremic. Factors that increase the risk of vertical transmission include high maternal HCV viral loads over 105-106 copies/ml and maternal coinfection with HIV. Coinfection with HIV increases the risk of vertical transmission to as much as 44%, but in mothers infected with both HIV and HCV who receive HIV antiretroviral treatment during pregnancy, the risk of transmission is similar to mothers who are infected with HCV alone. The route of delivery (vaginal versus cesarean section) does not affect the risk of vertical transmission, and therefore the decision to perform cesarean section should be based on other maternal and fetal indications.

The safety and efficacy of treating pregnant women to prevent transmission has not been established. Ideally, women of child-bearing potential should be treated before they become pregnant.

Ribavirin is listed as pregnancy category X, and patients receiving treatment (and female partners of males receiving treatment) must use two forms of contraception during treatment and for 6 months after completion of therapy. Pegylated interferon is pregnancy class C and is generally avoided during pregnancy. Most newer agents are pregnancy class B. Due to the slow natural history of the disease and potential harm to the fetus, treatment of chronic HCV infection in pregnant women is typically deferred until after delivery. There is limited data regarding lactation safety of these medicines.

Routine prenatal screening for HCV is not recommended, but women with significant risk factors should be offered antibody screening.

Breastfeeding has not been associated with increased risk of neonatal HCV infection and maternal HCV infection is not a contraindication for breastfeeding, although mothers may be cautioned if nipples are cracked or bleeding.

HCV in Children and Neonates The estimated burden of pediatric HCV infection in the U.S. is 68,000-102,000. Vertical transmission is the most common route of infection in the pediatric population. Infants with vertically acquired HCV are usually asymptomatic. Infants may have elevated transaminases with mild chronic hepatitis, but fulminant hepatic failure is rare. Acute HCV infection resolves 50% of the time in children; long term data regarding rates of cirrhosis is limiting, but is estimated at 5-10% of cases.

Special considerations apply to diagnosis of HCV infection in neonates. Diagnosis should be postponed until after one year of age, because infants may have transient viremia in the first year of life. In addition, infants may have passively acquired maternal antibodies; of children born to HCVinfected mothers, anti-HCV antibodies are universally present at birth but by age two years is positive only in children with chronic infection. Therefore, Pediatric Infectious Disease recommendations for diagnosis are to perform qualitative PCR for HCV, and if positive, repeat at age 18-24 months. A positive qualitative PCR after age 18-24 months is likely to be a chronic infection.

Data regarding treatment of children is limited and is often extrapolated from studies on adults.

Children with chronic HCV infection should receive hepatitis A and B vaccines, be cautioned regarding hepatotoxins (such as acetaminophen). Adolescents should be counseled regarding alcohol use, drug use, and potential for transmission via sharing razors and toothbrushes.

References on page 37 >>

ATTENTION RESIDENTS Do you need to be published?

Submit your report to be published as a Resident Grand Rounds article in our quarterly Missouri Family Physician magazine. Contact MAFP staff at office@mo-afp.org

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PRESIDENT'S REPORT

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MEMBER INPUT

A Fresh Team-Based Approach to

E Kurt R. Bravata, MD Family Medicine Citizens Memorial Healthcare

"

I wanted to be liberated from treating the computer so I could get back to the warm bodies that actually needed my attention."

Kurt R. Bravata, MD

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lectronic Health Records (EHRs), just the name itself unleashes a torrent of feelings.

We love them, we hate them, we depend on them, we resent our dependence on them, and we are told that they should help to streamline our practice, when in reality, they often seem to slow us down. Our daily workflow rhythm is set by a cacophony of clicks on a mouse or keypad. Our work stations often sound like a writerâ&#x20AC;&#x2122;s room at the New York Times - "Click, click, clickity, click, clack, click!"

Or "Click, click... Begin dictation, muffled speech, something unintelligible, ..........End dictation, ...... click, clack, clackety, click, clack, click!"

I can recall during my second year of residency, the time management challenges I faced when we made the difficult transition from paper to electronic records while I was on the inpatient unit.

I remember feeling like I was both a pilot and a flight attendant who spent 75 percent of his time at the controls (my computer) and 15 percent of my time checking on the passengers (my patients). My thought at the time was, in effect, that this was a massive waste of my time and had very little to do with actual patient care. I wanted to be liberated from treating the computer so I could get back to the warm bodies that actually needed my attention.

I joked at the time that what I really needed was a scribe. Little did I know that this would someday be my reality.

Enter the medical scribe!

It was two years later, when I joined a hospital owned family practice that I came to experience the true joys and benefits of having a medical scribe. To my good fortune, the clinic that hired me, already had an established medical scribe program which allowed for one scribe per physician, as long as you met the productivity requirements, which were pretty reasonable. This is in addition to the standard rooming nurse assigned to each provider. Funds for this are dispensed out of the clinics staff salary allotment based on the premise that physicians are more productive and do better documenting when they have a scribe. Hence, more patients are seen and more work is captured in the notes, resulting in better reimbursement.

So, how does this system work? Well, my rooming nurse opens the chart and starts the note, and then she gets the patient from the waiting room, takes vitals, reconciles meds, narrows the focus of the visit, and obtains a brief history and review of systems. On my instruction, she may also order tests, such as labs, EKG, or imaging, as well as any

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needed vaccines. The rooming nurse also pulls into my note any labs, imaging, or reports to be reviewed with the patient during the encounter. Meanwhile, I am working with my scribe on completing previous notes or preparing for the next encounter. If time allows, my scribe will often start the note for the next patient and help predict the agenda for the visit bases on past notes or visit reason given by scheduling. Much ground is covered this way, even before we go in the room and I rarely have more than 3 notes unsigned at a time. When the next patient is ready, my rooming nurse changes the visit status from 'with nurse' to 'nurse complete' and both my scribe and I enter the room. Although some providers don't, I still frequently bring my laptop in to the room, so I can maintain my focus on the patients documented complaints and reason for visit, as well as accurately review with the patients their consultations, labs, and imaging.

This only enhances my work flow as I do not need to interrupt my train of thought to document and am free to set my computer down and carry out my interview and exam knowing that my scribe is transcribing everything into the note in real time.

Knowing this, I repeat back to the patient what I understand to be their history and concerns, narrate my physical, and plan out loud so everything is understood by the patient and scribe. If I leave anything out, my scribe is at liberty to cue me as needed so nothing is missed. An added bonus is I always have an assistant in the room to help me with procedures and my scribe serves as a built in chaperone, assuring that I am never alone with a patient and who can corroborate everything that transpired during a patient encounter. Once the visit is complete, my scribe may follow me immediately, or may linger to review instructions, perform wound care, administer a PPD or injection, or assist the patient in some other way, while I am free to move on to charting or seeing the next patient.

Taking it to the next level!

So, here's where efficiency really picks up - by cross training. I began to notice that there would often be a disconnect between the agenda discussed between my rooming nurse and the patient and that which developed once my scribe and I entered the room. Naturally, this slowed things down. I also met with the reality that although it was enormously helpful to have my scribe linger in the room to finalize things with the patient after I stepped out, I could easily get behind by waiting for her to be ready or by moving on without her there

MEMBER INPUT

Efficient Practice Management to document. To remedy this, I started cross training my rooming nurse as a scribe with the support of my clinic management. Once I felt she was ready to take on the full responsibility of scribing, I began what I call the piggyback approach to rooming and scribing. This approach works, because my scribe is also a nurse, but would work about as well if she was an medical assistant.

The piggy-back system is simple: The cross trained nurse scribe starts the note, rooms the patient, and stays in the room from beginning to end, scribing all the while and providing any nursing services as needed.

By doing this, the nurse scribe is better able to help keep the visit focused in a way that addresses the patient's agenda while also meeting my own. I find that documentation is more seamless and more work actually gets done because the nurse who rooms the patient feels no pressure to rush out and move on to the next patient. This results in better agenda setting, more accurate medication reconciliation and renewal, and more complete history and health maintenance updating.

An added bonus is that patients never wait in the room alone, so they may have the perception of shorter wait times, or at least feel attended to while waiting for the physician. By the time I get in the room, much of the HPI had been written, the patient has had many questions answered by the nurse, medication issues have been addressed, any in clinic labs/imaging have been obtained, required vaccines have been given, and often mammograms or colonoscopies have been ordered, along with any other health maintenance updates.

My nurses tell me they love this method because they feel more ownership of the visits, are less tired because they are seeing half the patients, and feel less stressed overall. All this amounts to more patient and staff satisfaction, increased efficiency, less errors, and better documentation. Frequently, I will have two visits scheduled at the same time at the start of the morning or afternoon session (one new encounter to establish care and one acute or follow-up visit) and will have both nurses room at the same time. I will then go in and complete the shorter visit first and then move on the new encounter which consistently takes longer to room.

The only downsides I have seen to the piggy-back method are: 1) the tendency to lose the sense of urgency to move on to the next patient and 2) the bind you get in if one of your cross-trained nurse-scribes is unable to work. The first is easily reminded by a team huddle and the second requires a shift back to the old way of rooming and scribing until more than one cross trained nurse-scribe is available.

The conclusion: Scribes increase practice efficiency, especially when employed in tandem using the piggyback method.

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NURSING STAFF CONTRIBUTIONS: “I feel the pros of having two scribes called the piggy-back approach included that it is far more beneficial in increasing productivity as well as the quality of the patient encounters.

The patient feels the physician has spent more time addressing their concerns and is more likely to be satisfied even if long wait times do happen to occur from time to time.

The cons would be that as a scribe, it is difficult to keep track of concerns after the patient has left the office, as some things discussed at a visit (under another nurse or scribe) may not have been documented during that visit but may still be important for the scribe to know. Such knowledge is often helpful in building and maintaining the trust of the patients.

Another issue is that patients tend to get attached to one nurse or MA more than the other, and hence, only want them involved in their care. The piggy-back approach does not allow this.” - Laurie Vanderhoof, MA "I started out as Dr. Bravata's rooming nurse but eventually had more and more opportunities to learn how to scribe. We came up with the idea of the "piggy-back" approach as we thought It might help improve our work flow, decrease stress, and decrease our patient wait times.

The "piggy-back" approach is where you have two nurses rooming and scribing. Each nurse would take turns rooming a patient and then stay with them for the duration of the visit. This included scribing and completing the visit note. I feel that it did help cut down on the patient's wait time to see the provider.

I also feel that it helped decrease the patient’s perception of how long they were waiting because they were never left alone in the room. It was less stressful as a nurse because I was not stressing about getting out of the room to go grab the next patient. Most of the time it did help everything run a lot smoother.

However, it did not always go as planned. It really only worked as long as one of the nurses did not get hung up in a room. This was often the case with some of our new or more difficult patients. The other nurse would then have to grab the next patient. This would either cause the provider to see a patient without a scribe or he would wait until one of his nurses were free. This caused our visits to get even further behind.

I recently was given the opportunity to scribe full time and we went back to the traditional method of rooming and scribing after about 2 months. I have to say that overall. I did like the "piggy-back" approach but the key for it to be a success is time management. I like my new role of scribing full time because there is more consistency and I am able to focus more on documentation.

However, even with the traditional method, we often find ourselves running behind all day. It really just depends on the patients you are seeing and how complex their visits are. I feel there are pros and cons to each method and I don't have a preference. The goal is to try and provide good quality patient care in a timely manner." - Tyla Buxbaum, RN Dr. Bravata, front row, his nurse scribe Tyla, directly behind him (stocking cap) and nurse scribe, Laurie, in front of tree (in red). Dr. Kristina Kaufmann, D.O. (front row in red scrubs), Lisa Stringfellow, FNP (burgundy scarf), Dave Hunzinger, FNP (gray scrubs and stocking cap), Lydia Novruzov, PA-C (right of Dave, red scarf), and Office Manager Christie Wimberly (second from left, back row, green scarf), and Dallas County Family Medical Center office staff.

MO-AFP.ORG 25

MEMBERS the

IN NEWS News to share?

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

Patil Receives Dr. Barbara Starfield Award

Pictured: Sonal Patil, MD; Co-investigators on this project included: Richelle Koopman, MD, MS; Erik Lindbloom, MD, MSPH; Todd Ruppar, PhD, RN; Vicki Conn, PhD, RN; Susan Elliott, MLS; David Mehr, MD, MS

Sonal Patil, MD, Academic Fellow at the University of Missouri Department of Family and Community Medicine, received the 2015 Dr. Barbara Starfield Award for her presentation, “What is the Effect of Peer Support Interventions on Glycemic Control? A Systematic Review and Meta-Analysis.”

This recognition is given to the trainee who conducted the best primary care research project last year. Her project was rated highest among all trainee submissions received for the 2015 North American Primary Care Research Group (NAPCRG) meeting. Dr. Patil accepted this award at NAPCRG’s annual meeting, which was held this fall in Cancun, Mexico.

Heafner Appointed as AAFP FMIG Regional Coordinator John Heafner, MPH, Saint Louis University School of Medicine, St. Louis, Missouri, was appointed as an American Academy of Family Physicians (AAFP) Family Medicine Interest Group (FMIG) Network Regional Coordinator. Heafner's appointment began January 1, 2016.

Hix Appointed to Serve on AAFP Commission on Membership and Member Services Kenetra Hix, MD, MPH, Saint Louis University, Family Medicine Residency Program, St. Louis, Missouri, was appointed to serve on the AAFP Commission: Membership and Member Services. The mission of the American Academy of Family Physicians (AAFP) is to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity. Hix's appointment began January 1, 2016.

Davis, OMS-IV Attends Family Medicine Midwest Conference "Thank you to the Missouri Academy of Family Physicians for my scholarship to attend the Family Medicine Midwest Conference in Chicago, Illinois this year. My experience was incredible - I learned so much from the numerous speakers and valued my interactions with other medical students, residents, and physicians.

I appreciate your investment in my future career as a family physician in the state of Missouri." The Missouri Academy of Family Physicians provided a scholarship to a Missouri student attending the Family Medicine Midwest Conference, October 9-11, 2015, in Chicago, Illinois. Kelsey Davis-Humes, a 4th-year medical student at AT Still Osteopathic School of Medicine was the recipient of this scholarship.

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Davis-Humes at the Family Medicine Midwest Conference

MAFP Mayes, Morris to Serve on Advisory Committee on Childhood Immunizations Lisa Mayes, DO and Laura Morris, MD have been appointed to three-year terms on the Advisory Committee on Childhood Immunizations at the Missouri Department of Health and Senior Servicesâ&#x20AC;&#x2122; Bureau of Immunization Assessment and Assurance. Dr. Mayes is a family physician in Macon, Missouri and Dr. Morris practices at the University of Missouri Fulton Clinic. By serving on this committee, they will be responsible for: 1. Identifying existing immunization record-keeping systems and their suitability for inclusion in a comprehensive monitoring system, computerized and linked to regional, state or federal systems.

2. Determining how demographic and immunization data on all children under the age of five years shall be obtained and entered into the computer system and how it shall be kept up to date.

3. Determining how the data collected in immunizations shall be analyzed and communicated to parents, health care providers, and public officials while maintaining the confidentiality of patient records.

4. Developing plans for increasing the rate of childhood immunizations in this state, giving due consideration to factors related to cultural differences among the various population groups in this state.

Mayes

Congratulations Dr. Mayes and Dr. Morris for representing the Academy on this important committee.

Morris

Ratcliff Opens Renaissance Family Health Care Clinic Congratulations to Dr. Keith Ratcliff on opening Renaissance Family Health Care, the first direct primary care practice in Washington, Missouri.

MAFP Staff, Representative Keith Frederick, DO, and Dr. Ratcliff's many family and friends attended the ribbon cutting on October 6, 2015.

MAFP Membership Survey Coming to you soon! Watch your email to participate in the MAFP membership survey so we can assess how we are doing, what your needs are, and legislative/ regulatory priorities. The outcomes will guide the MAFP Board of Directors to determine how to allocate resources and best serve the membership. Survey responses will be anonymous and presented in an aggregate report. Each survey participant (who self identifies) will be eligible for one of three $100 MasterCard gift cards. A quick link will be available on the MAFP website on January 15. Paper copies of the survey will be available by request only. We need to hear from you! Complete your survey and win!

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Stevermer, Shaffer Appointed to AAFP Commissions

Stevermer

Shaffer

Jim Stevermer, MD, MSPH, FAAFP, was appointed to the AAFP Commission on Health of the Public and Science, and Todd Shaffer, MD, MBA, FAAFP was appointed to the AAFP Commission on Continuing Professional Development during the December 7-12, 2015 AAFP Board of Directors' meeting. Their terms of service began on December 15, 2015 and end on December 14, 2019.

Service on these commissions will direct AAFP policies and programs. Appointments to commissions are for a single, four-year term, and are nonrenewable. For more information on these commissions, visit www.aafp.org.

MO-AFP.ORG 27

SIMULATION PROGRAM

Critical Patient Assessment Simulation Program

F

"

Jack Wells, Jr., MD, MHA

It is important that family physicians have the required skill, knowledge, and experience to be able to manage crisis situations on the inpatient unit. While these events are relatively rare, they can be very high stakes."

Jack Wells, Jr., MD, MHA

Top right: Resident physicians Chase Ellingsworth, MD and Alicia Ludden-Schlatter, MD are pictured with members of the multidisciplinary team.

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amily Medicine residents are often required to evaluate hospitalized patients that have become clinically unstable outside of the ICU setting. These situations are often anxietyproducing, and residents can have uncertainty in evaluating and stabilizing these patients.

Fortunately this kind of clinical decompensation is a relatively rare occurrence, however the result from a learnerâ&#x20AC;&#x2122;s perspective is infrequent exposure to these critical patient situations. Additionally, residents are often required to manage multidisciplinary teams in the resuscitation of critically ill patients. Very likely the first experience that a resident has in critical patient assessment is a situation that arises on the medical floor during actual patient care. It usually involves the unexpected or sudden deterioration of a patient on the nursing unit, and the physician responding initially may be very inexperienced and uncertain about his or her own abilities in a critical situation. This combination of factors can often lead to less than optimal clinical outcomes.

Residency programs realize critical situations can occur and provide some appropriate training. Most if not all family medicine residency programs require incoming residents to become certified in CPR and ACLS. Many also require PALS. Unfortunately it is all too common that the training stops at that point. Skills and knowledge that are not used tend to degrade, and ultimately can be lost. In order to be prepared for critical events, it is imperative to practice skills learned in as realistic a situation as possible, and to continue ongoing training.

Residents are not the only professionals providing care in acute situations. nurses, respiratory therapists, and critical care response teams can all respond to critical situations. As the physician, and as the highest level provider on the team, it is incumbent on that individual that he or she possesses the requisite knowledge, skills, and experience to assume a leadership role in a crisis situation. Ultimately, the physician is the leader and decision maker in a crisis scenario.

It is important that family physicians have the required skill, knowledge, and experience to be able to manage crisis situations on the inpatient unit.

While these events are relatively rare, they can be very high stakes. These situations frequently call for sound clinical judgment, rapid decision making, confidence, communication and professionalism.

Many times the clinical outcome of the patient is determined by the actions taken early on in the critical situation. Without preparation that comes

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through training and practice, even the best resuscitation skills can deteriorate. Similarly, if physicians have no experience in working with other professionals in a crisis situation other than in actual events, the clinical outcome for the patient could be jeopardized.

Simulation provides faculty the opportunity to observe residents in an environment that is as realistic as possible. Through direct observation learnersâ&#x20AC;&#x2122; skills can be evaluated, with appropriate milestone development being assessed. In this setting it is possible to offer real-time feedback to the learners as well as provide the opportunity for self-assessment from the learners.

Our simulation curriculum offers weekly simulation sessions to provide training, exposure, and repetition in evaluating, stabilizing, and managing hospitalized patients that have become unstable in a non-critical care setting. This program includes simulation scenarios drawn from the most likely incidents that the residents are likely to see in the University Hospital. Clinical scenarios include cases involving shock, respiratory distress, arrhythmia, seizure, and other appropriate cases.

The scenarios call for proper intervention, decision making, communication and professionalism in working with multidisciplinary teams.

Recently the American Board of Family Medicine and the ACGME collaborated to develop a measuring tool known as the Family Medicine Milestone Project. This is designed to allow preceptors to score professional and developmental clinical and professional milestones as residentsâ&#x20AC;&#x2122; progress through their training. The cases in the simulation scenarios include appropriate case specific milestones that may be scored during simulation sessions. This provides a way to determine the progress of learners and to identify areas of

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ADULT VACCINATIONS

ABFM Part IV- Performance in Practice Module Available University of Pittsburgh School of Medicine Dept of Family Medicine 3518 Fifth Ave Pittsburgh, PA 15261 For questions please contact: Sean Saul Phone: 412-770-7261 Available accreditation: ABFM MOC PART IV Visit: www.4pillarstoolkit. pitt.edu/abfm for more information

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T

his activity is designed for physicians who wish to increase adult vaccination rates including influenza, Tdap, HPV, PPSV, PCV, zoster and/or hepatitis B vaccines. The activity has 4 phases – 1) determination of the current state: selection of immunizations, snapshot of current vaccination levels and review of known barriers to immunization; 2) physician selection of interventions to improve vaccination rates from the 4 Pillars Immunization Toolkit; 3) implementation of the selected interventions, and 4) evaluation of improvement. The 4 Pillars™ Immunization Toolkit is an evidence-based, practical toolkit that facilitates vaccination by suggesting 1) convenience, 2) messaging to patients, 3) enhanced office systems, and 4) motivation. This Toolkit was developed with CDC involvement and is up to date on immunization science. The Toolkit has proven effective in those practices that actively implement it.

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The first 30 participants to sign up and complete the module before February 15, 2016 will be rewarded with $250 via a WePay payment card. Effective 11/11/2015. You will be notified by email if you are one of the first 30 participants.

This activity has been approved by the American Board of Family Medicine for Maintenance of Certification for Family Physicians Part IV credit. Term of approval is for two years beginning July 20, 2015, with the option for yearly renewal thereafter.

Requirements: Required: • Choose, read, and reflect on one case study • Test your knowledge regarding vaccination systems, science, and policy • Conduct a minimum of 10 chart audits • Read a self-learning module • Conduct a post-audit • Complete a short activity evalution survey Optional: • Evaluate your patient vaccination

systems, pateint notification, convenience & access to vaccines, and motivation and leadership among staff members • Evaluate process measures to track over the course of the intervention

EXTERNSHIP EXPERIENCE

Romig Shares Summer Externship Experience

D

uring my externship at Truman Medical Center-Lakewood last summer, I saw how continuity of care provides a common connection across the wide breadth of practice that is available to family physicians.

I had the opportunity to be present at the birth of a child in labor and delivery, and then saw her again in the pediatric clinic a few days later.

The moment of recognition that passed between the parents and me offered a glimpse of what continuity of care can truly mean to patients as well as the provider. It means seeing a familiar face instead of a new provider at each visit. It means knowing a patientâ&#x20AC;&#x2122;s story before walking in the room.

Simple things like this can then multiply into so much moreâ&#x20AC;&#x201D;a less stressful visit for the

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patient, a more impactful conversation, a kept follow-up appointment, better health.

I love the idea that family medicine doctors can draw on their past experiences with a patient to offer meaningful care for someone in a variety of settings, from clinic to hospital, and that patients can count on family doctors to know their story.

Thank you to the Missouri Academy of Family Physicians and the AAFP for sponsoring this externship, and offering me the opportunity to learn about the practice of family medicine in its many forms. I look forward to developing continuing relationships with patients in my future practice and leveraging the power of continuity of care to positively affect patients' well-being.

Rene Romig MD Candidate Class of 2018 University of Missouri School of Medicine

MO-AFP.ORG 31

TMF Health Quality Institute

The Evolving Value Modifier Program: Improve Performance to Achieve Maximum Reimbursement

A Clifford K. Moy, MD, ETC., serves as TMF’s medical director for Behavioral Health.

He supports TMF’s medical directors on the Texas Medicaid Healthcare Partnership project and helps develop and operationalize behavioral health quality improvement opportunities. Dr. Moy is board certified by the American Board of Psychiatry and Neurology.

s the Centers for Medicare & Medicaid Services (CMS) continues to refine and expand the Physician Value-Based Payment Modifier program, physicians and other health care providers must understand and stay current with the new methodology in order to achieve performance goals for better reimbursement. The Value Modifier combines PQRS quality measures, outcome measures, cost measures and a payment adjustment for physicians.

To help accomplish that, TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization (QINQIO) for Texas, Oklahoma, Arkansas, Missouri and Puerto Rico, provides free education and technical support that enable physicians and other health care providers to meet the evolving Value Modifier requirements. TMF has a successful history of working with providers to help them meet the reporting requirements for various programs, including for the Physician Quality Reporting System (PQRS). TMF works with physician practices to provide free assistance to help them meet the requirements of the Value Modifier Program. Part of that assistance is to help physician offices understand how the Value Modifier is calculated. The scoring is noted within the Quality and Resource Use Report (QRUR).

Below are some recent updates related to the QRUR: • On Sept. 9, 2015, CMS made available the 2014 Annual QRURs to every group practice and solo practitioner nationwide. Groups and solo practitioners are identified in the QRURs by Taxpayer Identification Number (TIN).

• The 2014 Annual QRURs show how groups and solo practitioners performed in 2014 on the quality and cost measures used to calculate the 2016 Value Modifier. For groups with 10 or more eligible providers who are subject to the 2016 Value Modifier, the QRUR shows how the Value Modifier will apply to physician payments under

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the Medicare Physician Fee Schedule (PFS) for physicians who bill under the group’s TIN in 2016.

For all other groups and solo practitioners, the QRUR is for informational purposes only and will not affect their payments under the Medicare PFS in 2016.

• Authorized representatives of group and solo practitioners can access the 2014 Annual QRURs on the CMS Enterprise Portal using an Enterprise Identify Data Management account with the correct role. For more information, visit How to Obtain a QRUR. • CMS established a 60-day Informal Review Period that begins after the release of the 2014 Annual QRURs, to request a correction of a perceived error in CMS’ 2016 Value Modifier calculation. More information about the 2014 Annual QRURs visit can be found on the CMS 2014 Annual Quality and Resource Use Reports webpage.

Join Our Network for More Information The TMF QIN-QIO Value-Based Improvement and Outcomes Learning and Action Network provides more information about the above topic areas as well as upcoming educational events and resources. If you aren’t already a member of this network, go to https://www.tmfqin.org/, create a free account and then join the ValueBased Improvement and Outcomes Network. As a member, quality improvement consultants will work directly with you and your staff to help you understand reporting requirements and ensure your practice receives the reimbursements it is entitled to.

Contact Us: Missouri providers may contact Sandy Pogones, TMF QIN-QIO Quality Improvement Consultant, with questions and for more information: sandy.pogones@area-b.hcqis.org, 573-673-4531.

Chapter Revenue Sharing

Self-Study CME Revenue Share EARN CME. SUPPORT YOUR CHAPTER.

I

mprove patient care and bridge your knowledge gaps with AAFP self-study CME—when and where it’s convenient for you—and help your chapter earn additional revenue through the AAFP Self-Study CME Revenue Share program.

Clinical Packages: Use AAFP self-study packages to enhance your expertise and expand your knowledge on common family medicine topics.

Featuring recorded audio and video presentations from current AAFP live clinical courses, these interactive self-study packages take approximately 20-45 hours to complete and include: • 18-43 lectures between 30 and 60 minutes in length • Opportunities to report CME and evaluate after each lecture • Interactive interface with QuestionPause™ to briefly halt the presentations • Post-test (online)

Choose the package format that’s right for you: *BEST VALUE: A one-year online subscription and USB Flash Drive. Smartphone/tablet compatible.

Includes a print and PDF color syllabus.

Online Access Study when and where you want with a one-year online subscription. Smartphone/tablet compatible.

Includes a PDF color syllabus.

USB Flash Drive Convenient, portable access to all of your self-study materials. Includes a USB Flash Drive, audio CDs with select packages, and a print and PDF color syllabus.

Online access valid one year from purchase date of online-inclusive package.

How to Benefit Your Chapter through the AAFP Revenue Share Program: Visit aafp.org/chapter-selfstudy. At checkout, add 4MYCHAPTER in the source code box (see below) and a portion of your purchase revenue will be shared back with your chapter.

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MO-AFP.ORG 33

MISSOURI RECOVERY NETWORK

A Guide to Recovery-Oriented Systems of Care

T Leslie Pritchard Project Coordinator Missouri Recovery Network

he Missouri Recovery Network (MRN) is a statewide, nonprofit organization whose mission is to promote awareness of substance use disorders and strengthen recovery.

Historically, a patient who left a substance abuse treatment program was sent on his or her way with a wish for the best and perhaps a referral to a mutual support group, such as Alcoholics Anonymous. If the person relapsed, hopefully a program was available to provide care. Over time, researchers realized that this approach perpetuated a cycle of revolving into and out of treatment programs that could only be solved by significant system improvements.

Enter recovery-oriented systems of care (ROSC).

A ROSC system is a network of formal and informal services developed and mobilized to sustain long-term recovery for individuals and families impacted by severe substance use disorders. The system in ROSC is not a treatment agency, but a macro level organization of a community, state, or nation.

The primary goals of recovery-based care for addiction are to: • Prevent addiction and intervene early with those who develop substance use problems; • Support sustained recovery for those who are in recovery; and • Improve the health and wellness of individuals, families, and communities.

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ROSC is not a template that can be superimposed on any community. Transformation efforts will look differently based on the needs of the community, culture, resources, etc.

Furthermore, in the ROSC approach, the treatment agency is viewed as one of the many resources needed for a client’s successful integration into the community – no one source of support is more dominant than another.

Recovery-oriented systems of care have been successfully implemented in other states around the nation, most notably Connecticut, who pioneered the shift to state-level recoverybased care. Results from this initiative have been positive, with clients staying in treatment longer, and fewer readmissions to treatment. The number of admissions into inpatient care also has dropped by 56 percent since implementation began in 2002. Admissions were replaced by less costly outpatient services, resulting in net savings to the state of $2.6 million.

Success with ROSC in other states holds promise for Missouri, where 10 percent of our residents have an alcohol or other drug dependence, and residents chronically use opioid painkillers at a rate of 36% above the national average (National Survey on Drug Use and Health). Building a ROSC will take significant investment and commitment, but the impact on a macro and micro level will be immeasurable.

OPIOID ABUSE

Opioid Emergency Department Prescribing Recommendations:

Endorsed by Six Health Care Provider Organizations

M

AFP joined five other healthcare organizations representing Missouri health care providers and issued recommendations to their collective memberships on an initial step to reduce opioid painkiller misuse and abuse. The Missouri Academy of Family Physicians, Missouri Association of Osteopathic Physicians and Surgeons, Missouri College of Emergency Physicians, Missouri Dental Association, Missouri Hospital Association and Missouri State Medical Association jointly recommended that health care providers adopt a core set of actions to reduce variation in emergency department opioid-prescribing practices.

State-specific research released earlier this year found that hospital treatment for commonlyprescribed opioid painkillers — where overuse is a primary or contributing factor for inpatient or emergency care — increased 137 percent in Missouri between 2005 and 2015. Additionally, separate research suggests a strong link in opioid abuse and heroin addiction, and submits as many as three out of four prescription opioid abusers will eventually use heroin as a less expensive source of opioids. This inappropriate use of controlled substances is having a major negative impact on the lives of many Missourians and the communities where they live.

Many of the state’s emergency departments have existing systems to reduce the incidence and risk of opioid misuse and abuse among patients. However, there has not been a consistent set of guidelines statewide for every emergency department throughout the state. The ten newly recommended actions can be adopted as a stand-alone policy, or in addition to existing successful strategies. The policy recognizes the importance of medical staff decision-making and clinical judgment at the patient level, while providing a framework for informed decisions.

“Health care providers have a responsibility to their patients and communities to lead in efforts to reduce opioid misuse and abuse,” said Peter Koopman, MD, MAFP President. “This is an important initial effort to address the problem of prescription drug abuse. However, in the long run, 35

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it will require a multi-disciplinary, public-private approach to provide treatment, reduce abuse and its costs.”

Recommended Opioid Approach for Emergency Departments • A focused pain assessment prior to determination of treatment plan; if the patient’s pain prohibits a comprehensive assessment, then judicious use of opioids to alleviate pain is suggested. While the pain assessment should include risk factors for addiction and the incorporation of non-narcotic analgesics, a specific written, comprehensive assessment is not required.

Consulting packages are available, providing our proven business model to help build a strong DPC clinic providing exceptional and affordable care to all.

Contact Dr. Jenny Powell at (573)933-0872 or (417)664-5054.

MO-AFP.ORG 35

OPIOID ABUSE

limited to no more than 72 hours, if clinically appropriate and assessing the feasibility of timely access for follow-up care.

• For new conditions requiring narcotics, the length of the opioid prescription should be at the provider’s discretion. The provider should limit the prescription to the shortest duration needed that effectively controls the patient’s pain.

Outpatient access to follow-up care should be taken into consideration regarding the length of the prescription.

• Emergency department physicians and providers should not provide prescriptions for controlled substances that are claimed to be lost or destroyed.

• Unless otherwise clinically indicated, emergency department physicians and providers should not prescribe long-acting or controlled release opioids. If indicated, prescribers should provide tamperresistant, or abuse deterrent, forms of opioids.

• When narcotics are prescribed, emergency department staff should counsel patients on proper use, storage, and disposal of narcotic medications.

• Beyond the emergency room, health care providers should encourage policies that allow providers to prescribe and dispense naloxone to public health, law enforcement and family as an antidote for Southeast Hospital in Cape Girardeau opioid overdoses. » TJC-accredited flagship of SoutheastHEALTH with 96% RNs Pat Patterson Photography

• Diagnoses based on evidence-based guidelines and appropriate diagnostics whenever possible.

• Non-narcotic treatment of symptomatic, nontraumatic tooth pain should be utilized when possible.

• Treatment of patients with acute exacerbation of existing chronic pain should begin with an attempt to contact the primary opioid prescriber or primary care provider, if circumstances are conducive.

• Opioid analgesic prescriptions for chronic conditions, including acute exacerbation of existing chronic pain, management should be

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and nearly 300 beds » Situated on Mississippi River, city is region’s hub for commerce, entertainment, the arts, higher education and healthcare » Population of 40,000 with average commute of 20 minutes

Southeast Health Center of Stoddard County in Dexter » Expanding medical facility with nearly 50 beds, ED, ICU, telemetry unit and new MOB » County population of nearly 30,000: 70% rural » 7 wildlife conservation areas, including Mingo Wildlife Refuge, for hunting, fishing, nature watching, hiking and camping

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contact Mandie at 573-331-6374 or mpresser@SEhealth.org 36

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GRAND ROUNDS REFERENCES References from Resident Grand Rounds >>

References

1. Wilkins, Thad, MD, et al. “Diagnosis and Management of Hepatitis C.” American Family Physician.

Volume 91, number 12, June 15, 2015.

2. “HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C” Infectious Diseases Society of America. http://www.hcvguidelines.org/full-report-view 3. ACOG Practice Bulletin “Viral Hepatitis in Pregnancy” Vol. 110, No. 4, October 2007.

4. Slowik, May K. MD, and Ravi Jhaveri, MD “Hepatitis B and C Viruses in Infants and Young Children.” Seminars in Pediatric Infecious Disease 16:296-305, 2005.

5. Friedman, Lawrence S. "Liver, Biliary Tract, & Pancreas Disorders." Current Medical Diagnosis & Treatment 2015. Eds. Maxine A. Papadakis, et al. New York, NY: McGraw-Hill, 2014. n. pag.

AccessMedicine. Web. 2 Oct. 2015.http://accessmedicine.mhmedical.com.proxy.mul.missouri.edu/ content.aspx?bookid=1019&Sectionid=57668608.

6. Moyer, Virginia A., MD, MPH, on behalf of the USPSTF. “Screening for Hepatitis C Virus Infection in Adults: U.S. Preventive Services Task Force Recommendation Statement.” Annals of Internal Medicine.

Vol 159, Number 5. September 2013.

7. Dienstag, Jules L. "Acute Viral Hepatitis." Harrison's Principles of Internal Medicine, 19e. Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J Eds. Dennis Kasper, et al. New York, NY: McGraw-Hill, 2015. n. pag. AccessMedicine. Web. 12 Oct. 2015. <http://accessmedicine.mhmedical.com.proxy.mul.missouri.edu/content.aspx?bookid= 1130&Sectionid=79748507>.

8. "Hepatitis C." American College of Gastroenterology. American College of Gastroenterology, 2015.

Web. 2015.

9. Sangiovanni A, Prati GM, Fasani P, et al. The natural history of compensated cirrhosis due to hepatitis C virus. Hepatology. 2006;43(6):1303–1310 10. Jezequel C, Bardou-Jacquet E, Desille Y et al. Survival of patients infected by chronic hepatitis C and F0F1 fibrosis at baseline after a 15 year follow-up. 50th Annual Meeting of the European Association for the Study of the Liver (EASL). April 22-26, 2015;S589; Vienna, Austria.

11. Ghany, M. G., Strader, D. B., Thomas, D. L. and Seeff, L. B. (2009), Diagnosis, management, and treatment of hepatitis C: An update. Hepatology, 49: 1335–1374. doi: 10.1002/hep.22759 12. Abdo, Ayman A. “Hepatitis C and Poor Quality of Life: Is It the Virus or the Patient?” Saudi Journal of Gastroenterology: Official Journal of the Saudi Gastroenterology Association 14.3 (2008): 109–113. PMC. Web. 13 Oct. 2015.

13. Morgan RL, Baack B, Smith BD, Yartel A, Pitasi M, Falck-Ytter Y. Eradication of hepatitis C virus infection and the development of hepatocellular carcinoma: a meta-analysis of observational studies.

Ann Intern Med. 2013;158(5 Pt 1):329-337.

14. Weber, David, William Rutala, and Joseph Erob. "Prevention of Hepatitis B Virus and Hepatitis C Virus Infection among Healthcare Providers."Prevention of Hepatitis B Virus and Hepatitis C Virus Infection among Healthcare Providers. Web. 18 Oct. 2015.

15. Medication Pregnancy considerations and Breastfeeding information: per Lexicomp: “ Pegylated interferon (peginterferon) alfa-2a: Drug Information,” “Ribavirin: Drug information.” ,“Simeprevir: Drug Information,” “Ombitasvir, paritaprevir, ritonavir, plus dasabuvir (copackaged): Drug Information”, Ledipasvir and sofosbuvir: Drug Information” 16. Jou, Janice, and Andrew Muir. "Hepatitis C." Annals of Internal Medicine: In the Clinic (2012): ITC6-16. Print.

17. Arora, Sanjeev, Karla Thornton, Glen Murata, Paulina Deming, Summers Kalishman, Denise Dion, Brooke Parish, Thomas Burke, Wesley Pak, Jeffrey Dunkelberg, Martin Kistin, John Brown, Steven Jenkusky, Miriam Komaromy, and Clifford Qualls. "Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers." New England Journal of Medicine N Engl J Med (2011): 2199207. Print.

18. "Project ECHO: A Revolution in Medical Education and Care Delivery." Project ECHO. 2015. Web. 21 Oct. 2015.

Today

more than 3,500 children will try their first cigarette.

Stop kids from starting.

Volunteer to be a Tar Wars presenter.

www.tarwars.org

Citations of Figures Figure 1, Figure 2, Figure 3: Wilkins, Thad, MD, et al. “Diagnosis and Management of Hepatitis C.” American Family Physician. Volume 91, number 12, June 15, 2015.

Supported in part by a grant from the American Academy of Family Physicians Foundation.

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MO-AFP.ORG 37 TW hlf vert.10_v2.indd 1

9/3/10 11:57 AM

Find Your Kind in OPIOID ABUSE an AAFP Member Interest Group The AAFP is committed to giving all members a voice within our increasingly diverse organization. Member interest groups (MIGs) have been created as a way to define, recognize, and support AAFP members with shared professional interests. MIGs support members interested in professional and leadership development and provide connections to existing AAFP resources, opportunities to suggest AAFP policy, and networking events with like-minded peers.

Current AAFP MIGs include: • Direct Primary Care • Emergency Medicine/Urgent Care • Global Health • Hospital Medicine • Independent Solo/Small Group Practice • Oral Health • Reproductive Health Care • Rural Health • Single Payer Health Care • Telehealth

Visit aafp.org/mig to learn more, join a MIG, or start your own.

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ANNUAL SCIENTIFIC ASSEMBLY

date in

the

e m c n r a e k r o w t ne relax

Save

2016

june 3-4

2016

The Lodge at Old Kinderhook

ANNUAL fall conference november 4-6

big cedar lodge 39

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2016 MO-AFP.ORG 39

2016 nominate the

MAFP

family physician of the year

Nomination Deadline: Monday, February 1, 2016

mo-afp.org

Missouri Family Physician January-March MO-AFP.ORG 2016 40 40

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