Respiratory Illnesses and Diseases by mo-afp

FP SPRING 2021

MISSOURI FAMILY PHYSICIAN VOLUME 40, ISSUE 2

RESPIRATORY ILLNESSES & DISEASES

FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION BOARD CHAIR Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT-ELECT John Burroughs, MD (Liberty) VICE PRESIDENT Kara Mayes, MD (St. Louis) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR Arihant Jain, MD (Cameron) ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Brooks Beal, DO (Kirksville) ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis) DIRECTOR Dawn Davis, MD (St. Louis) ALTERNATE Lauren Wilfling, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald) ALTERNATE Jennifer Allen, MD (Hermann) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia) ALTERNATE Amanda Shipp, MD (Versailles) DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville) ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Beth Rosemergey, DO, FAAFP (Kansas City) DIRECTOR Afsheen Patel, MD (Kansas City) ALTERNATE Wael Mourad, MD, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Andi Selby, DO (Joplin) ALTERNATE Barbara Miller, MD (Buffalo) DISTRICT 9 DIRECTOR Vacant ALTERNATE Vacant DISTRICT 10 DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau) ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Lees Summit)

CONTENTS 4 Fresh Air, Immunizations, and Respiratory Illnesses 6 COVID-19 Trends for Children and Young Adults 8 Chronic Sinusitis 12 Asthma Management Guidelines 16 Asthma Extension for Community Health Outcomes (ECHO®) Road to Best Practices 20 Inhaler Use and Adherence in Children 22 Advocacy Day – Your Way 24 MAFP Priority Issues and Messages 25 Preceptor Workforce Program Measure Advances 26 Leveraging Primary Care Physicians to Accelerate COVID-19 Vaccination 28 Members in the News 31 References

RESIDENT DIRECTORS

John Heafner, MD, SLU Morgan Murray, MD, UMKC (Alternate)

STUDENT DIRECTORS

Noah Brown, UMKC Kelly Dougherty, UMC (Alternate)

AAFP DELEGATES Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon. Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

MARK YOUR CALENDAR April 23 Live CME Meeting (Virtual) 12:00-4:00pm More info on page 26 November 12-13 29th Annual Fall Conference Big Cedar Lodge More info on back cover April 30 MAFP Award Nomination Deadline More info on page 27

Mission Statement:

The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.

MO-AFP.ORG 3

Fresh Air, Immunizations, and Respiratory Illnesses

John Paulson, DO, PhD, FAAFP MAFP President

“When you arise in the morning think of what a privilege it is to be alive, to think, to enjoy, to love …” - Marcus Aurelius

Karstan Luchini, Medical student at KCU, Joplin, MO

he snow has finally melted and we are out of the negative temperatures that February delivered Missouri in 2021. The certainty of the upcoming additional hours of daily sunshine brings a smile to my face. Last week, I was outside with the warm sun shining down on my face and I stopped, took a big deep breath of that rural Missouri air, and felt a calming sense come over my body. What a great way to introduce this issue on Respiratory Illnesses & Diseases! Perhaps, my prescription to our readers is for each of you to make the time to go outside, find the sunshine, some social distance, take the mask off, and take in a heaping dose of Missouri fresh air. We still have a way to go but it is my personal feeling and prayer that we will be coming out of this pandemic sooner than we think! Ten years ago this May, an EF5 tornado devastated a significant portion of Joplin, MO. 162 people lost their lives. Many others lost their jobs, homes, cars, keepsakes, and loved ones. Part of that destruction involved one of the two hospitals in town. A temporary hospital was put up just a couple blocks away to care for patients while they reduced the old hospital into a park for remembrance and built a new state-of-the-art hospital along the highway. Upon completion of the new hospital, the temporary one had to find a home. So, in 2017, Kansas City University (KCU) used it to open the newest medical school in Missouri in nearly 50 years. This year we will graduate our first class. How do these stories come together? The sunshine and deep breath I found outside was from Anderson, MO at one of the outdoor National Guard

began medical school in fall of 2019 eager to make the most of my experience. I was adjusting to the curriculum and learning so much when the whirlwind year of 2020 began. COVID-19 hit the US and my attention immediately switched from 100% focus on school to how the virus was affecting people locally. Fortunately, I found an opportunity to contribute to the cause early on and landed a research project dedicated to developing PPE for the local community. After the research project, our school went to a completely virtual curriculum and I had a

MISSOURI FAMILY PHYSICIAN April - June 2021

COVID-19 mass vaccination drive thru clinics. I had the opportunity to oversee nearly a dozen 1st and 2nd year KCU medical students as they immunized hundreds of thankful patients. I volunteer at a regional event nearly every week with about a dozen medical students at my side. It is our hope that utilizing medical students at these volunteer clinics will keep our front-line physicians and nurses in their offices and hospitals caring for their patients. Meanwhile, we will be actively teaching our students the importance of immunizations and primary care. There is not a better modern-day picture of rural medicine than a drive thru immunization clinic with a cow pasture in the background. I myself see that as fertile ground to plant and grow family medicine physicians - future physicians who will go where needed and meet patients where they are to deliver the highest quality of care and compassion. It may be a cow pasture, parking lot, or stadium where your regional clinics are occurring, but just remember that each student you see at those events are a seed that I hope each of you will water and fertilize with the notion to choose the specialty of family medicine, for our patients! This issue is dedicated to Respiratory Illnesses and Diseases of all types. Although we have been inundated with COVID-19 for more than a year, we will always have patients with other respiratory illnesses to treat. As we continue caring for our patients and communities, I can “breathe easier” knowing our Academy delivers these great resources and we have wonderful students like Karstan Luchini to continue providing care to Missourians.

tough time adjusting to online learning. Though the transition was difficult, it was a minor inconvenience compared to the impact of the virus on Missouri families and frontline workers. Before I knew it, coronavirus was impacting lives all around me. I had friends in healthcare who were overworked. I had family members receive diagnoses months apart. I even had family friends who ended up being admitted to the hospital with severe infections. With all this happening, I wanted to find more ways to help.

Karstan Luchini at the mass vaccination clinic in Anderson, MO

KCU students at the mass vaccination clinic in Springfield, MO.

SPRINGFIELD MISSOURI

In 2021, I had the opportunity to help with the mass vaccination clinics alongside the Missouri National Guard. This experience has further cemented my love for family and community medicine. My burning desire to contribute to the cause led me to sign up to volunteer as quickly as I could. So far, I have been able to participate in various mass-vax clinics across southwest Missouri and I have found it to be very rewarding. Some of the most impactful conversations I have had in these clinics have been with elderly patients who have had to pass on things like holiday celebrations, the births of their grandchildren, family weddings, and even going to the grocery store out of fear of contracting the virus. I am hopeful that with the combined efforts of the National Guard and healthcare workers across the state, all of Missouri will soon be vaccinated. If we mask up, remain socially distanced, and encourage others to get vaccinated, together, we will put an end to coronavirus.

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COVID-19 Trends for Children and Young Adults

A Brief Review of: Leidman, et.al. COVID-19 Trends Among Persons Aged 0-24 – United States, March 1-December 12, 2020, MMWR Early Release/Vol.70 January 13, 2021. http://dx.doi.org/10.15585/mmwr.mm7003e1.

David Voran, MD Informatics Director Community and Family Medicine Truman Medical Center – Lakewood, Kansas City

he CDC released a reassuring discussion of recent COVID-19 trends among pre-school and school age children indicating they are not a significant source of community spread. The data analysis from nearly 3 million case and laboratory data collected from March 1 to December 12, 2020 showed that school-aged patients mirrored the trends in adults and seniors across the nation. It is reasonable to assume an age group responsible for triggering outbreaks would show up as spikes in incidents that preceded the other age groups by a week or more. The current data shown in Figure 1 does not show any leading waves for any age group. The authors, with appropriate caveats, suggest this data supports early return to in-person schooling without exposing the rest of the population to additional risks or disease consistent with other findings. Several thoughts came to mind upon reading this report. First was how quickly massive amounts of data were analyzed. Second, “Big Data”. The authors (and all of us) have access to tools that let us study the entire population instead of generalizing from

small sample sizes. Third was how much this little virus has changed the world. These authors are working with data less than a week old submitted electronically from over 44 states. Massive amounts of data now flow into data marts that many analytic tools at our fingertips such as R. Tableau, and even MS Excel can use to answer questions. All of this in periods that were difficult, if not impossible, a few years ago. We have witnessed how this virus has changed medicine, scientific datasharing, and human behavior. I was curious whether our own data at Truman Medical Center, where we have performed over 100,000 COVID tests, would mirror the CDC data. Even though our pediatric numbers are very low, Figure 2 shows our data matched national data where spikes in COVID cases occurred simultaneously. Timing of the peaks matched the post Memorial Day, July 4th, and most recent surges. This is all reassuring and we family physicians should use this to support in-person schooling for our young patients and vigorously support the use of proven mitigation steps in schools.

Figure 1. Weekly test volume and percentage of SARS-CoV-2-positive test results* among persons aged 0–24 years, by age group — United States, May 31–December 12, 2020† 6

MISSOURI FAMILY PHYSICIAN April - June 2021

TMC COVID Posi ve Tests by Week and Age Group

Figure 2.

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Chronic Sinusitis Michael J. Simmons, M.D. Jefferson City Medical Group Department Chair ENT and Sinus Surgery Division

hinosinusitis is one of the most commonly diagnosed conditions in the United States. Early in this century, it was estimated that of all antibiotics prescribed in the United States, 18% for adults and 9% for children were prescribed for the diagnosis of sinusitis.1 Rhinosinusitis in the broadest terms is defined as inflammation of the paranasal sinus cavities and/or the nasal cavity itself. This diagnosis is made with a history of two major factors or one major and two minor factors which include: 2 Major Factors 1. Facial pain and/or pressure 2. Nasal obstruction 3. Purulent/discolored nasal or postnasal drainage 4. Anosmia or hyposmia 5. Fever Minor Factors 1. Headache 2. Halitosis 3. Fatigue 4. Dental pain 5. Cough 6. Ear pain and/or pressure 8

MISSOURI FAMILY PHYSICIAN April - June 2021

On examination, physical findings include purulent drainage, mucosal or turbinate edema or polyps and may be supported by x-rays which show opacification or air/fluid levels in the air spaces of the paranasal sinuses. The vast majority of acute rhinosinusitis episodes are viral events and are expected to be self-limiting without antibiotic requirement. Even acute bacterial sinusitis begins in most cases as a viral upper respiratory infection or an acute exacerbation of inhalant allergic disease which at onset do not require antibiotic treatment. If signs or symptoms last beyond ten days, bacterial infection may be present and antibiotics are indicated if the clinical situation warrants. The general pathogenesis of acute and chronic rhinosinusitis includes inflammation that causes obstruction of the sinus ostium. This triggers a cascade of impaired mucociliary clearance, mucus stasis, and subsequent bacterial overgrowth. Chronic rhinosinusitis (CRS) is defined by both duration and clinical criteria. Chronic rhinosinusitis is defined as 12 weeks or longer of two major symptoms listed above. An alternative to CRS is recurrent acute rhinosinusitis in which four or greater episodes of bacterial sinusitis requiring antibiotic therapy occur within a year. The patient has symptom resolution between episodes. Chronic rhinosinusitis is further defined by the absence (CRSsNP) or presence of intranasal polyps (CRSwNP).

“

The physical examination should reflect infection and edema and document the presence or absence of a nasal septal deviation or polyps. Specialty examination would include nasal endoscopy in the decongested state.

”

The pathophysiology of CRS is incompletely understood and is likely multifactorial, resulting from interactions of anatomy, genetics and environmental influences. Unlike acute rhinosinusitis, which is usually caused by an infectious viral agent, CRS may be caused by immunoglobulin E (IgE) mediated allergic disease, bacterial biofilms, osteitis, fungi, and host immune system deficiencies. Allergic disease mediated by IgE reactions is very common in the United States. Up to 25% of the population has allergic rhinitis. There is an increased prevalence of allergy among those with CRS. The exact mechanism is unknown; but importantly, mucosal edema caused by antigen reactivity may lead to reduced mucociliary clearance. Bacterial biofilms are often diagnosed in culture positive exacerbations of CRS, frequently post-surgical, and are typically caused by Peudomonas aeruginosa, Staphylococcus aureus and Hemophilus influenza. Only the latter is also common in acute bacterial rhinosinusitis. How frequently these might be a cause rather than an effect of CRS is unknown. Osteitis is appreciated radiographically as bone remodeling or thickening and histologically may show inflammatory infiltrates and bony sclerosis. This is likely due to an increased concentration of local inflammatory mediators. It is not clearly understood whether this is a consequence of CRS or a causative factor.

Fungi rarely cause infection or invasion in the immunocompetent host but select fungi such as Alternaria and Candida have been shown to upregulate interleukin-5 and IL-13 in some individuals. These chemokines are involved in the eosinophilic response leading to edema and possibly polyp formation. Allergic fungal rhinosinusitis is a subtype of CRS, usually associated with polyps and allergic mucin and generally more isolated disease than CRSwNP. Immunodeficiencies can increase the potential for patients to develop CRS. Systemic conditions including autoimmune/ granulomatous diseases such as Wegener’s granulomatosis, aspirin sensitivity triad, cystic fibrosis and primary ciliary dyskinesia all lead to high rates of CRS with and without polyposis. Beyond the clinical signs and symptoms and allowing for the diagnostic criteria for CRS, staging the condition includes several modalities. The physical examination should reflect infection and edema and document the presence or absence of a nasal septal deviation or polyps. Specialty examination would include nasal endoscopy in the decongested state. Imaging is best performed by non-contrast enhanced CT scan of the sinuses in coronal and axial planes. If non-obstructed mucosal disease is seen on CT, IgE antigen screening may be appropriate. If compromised immune system conditions are suspected, laboratory evaluations such as cytoplasmic-antineutrophil cytoplasmic antibody (C-ANCA), P-ANCA, erythrocyte sedimentation rate (ESR), c-reactive protein, immunoreactive trypsinogin (IRT) or sweat test may be warranted. 3 Medical treatment for CRS can be stratified into three groups: anti-inflammatory, antimicrobial and mechanical. Anti-inflammatory medications include topical and systemic steroids. Nasal steroid sprays are a mainstay of CRS therapy. They directly address the mucosal inflammation and polyps which are the basis for sinus ostial obstruction. They are useful in allergic and non-allergic mediated cases of CRS. They may be delivered in pump or aerosol devices or may be mixed within saline solution for larger volume application. Within the broader scope of anti-inflammatory treatment, if allergy is clinically suspected, IgE inhalant allergen testing followed by directed immunotherapy is indicated for long-term reduction of CRS exacerbations and reduced primary allergic symptomatology. continued on page 10 MO-AFP.ORG 9

continued from page 9

To that end, antihistamines and leukotriene antagonists are beneficial in the treatment of allergic disease. Antimicrobial treatments for CRS are best directed toward sensitivities of positive bacterial cultures. Frequently treated exacerbations often lead to identifying antimicrobial resistant bacteria on cultures. Those bacteria which form biofilms are often implicated. In post-surgical exacerbations, topical antibiotic preparations may be delivered directly through powered atomized concentrations or in high volume saline/ antibiotic irrigations. This allows for topical delivery of medication that otherwise might require intravenous delivery. Macrolide antibiotics have also been shown to exert an antiinflammatory effect beyond their antimicrobial action and may be a good empiric choice. Mechanical treatments are used to promote mucociliary clearance. Nasal saline irrigation is the most important type. It must be stressed as an important daily necessity to reduce exacerbations of CRS. Additional benefits for mucociliary clearance can be derived from systemic mucolytic agents such as guaifenesin and brief uses of topical decongestants such as oxymetazoline hydrochloride. Surgical treatment for CRS is primarily endoscopic sinus surgery (ESS). The indications for surgery are based on the proper clinical diagnosis of CRS, lack of benefit from sufficient medical management and endoscopic and radiographic staging which 10

MISSOURI FAMILY PHYSICIAN April - June 2021

supports ostial manipulation and/or removal of paranasal sinus tissue. This procedure has various iterations to include officebased balloon ostial dilation of the maxillary sinuses to complete operative spheno-ethmoidectomy with or without frontal sinus drill out. Endoscopic sinus surgery is useful for both CRSsNP and CRSwNP. The latter diagnosis has a higher rate of recurrent disease, often resulting in additional procedures and greater need for long-term medical management. Placement of mometasone furoate drug eluting stents within the operative ethmoid cavities has been shown to reduce recurrence of CRSwNP. 4 Additionally, newer therapies for CRSwNP involve the uses of monoclonal antibodies targeted toward IgE and interleukin mediated disease. Omalizumab (Xolair R) inhibits the binding of IgE to the high-affinity IgE receptor, thus down-regulating mast cells and basophils, reducing IL-4, IL-5 and IL-13, all potent mediators allergic respiratory disease found in asthma and CRSwNP. 5 Dupilumab (Dupixent R) is a fully human IgG4 monoclonal antibody against IL-4 receptor alpha subunit. By blocking this subunit, dupilumab inhibits IL-4 and IL-13 which drive type 2 inflammatory disease (asthma, atopic dermatitis and CRSwNP). 6 In summary, rhinosinusitis is a common diagnosis and frequently diagnosed by the family physician. If CRS is diagnosed in spite of appropriate management, then indications for imaging and referral for more advanced care may be warranted. References found on page 31

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Asthma Management Guidelines

Benjamin D. Francisco, PhD, PNP, AE-C Professor, Pulmonary Medicine & Allergy University of Missouri School of Medicine, Department of Child Health

n December of 2020, the National Heart, Lung and Blood Institute published updates to 2007 Expert Panel Report 3 (EPR-3) asthma guidelines (https://www.nhlbi.nih.gov/health-topics/ guidelines-for-diagnosis-management-of-asthma). Rather than issuing an entirely new set of guidelines, the committee identified six topics for which new evidence warranted critical reviews. Updated topics include: 1) use inhaled corticosteroids for intermittent or worsening asthma symptoms; 2) sublingual and subcutaneous immunotherapy; 3) modification of indoor trigger exposure; 4) longacting muscarinic antagonists; 5) use of fractional exhaled nitric oxide (FeNO) in asthma management; and 6) bronchial thermoplasty. The greatest change comes in revised therapy steps for the treatment of asthma. For ready access to documents that will be useful in your practice go to: https://www.nhlbi.nih.gov/health-topics/ asthma-management-guidelines-2020-updates/

MISSOURI FAMILY PHYSICIAN April - June 2021

digital-toolkit. The “Clinician’s Guide” is a readable 16 page synopsis of the 19 recommendations contained in the 2020 Updates, including the new therapy steps. “At-a Glance” guide only includes tables with annotations for the 6 therapy steps by age group (0-4, 5-11, 12 and older). You will probably want to print this document for quick reference when prescribing. Another useful resource found at the digital toolkit URL above is a set of fact sheets that summarize the 2020 Updates in language patients and staff will be able to understand. A brief overview of the 2020 Updates is discussed below in order of topics most likely to redefine best asthma practices. Italicized text indicates a direct quote from the 2020 Updates. One of the most debated aspects of asthma care is when and how to use inhaled corticosteroids (ICS). Advocates for intermittent ICS use have previously lacked support from expert guidelines. A related polarizing discussion has been the effectiveness of increasing ICS dose when asthma is not controlled. The 2020 Updates recommend intermittent ICS use for two age groups, 0-4 years and 12 years and older, under specific conditions. • In children ages 0-4 years with recurrent wheezing, a short (7-10 day) course of daily inhaled corticosteroids along with an as-needed short-acting bronchodilator (such as albuterol sulfate) is recommended at the start of a respiratory tract infection (conditional recommendation, high certainty of evidence). • People ages 12 and older with mild persistent asthma may benefit from inhaled corticosteroids with a short-acting bronchodilator for quick relief. Treatment may include inhaled corticosteroids daily or as needed when asthma gets worse (conditional recommendation, moderate certainly of evidence). Stepping up ICS dose during times when symptoms are present (loss of control) is recommended for ages 4 and older with moderate to severe asthma only when an ICS/formoterol inhaler is in use. • For people ages 4 and older with moderate to severe persistent asthma, the preferred treatment is a single inhaler that contains an inhaled corticosteroid and the bronchodilator formoterol. This should be used as both a daily asthma controller and quick-relief therapy (Strong recommendation, high certainty of evidence for individuals 12 years and older, moderate certainty of evidence for individuals 4-11 years)

Herein lies the most consequential change in asthma treatment dubbed the SMART plan. Single Maintenance and Reliever Therapy (SMART) is an approach whereby the same inhaler used for daily therapy can be used for additional doses when symptoms are present (Bisgaard, Le Roux et al. 2006). This is a departure from the traditional two inhaler strategy – one for control and another for quick relief (usually albuterol). SMART is recommended based on well-designed clinical trials over the last decade that compared outcomes for three treatment arms: 1) SMART plan (using an inhaler containing an ICS with formoterol), 2) fixed dose ICS/LABA group and 3) an ICS only treatment group. The SMART group had fewer asthma exacerbations, used less ICS over months and grew better. It is important to note only formoterol was studied in these trials. The SMART recommendation does not apply to ICS/LABA inhalers containing other LABAs, such as salmeterol. Currently in the US one generic and two branded ICS/formoterol inhalers are available: budesonide/formoterol, also branded as Symbicort™ and Dulera™ (mometasone and formoterol). Practical considerations for adopting a SMART plan for appropriate patients include insurance restrictions, out of pocket costs and access. When a one puff twice daily regimen is appropriate and effective these barriers are minimized. Since available ICS/formoterol MDI inhalers are dispensed with 120 usable puffs, with a one puff twice daily regimen an inhaler should last 2 months in the absence of the need to take PRN doses. During periods of breakthrough symptoms taking additional puffs would probably not exhaust supply for the month’s regular BID regimen. It is important to state the PRN regimen on the prescription to avoid denials for a one per month supply. However, with a 2 puff BID regimen more than one inhaler will be required monthly if the patient is perfectly adherent

and has symptomatic days requiring extra doses. Pharmacists and insurers have had mixed responses to SMART plans, as might be expected during early adoption. Some insurers have authorized more than one ICS/formoterol inhaler per month, while others respond with denials. Meanwhile using higher ICS formulations with a one puff twice daily regimen is expedient and has the result of lowering total out of pocket costs for many families. Access is an issue when the ICS/formoterol inhaler remains at home and the patient is at school or work. Transporting the ICS/formoterol inhaler might predispose to temperature extremes that can degrade the drugs and forgetting to return home with the inhaler for routine evening and morning doses. In summary, formoterol has an onset of action similar to albuterol with fewer adrenergic effects and potentially much longer duration of action, making this drug suitable for symptom relief. When an ICS is combined with formoterol and the SMART plan is used by patients, symptoms are managed while simultaneously stepping up the ICS dose and delivering an anti-inflammatory boost that likely addresses an underlying airway provocation. For safety with this “sliding scale” approach, maximum daily doses of ICS/formoterol must be specified – up to 8 puffs per day for patients 4-11 years of age and up to 12 puffs per day for 12 years and older were found to be safe and effective. It is important to also note the number of days this approach may be used before prompting a call for follow-up at the clinic. High numbers of daily doses are not intended for weeks of use. Alternative diagnoses and treatments must be considered when episodes are prolonged. Another important change in asthma therapy steps is the use of long-acting muscarinic antagonists (LAMA). Whereas ipratropium continued on page 14 MO-AFP.ORG 13

continued from page 13

has long been an important medication in asthma management (Rodrigo and Castro-Rodriguez 2005) expert guidelines did not previously recommend use of more recently available LAMAs. Four recommendations in the 2020 Focused Update address use of LAMAs: • If inhaled corticosteroids alone do not control asthma, a health care provider may add a long-acting bronchodilator such as a long-acting beta2-agonist (LABA) or LAMA. • For children under 12 and most people ages 12 and older with asthma that is not controlled by an inhaled corticosteroid alone, adding a LABA rather than a LAMA to an inhaled corticosteroid is preferred (conditional recommendation, moderate certainly of evidence). • For people 12 years old and older, if a LABA cannot be used, a LAMA may be used with inhaled corticosteroid treatment instead of continuing the inhaled corticosteroid alone (conditional recommendation, moderate certainly of evidence). • For people 12 years old and older whose asthma is not controlled with an inhaled corticosteroid plus a LABA, adding a LAMA is recommended (conditional recommendation, moderate certainly of evidence). An important consideration when applying these recommendations is the cost and inhaler types of LAMAcontaining medications. Currently, these are only available in Respimat (a soft mist inhaler - SMI) or dry power inhalers (DPI). A major challenge in asthma care is promoting good inhalation technique so patients actually inhale aerosol droplets or particles deeply into the lungs and fully benefit from the medication. Mixing inhaler types introduces the high likelihood that patients will not practice optimal inhalation technique. For example, a patient using albuterol MDI (SABA), Breo Elipta DPI (ICS and LABA) and Spiriva Respimat SMI (LAMA) would have to learn three different inhaler techniques. If an ICS/LABA/LAMA DPI is used by a patient, a DPI albuterol would likely be the best choice to keep the inhaler type and inhalation technique consistently DPI. Another controversial aspect of asthma care has been the role of immunotherapy. Two recommendations address this topic: • Allergy shots, known as subcutaneous immunotherapy, are recommended for people who have allergic asthma and whose symptoms worsen after exposure to certain allergens (conditional recommendation, moderate certainly of evidence). • Sublingual immunotherapy, which involves placing liquid drops or tablets containing allergens under your tongue, is not recommended for the treatment of allergic asthma (conditional recommendation, moderate certainly of evidence). These recommendations seem to limit and focus the role of immunotherapy in asthma treatment. Subcutaneous immunotherapy (SCIT) is recommended for allergic asthma when there is an historical relationship between exposure and worsening symptoms, not merely because sensitivity to aeroallergens has been demonstrated by prick testing or Immunocaps. Sublingual immunotherapy (SLIT) is not recommended for treatment of allergic asthma. 14

MISSOURI FAMILY PHYSICIAN April - June 2021

A related topic is the role of environmental abatement in the home and school as a primary approach to reduce the expression of asthma and need for therapeutics. The following recommendations emphasize a multicomponent approach when there is known sensitization to specific perennial allergens. • For people with asthma who are sensitive to indoor substances (such as house dust mites), using multiple strategies to reduce the allergen is recommended (such as air purifiers, HEPA vacuum cleaners, and pillow and mattress covers that prevent dust mites from going through them). Using only one strategy often does not improve asthma outcomes (conditional recommendation, moderate certainly of evidence). • Integrated pest management is recommended for those who are allergic and exposed to cockroaches, mice, or rats (conditional recommendation, low certainly of evidence) • These strategies are not recommended for people who are not allergic to indoor substances (conditional recommendation, low certainly of evidence). Use of fractional expired nitric oxide in the management of asthma has remained controversial despite this technology becoming widely available and less expensive. The 2020 Focused Updates include two related recommendations: • FeNO testing in individuals ages 5 and older is recommended when either the diagnosis or the approach to therapy is uncertain (conditional recommendation, moderate certainly of evidence). • FeNO testing should not be used alone to assess asthma control or predict the course of the ailment. In children ages 4 years and younger who have recurrent episodes of wheezing, FeNO measurement does not reliably predict the future development of asthma (strong recommendation, low certainly of evidence). These recommendations seem unlikely to significantly change clinical practice. Repeated measures over time of forced expiratory volume in one second (FEV1) for adults, FEV1 percent predicted for growing children (5 years and older) or complete spirometry remain the gold standard for objective assessment of asthma (Global Lung Initiative reference values for FEV1 available at http://gligastransfer.org.au/calcs/spiro.html ). Finally, the emergence of bronchial thermoplasty warranted a critical review and the following recommendations: • Most individuals ages 18 years and older with uncontrolled, moderate to severe persistent asthma should not undergo bronchial thermoplasty because the benefits are small, the risks are moderate, and the long-term outcomes are uncertain (conditional recommendation, low certainly of evidence). • Some individuals with moderate to severe persistent asthma who have troublesome symptoms may be willing to accept the risks of bronchial thermoplasty and, therefore, might choose this intervention after shared decision making with their health care provider (conditional recommendation, low certainly of evidence). References found on page 31

Asthma Extension for Community Health Outcomes (ECHO®) Road to Best Practices

Sherri G. Homan, PhD, RN, FNP

Benjamin D. Francisco, PhD, PNP, AE-C

Tammy L. Rood, DNP, CPNP-PC, AE-C

Paul M. Foreman, PhD

Introduction Pediatric asthma is a serious health condition for many children, currently impacting 5.5 million children in the US and disproportionally affecting low socioeconomic and minority populations.1, 2, 3 In Missouri, the prevalence of childhood asthma is 8.4% or > 108,000 children.1 More than one-third of all children in Missouri (37%) are provided health care coverage by the state’s Medicaid program.4 According to Medicaid administrative claims analysis, a substantial proportion of children with asthma are uncontrolled (25%), defined as high utilization of acute care services and risky medications such as systemic oral steroids for asthma episodes. Delivering guidelines-based asthma care5,6 through best practices is crucial to improving outcomes. With the volume of information being generated so rapidly, combined with limited time, it is a challenge to stay current. A core aim of continuing medical education is to bridge the gap between evidence and practice. Continuing education is effective in reaching objectives when barriers were minimized7 and in knowledge, attitudes, skills, practice behaviors, and clinical practice outcomes. 8 Optimizing the time for continuing medical education is important and a key component to improving asthma care.9 Project ECHO® is a collaborative learning model that uses video-conferencing technology to build communities of practice and expand access to specialty medical care by sharing knowledge and best practices.10, 11, 12 Asthma Ready© Communities has developed three complementary ECHO programs designed to drive better pediatric asthma population health outcomes.13,14 This article describes this collaborative education approach, reach and practice outcomes. The ECHO® Model Project ECHO® is a model that revolutionizes medical education to provide best practice, specialty-level care to rural and underserved urban populations with funding provided by the State of Missouri general revenue to the Missouri Telehealth Network (MTN).15, 16 The ECHO model™ breaks down walls between specialty and primary care. It links expert specialist teams at an academic ‘hub’ with primary care clinicians in local communities – the ‘spokes’ of the model. Together, they participate in weekly ECHO™ clinics, which are like virtual grand rounds, combined with mentoring, patient case

MISSOURI FAMILY PHYSICIAN April - June 2021

presentations and discussions. The model allows a greater number of patients to receive specialty-level care by equipping primary and community-level providers to assess, treat, manage, and monitor acute and chronic conditions.12, 14, 17 The Missouri Asthma ECHOs Asthma 1 – Essentials: Impact Asthma Asthma Essentials ECHO, initiated in 2015, has trained hundreds of health professionals.18 The Hub is an expert, interdisciplinary team composed of both clinical/health care specialists (e.g., clinicians, specialists, school nurses, community health workers, environmental assessors, social work professionals) and community asthma educators/champions who have a multi-county reach. Specialists serve as mentors and colleagues, sharing their medical knowledge and expertise with primary care clinicians. Asthma Essentials provides an introduction to asthma expert guidelines and in-depth care discussion of an asthma case. Best practices are based on national standards, Guidelines for Diagnosing & Managing Asthma Expert Panel Report (EPR) 3, and the Update 2020.5, 6 During ECHO clinics, de-identified case studies and didactics are used to review the essentials of guidelines-based care. Primary care clinicians from multiple sites present patient cases using a standard format completed in advance (chart, claims, community sources) to the specialist team and each other, discuss new developments relating to patients, and determine treatment. The case presentation is followed by a case summary by a facilitator, a call for clarifying questions, and open discussion with suggestions. Written recommendations are provided after the session. Some cases are presented in future sessions for case management. The didactic reinforces and enriches the case. Community health professionals can join one of six annual offerings of the Essentials series that meets noon to 1 pm on consecutive Tuesdays for 4 weeks and provides 4 hours Category One or American Academy of Family Physicians continuing medical education (CME) credits. This ECHO session is offered in January, February, May, June, September, and October. Once “graduating” from this Asthma ECHO program, clinicians often aspire to become asthma champions in their region. Participation in Asthma Care Accelerator ECHO provides a direct pathway for these health professionals.

2 - Asthma Care Accelerator, n = 217 17.5%

1 - Asthma Essen als, n = 710 57.1% 3 - Asthma Care & Educa on, n = 316 25.4% Figure 1. Number and Percentage of Learners by Asthma ECHO Program, Missouri, 2015 - 2020 Asthma 2 – QI/MOC: Asthma Care Accelerator The Asthma Care Accelerator (ACA) ECHO began in January 2018.19 This ECHO program is designed to enable clinic-based asthma champions - pediatricians, family physicians, and internists seeking maintenance of certification and nurse practitioners or physician assistants to implement asthma national guidelines in their clinic setting using a quality improvement (QI) format. The overarching goal is to support asthma champions in high-volume clinical practices. There are eight, one-hour videoconferences over 6 months with accompanying critical intervention activities to meet multi-specialty board requirements for the award of Maintenance of Certification (MOC) credit for pediatricians, family physicians, internists and others. This approach combines learning collaboration with practice facilitation for practical “real world” experience including case presentations and on-site clinical support for best practices. The global aim of the ACA ECHO project is to reduce the rate of uncontrolled asthma from participating provider-patient panels by at least 25%. Medicaid asthma health service utilization measures are displayed in Asthma Risk Panel Reports (ARPRs) every four months and annually for two additional years. ARPR include uncontrolled asthma rates, asthma medications dispensed, acute care days, and proportion of outpatient visits to total visits. In addition, the reports provide stratified lists of patients to support population health management by nurse care managers or other clinical staff. Lists include priority patients for follow-up appointments in 30, 60 and 90 days; health home eligible; likely to benefit from a home environmental assessment; and risk factor sorts, including emergency department (ED) visits, inpatient asthma days, systemic steroid bursts and excess short-acting beta agonist dispensing.

Profession

All

1,243 100.0

Nurses

309

24.9

Physicians

175

14.1

School Nurses

113

9.1

Unspecified

110

8.9

Nurse Practitioners

104

8.4

Other – Program Managers, Research Coordinators, etc.

7.9

Students

6.7

Health/Public Health Administrators

6.2

Other Health Professionals (Respiratory Therapists, Asthma Educators)

6.0

Education (Head Start, K-12, Higher Education) 35

2.8

Community Health Workers

2.6

Social Workers

1.5

Mental/Behavioral

0.7

Physician Assistants

0.4

Table 1.Asthma Extension for Community Health Outcomes (ECHO) Program Learners by Profession, Missouri, 2015-2020

continued on page 18 MO-AFP.ORG 17

continued from page 17

Sample

Pre

Post

Number adopted

Percent

Number adopted

Significance Percent

44.1

55.9

26.5

55.9

23.5

70.6

29.4

67.6

29.4

67.6

10.2

21.6

Mean

(SD 2.775)

.005

(SD 2.408)

Table 2. Adoption of Best Practices by Asthma Extension for Community Health Outcomes (ECHO) by Clinicians, Missouri (N = 5)

Figure 2. Asthma Extension for Community Health Outcomes (ECHO) Program Reach by Geographic Areas, Missouri, 2015-2020 A pre-post 34-item inventory of asthma guideline practice routines called “My Action Steps-Routine in My Practice” survey based on the EPR-3 guidelines is completed and was analyzed using paired t-test with alpha set at < .05. Also, monthly run charts track 10 asthma patients to assess quality indicators: documented asthma severity and control, use of objective measures of airflow, coaching with assessment of adequacy of inhalation effort, inhaled corticosteroids dispensing rate, request for preventative services, and provision of an asthma action plan. Asthma 3 – Community: Asthma Care and Education The Asthma 3 ECHO was designed and launched in 2017 – Asthma Care & Education (ACE).20 The goal is to build and network 18

MISSOURI FAMILY PHYSICIAN April - June 2021

community health professionals with clinical teams. ACE ECHO has also trained hundreds of Missouri school nurses, community health workers (CHWs), nurse managers, environmental assessors, and others. Ten sessions annually, noon to 1 pm, granting 1.0 CME, address national standards and resources for asthma assessment, self-care education, health home “touches”, home environmental assessments, reimbursable community preventive asthma services, and during the pandemic was expanded to include coronavirus disease (COVID-19) safety recommendations and precautions for care and telehealth asthma protocols. Sessions address social determinants of health and family barriers to control for care managers, community health workers, asthma educators and home assessors using the Childhood Asthma

Risk Assessment Tool (CARAT), a validated survey to address the social determinants for health as well as family barriers to selfcare, or PRAPARE, a protocol for responding to and assessing patients’ assets, risks, and experiences 21, 22 as case formats. Home environmental assessment and trigger reduction presenters use a room-by-room analysis case format. School nurses use Teaming Up for Asthma Control for standardized assessments of students and case presentations on ACE. This ECHO also helps health professionals become certified as disease management providers to conduct either home-based asthma education or home environmental assessments for reimbursement. The ACE ECHO also serves as the convener for regional and state initiatives such as Breath UP Kansas City which engages families and partners to address uncontrolled asthma in children, Not One More Life sponsored by Allergy and Asthma Network, and “Becoming an Asthma Educator and Care Manager” with COVID 19 modifications for assessing airway obstruction for primary care managers sponsored by the Missouri Primary Care Association. Additional sessions have included school-based care for school nurses covering telehealth protocols during school closures, cleaning and ventilation, and care management. Outcomes The Asthma ECHO® programs have served > 1,200 learners (Figure 1) in 365 organizations, and reached 45% of Missouri’s counties during the first five years, 2015-2020 (Figure 2). Greater than 42 cases annually were presented including traditional clinical cases, single patient; community cases, single patient, CARAT or PRAPARE; home environmental and school-based assessments;

and population level cases. Participants have included many disciplines and areas of expertise (Table 1). Asthma best practices for a 3-year pre- and post-analysis of five clinicians showed that at the onset, a low mean (10 of 34 or 30%) of adoption of asthma best practices, but by the end of the post-period, the rate had more than doubled (22 of 34 or 65%) (p = .005) (Table 2). Two practices reduced asthma emergency department visits among their panel of patients, one practice reduced asthma hospital admissions, and 3 out of the 5 practices saw an increase in numbers of asthma patients. Also, the Asthma Risk Panel Reports for the sampled health professionals’ region showed a 4.5% (67% to 70%) increase in the proportion of outpatient and preventive services to total asthma encounters. Conclusion Combined, these ECHO programs assist with the fundamental components of asthma care, identify and address asthma risk and impairment in a panel of patients, promote effective ways to implement EPR3 guidelines, offer continuing education and maintenance of certification credits for clinicians, and support asthma champions. The Asthma ECHOs increase capacity, address gaps in care, and strive to reach children most at risk for asthma episodes and disparities. These programs have established asthma leaders in clinics, schools, hospitals and community agencies and are helping to keep the workforce current with asthma advances. Program results showed clinicians who adopted best practices after participating in Asthma ECHO® and earning MOC, reduced the asthma burden for their panel of patients and increased the number of children served by the health centers. References found on page 31

Saint Louis University, a Catholic, Jesuit ins tu on dedicated to student learning, research, healthcare, and service is seeking applicants for full me or part- me faculty posi ons in the Department of Family and Community Medicine. Board-cer fied family physicians with strong clinical skills and a commitment to training future family physicians are sought for clinical and academic faculty posi ons in a vibrant and collabora ve department.

Family Medicine Faculty posi ons include: • Clinical prac ce op ons: • Clinical ambulatory prac ce with faculty colleagues in an innova ve Pa ent Centered Medical Home on the campus at Saint Louis University • Clinical primary care with an underserved pa ent popula on at County Health Centers or Correc ons Medicine Medical student teaching • Op on for Family Medicine inpa ent teaching • Support and mentorship for scholarship and research. Applica on must be made online at h ps://www.slu.edu/working-at-slu.php and include cover le er and curriculum vitae. Applicants may contact the department directly by calling 314-977-8480, by sending CV and cover le er to Chris ne Jacobs, M.D., Professor and Chair, Family and Community Medicine, 1008 S. Spring Ave., 3rd Floor, St. Louis, MO 63110, or via e-mail to chris ne.jacobs@health.slu.edu.

MO-AFP.ORG 19

INHALER USE AND ADHERENCE IN CHILDREN

Shahed Faruk, MD

ccording to the American Lung Association, asthma is a chronic lung condition that affects roughly six million children in the US under the age of eighteen1. Inhalers are devices commonly used to deliver asthma medication. Although there are many different forms, adherence to these inhalers is sometimes difficult to achieve. The lack of adherence to treatment regimens of asthma therapy can lead to uncontrolled disease, frequent exacerbations, hospitalizations, missed school days and increased healthcare costs 5. In this article, the various types of inhalers available for therapeutic use, the pitfalls between different inhaler types, and reasons for reduced adherence will be discussed. Adherence is defined as a patient following a treatment regimen as directed by a provider4. There are many reasons for patient non-adherence of inhalers in the treatment of asthma including lack of education on the use of inhalers based on types of inhaler, failing to remember to take medication, cost of the inhaler, not understanding the side effects of the inhaler and feeling better4. There are different forms of inhalers which can be used to deliver inhaled asthma medication that may provide quick relief medication for exacerbation such as short acting beta 2 agonist inhaler (i.e., albuterol) or other types that can deliver chronic long-

MISSOURI FAMILY PHYSICIAN April - June 2021

term control medication for prevention of symptoms such as inhaled corticosteroids4, 6. To help with adherence, it is important for providers to understand how each type of inhaler works and examine why each method of delivery can have disadvantages. Inhalers come in a variety of forms including nebulizers, metered dose inhalers (MDI), MDI with a spacer, and dry powder inhaler (DPI) (2, 3). MDI are small, easy to carry devices that can distribute aerosolized medication but can be difficult to use for children due to issues with management of inhalation from soft palate, mouth, nose and then to the lungs (3). MDI with a spacer is an MDI with a chamber like device that can lower the velocity with which the particles travel. Some MDI with spacers can also have a valve that can help the medication be delivered during inhalation only. Dry powder inhaler (DPI) transports fine particles through a circular channel into a mouth piece. As the particles travel by going through a spiral channel, it decreases in size of the particles so that the medication can be penetrated by the lung as it is delivered through turbulence. The amount of medication that can be inhaled depends on the child’s inspiratory flow rate. Therefore, younger children may benefit less from the use of this form of inhaler. In clinical practice, this type of inhaler is not recommended for children younger than 5 years of age2, 3. A nebulizer is a machine that uses air or oxygen generated by electric compressor or cylinder and passes through tubing. Liquid from a reservoir is drawn through a tube, then the droplet aerosolizes and continues to re-nebulize and provide continuous flow of medication inhaled through a face piece covering the face and nose3. The amount of medication that actually reaches the child may be less as some of the medication

may stay within the reservoir as residual volume, though this varies from machine to machine 3. The downsides can include the device being expensive, difficult to transport, and takes more time to use. Education of the devices is important as it has been shown that the majority of patients incorrectly use their inhalers. Studies have shown that only 7-40% of medication reaches the lungs due to errors in inhaler use 7. Patients or caretakers should be instructed to shake the inhaler before use when using MDI or DPI. Angling the inhaler properly should be emphasized so the medication is not incorrectly directed into the mouth or tongue which would lead to inadequate medication delivery into the lungs. It is also important to instruct patients to start inhaling slightly before or at the time the inhaler is activated. Lastly, patients should be told to hold their breath for about 10 seconds to help transport the medication to the lungs 7. Children need to be educated on possible side effects such as tachycardia that may occur with certain inhalers. Children should be reassured that what they are feeling is normal occurrence while on the medication. This is important as these side effects may be distressing to a child 2. Qualitative studies have found that adolescents are usually more forgetful if they have fewer symptoms. They also tended to forget when rushing to everyday activities. Forgetfulness was less of an issue with younger children as they usually use inhalers with help from caretakers or in the supervision of caretakers who can remind the patient, but may forget if there are any changes to their routine. Another major reason behind non-adherence tended to occur if the patient used an as-needed approach when using inhalers even if the inhaler was a preventive corticosteroid. This was mainly due to patients feeling as though the inhaler was inconvenient to use, or if patients were not having any symptoms 7. It is not only important to recognize the mechanisms behind failed adherence to asthma therapy, but it is also vital to examine possible solutions to fix this problem. Electronic monitoring devices have been posited as a method in promoting asthma treatment management through the use of electronic monitoring devices (EMDs) 8, 9. This consists of using a chip to track use of the medication and providing reminders to the patient about when to use their inhaler through text messages and emails thus helping to establish a routine 8, 9. Although electronic monitoring has been heralded as a novel method of asthma management in pediatric populations, EMDs do not seem to function as primary motivators in inhaler adherence in pediatric and adolescent populations 8, 9. However, this may have other benefits such as promoting further conversations between children and their physicians about adherence training or identifying adolescents with severe asthmatic disease 10. Another study found success

“

in inhaler adherence through behavioral interventions facilitated by either the child’s allergist/immunologist or the school facilities (i.e., school

Studies have shown that only 7-40% of medication reaches the lungs due to errors in inhaler use.

”

nurse/counselor), and saw an increase in adherence patterns in children, especially if these interventions were performed in a group10. Thus, perhaps electronic monitoring coupled with behavioral therapy through a clinic or school could provide a useful method of inhaler adherence and decrease severe morbidities associated with improperly managed asthma. Many factors may go into the issue of adherence for children and adolescent patients, and there is no one thing to blame for why certain patients are unable to consistently use inhalers. It is important to consider age when deciding the type of inhaler to use as an MDI with spacer would be better for children younger than 5 years of age. DPI, however, is more appropriate for children older than 5. Nebulizers may be used for more severe cases or those with frequent exacerbations3. It is also vital to consider proper education of patients, stress adherence even if patients have no symptoms, and counsel on the usually benign potential side effects. Adherence must be stressed to make sure children do not have complications from nonuse or misuse of the inhalers, reducing health care costs and reducing number of days absent from school. References found on page 31 MO-AFP.ORG 21

Brian Bernskoetter provides MAFP members with a review of priority issues.

Advocacy Day – Your Way

his year’s legislative session is like no other and MAFP’s Annual Advocacy Day meeting was in the same circumstance – a hybrid approach to sharing our voice. In order to accommodate the request from the Missouri legislature, we moved this year’s event to a virtual format and platform. We took advantage of the unique situation by hosting our elected leaders to speak to members about their vision, goals, and perspective on key healthcare issues – including COVID-19 local authority restrictions and vaccine deployment. Over 40 members participated in the virtual sessions and/ or legislator appointments. The Advocacy Day series kicked off with a meeting with Missouri Governor Mike Parson. The Governor thanked family physicians for their service during the pandemic and taking care of Missourians. The vaccine distribution is no different than managing the disease itself. He stated that his goal is to make sure the most vulnerable population (65+) is immunized, considering the supply and demand issue of the vaccine. He did highlight that he has budgeted for the Constitutional amendment that expanded Medicaid. Mental health is a key focus for his administration along with telehealth, broadband access, behavioral health, developmental disabilities, and lastly, parity for physician and provider reimbursement. The next week featured Randall Williams, MD, Director, Missouri Department of Health and Senior Services, who 22

MISSOURI FAMILY PHYSICIAN April - June 2021

provided up to date information about the COVID-19 vaccine allocation and deployment. Members were engaged in asking questions about utilizing family physicians as a key point of contact in communities for the vaccine. Our very own Randy Scherr and Brian Bernskoetter, MAFP Governmental Consultants, provided a thorough review of our priority issues and messages that can be found on pages 24 – 25. Lastly, Representative Jeff Coleman, Chair, House Professional Registration and Licensure Committee, joined us for a frank discussion about scope of practice, licensure, and other issues. Representative Coleman understood that issues have two perspectives and will be open to hear from each side of an issue before making a decision. We reiterated the differences between physicians and mid-level providers’ education and clinic experiences. For those unable to join us during the virtual sessions or legislator appointments, a Speak Out platform was available to send a prepared message to legislators on preceptor workforce program, scope of practice, and public health authority during a pandemic. Recordings of the advocacy discussions are available to watch free on the LMS at https://mafp.mclms.net/ en/. It’s not too late to use your voice – if you are interested in becoming involved in MAFP’s advocacy efforts, contact Kathy Pabst, MAFP Executive Director (kpabst@mo-afp.org), for more information.

2021 National Residency Match Results A total of 38,106 positions were offered and 36,179 were filled. This represents a 2.6% increase of filled positions from the previous year. Of the 35,194 first-year (PGY-1) positions available, 33,535 were filled, representing a 2.9% increase of first-year filled positions. Primary Care* accounted for 17,649 (49.6%) of the first-year positions offered. Family medicine** accounted for 13.5% of the total positions offered with 4,493 matched applicants. This year marks the 12th consecutive year of growth for the specialty and the 10th consecutive year that an all-time record number of students matched into family medicine. Congratulations to our future family physicians!

University of Missouri-Kansas City medical student, Tony Phillips, matched to UMKC Family Medicine Residency Program.

he National Residency Match Program (NRMP) reported that the 2021 Main Residency Match was the largest on record with the number of applicants at an all-time high of 48,700. This was an 8.3% increase over 2020 and the largest singleyear bump in recorded history.

*Family Medicine, Internal Medicine, Internal Medicine –Pediatrics, Internal Medicine – Primary, Pediatrics, and Pediatrics – Primary. **Family medicine-categorical, plus combined programs: emergency medicinefamily medicine, family medicine-preventive medicine, and psychiatry family medicine. References: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/ uploads/2021/03/2021-MRM-Press-Release_FINAL.pdf https://www.aafp.org/dam/AAFP/documents/medical_education_residency/ the_match/2021-Match-Results-for-Family-Medicine.pdf

MO-AFP.ORG 23

MAFP Priority Issues and Messages MAFP SUPPORTS PRECEPTOR TAX CREDIT PROGRAM

SUPPORT HB 689 (Shields) • Preceptors are a critical component in the learning process for medical and physician assistant students. They provide invaluable experience for students to develop clinical skills and competencies, gain practical experience working with patients, and understand the diversity within the patient population and treatment settings. • Evidence shows that early and consistent primary care preceptor mentorships for medical students increases the likelihood of students choosing family medicine as a career. • MAFP supports this self-imposed license fee increase to fund this preceptor tax credit because of the significant need to incentivize preceptors to provide this critical learning opportunity, particularly in rural and healthcare shortage areas. • Primary care physicians and physician assistants will be able to take advantage of this tax credit program which will be eligible for up to 200 preceptor rotations a year. • Most preceptors at public schools of medicine are not paid for providing this service. • This tax credit could improve exposure of medical students and physician assistants to rural medicine.

MAFP SUPPORTS A PHYSICIAN TO LEAD THE HEALTH CARE TEAM

OPPOSE HB 84 (Stephens), HB 502 (Schroer), HB 684 (Chipman), HB 768 (Grier), HB 879 (Dinkins), SB 8 (Riddle), SB 41 (Burlison), SB 177 (Brown), SB 193 (Onder), SB 293 (Hoskins) • MAFP believes the physician-led team approach delivers the best and most cost-effective care to Missourians and that APRNs, PAs, and APs are dedicated, skilled members of the health care team. • While APRNs, PAs, and APs have an important role on the health care team, they have not completed training that affords them the same experience and skill as those who have completed a medical education. A Doctorate in Nursing Practice completes approximately 5,350 hours (of which 5001,500 are clinical) compared to 20,000 hours (of which 9,000 – 10,000 are clinical) for a physician. • Alternatives to an expanded scope of practice for APRNs, PAs, and APs are loan repayment/forgiveness/scholarships for primary care physicians; less administrative burden, such as prior authorizations; increased reimbursement for primary care services; and expand primary care residency slots.

MISSOURI FAMILY PHYSICIAN April - June 2021

PROTECT OUR PATIENTS

MAFP supports immunizations to protect Missouri’s infants, children, adolescents, adults, and seniors. Immunizations are among the most cost-effective and successful public health interventions. • SUPPORT HB 62 (Pike), HB 517 (Shaul), HB 868 (Nurrenbern), SB 124 (Hough) – Education can change behavior, and educating our youth about the effects of tobacco and vapor products as a drug can curb the use of these dangerous products. MAFP supports increasing the age to purchase tobacco and vapor products from 18 to 21, and adding vapor products to the definition of “smoking.” • SUPPORT HB 258 (Evans) – Prohibits the use of hand-held wireless communication devices and texting while driving.

COVID-19 AND PUBLIC HEALTH •

OPPOSE HB 392 (Kelley), HB 444 (McGirl), HB 566 (Eggleston), HB 572 (Haffner), HB 602 (Grier), SCS SB 12, 20, 21, 31, 56, 67 & 68 (Onder)– The MAFP supports local health agencies to develop public health policies and plans that could mitigate the impact of the epidemic on their communities. We support evidence-based decisions to ensure the safety and health of communities in ordinary times and in a state of emergency.

PATIENTS DESERVE ACCESS TO QUALITY HEALTH CARE •

The MAFP believes that all Missourians should have access to essential health care services, regardless of social, economic or political status, race, religion, gender, or sexual orientation. We support measures that increase Medicaid coverage to Missourians who lack affordable health care.

SAFEGUARD THE PHYSICIAN AND PATIENT RELATIONSHIP • •

•

OPPOSE HB 367 (Gregory), HB 986 (Aldridge) – Physical therapists should work with a referring physician to ensure proper diagnosis and treatment of the patient. OPPOSE HB 495 (Ruth), SB 284 (Crawford) – A physician and patient relationship is not established through a questionnaire. This is a useful tool in assessing an existing patient and for minor issues. It is important to interview the patient, take a medical history, and perform a physical exam. OPPOSE HB 628 (Busick), SB 322 (Roberts) – Dentists administering vaccines further fragments the patient and physician relationship by adding another provider of care. Dentists focus on oral health and treatment and do not have a patient’s full medical history. OPPOSE HB 370 (Christofanelli), HB 628 (Busick), HB 976 (Stephens), SB 322 (Roberts), SB 79 (Razer) – The pharmacist and physician work collaboratively so their combined expertise is used to optimize the therapeutic effect of pharmaceutical agents in patient care. When vaccines are administered elsewhere, the information should be transmitted back to the patient’s primary care physician and their state registry to assure continuity of the patient’s medical record.

MAFP CONTINUES TO SUPPORT EFFECTIVE OPIOID PRESCRIBING •

•

SUPPORT SB 63 (Rehder) - The MAFP supports a PDMP that monitors prescribing and dispensing of controlled substances, requires dispensers to electronically submit information within 24 hours of dispensation, and does not require a pharmacist or prescriber to obtain information from the database. In 2019, there were 1,094 opioid overdose deaths in Missouri. The first decline since 2015. The St. Louis County PDMP began in 2017. (Bureau of Vital Statistics, MDHSS) OPPOSE HB 329 (Ingle) and HB 438 (Appelbaum) – MAFP opposes codifying the CDC guidelines into regulations because it undermines the physician and patient shared decision making. It would also disrupt the care of patients who are currently receiving longterm chronic pain treatment. Missouri’s current treatment infrastructure does not have the capacity to absorb a large number of patients newly cut off from opioid treatment.

MEDICAL MALPRACTICE/LAWSUIT REFORM • •

S UPPORT HB 147 (DeGroot) – This bill modifies the rules for determining the admissibility of evidence of collateral source payments in civil actions. SUPPORT HB 759 (Lewis), HB 997 (DeGroot), SCS/SB 42 & SB 51 (Luetkemeyer) – MAFP supports protection of health care providers against liability in COVID-19 related actions, including setting the statute of limitations to one year after the alleged harm.

OTHER IMPORTANT LEGISLATION •

•

OPPOSE Expansion of Assistant Physician - HB 550 and HB 916 (Derges) - Medical school trains students to become residents, not physicians. Residency provides graduated responsibility, oversight, and progressive duties to many different patients (chronic and complex conditions), pathologies, practice settings, and undifferentiated signs and symptoms which require critical thinking and differential diagnosis. OPPOSE HB 516 (Shaul), SB 300 (Bernskoetter) – With the expansion of telehealth and workforce shortage, we support the need to join Interstate Medical Licensure Compact based on the Missouri Board for Registration of the Healing Arts oversight and board certification should not be required for physician participation. OPPOSE HB 937 (Fogle) – MAFP members are diverse and serve in diverse geographical locations across the state. We believe that physicians should select and engage in CME based on their own needs and professional practice gaps. SUPPORT SB 194 (Onder) – Supports board certification as a means to remain current on health care issues and treatments. We oppose using Maintenance of Certification and Maintenance of Licensure as a condition of employment, privileges, or reimbursement.

Pictured from left: Ed Kraemer, MD; Representative Brenda Shields; Carol Suit and Shanon Luke

Preceptor Workforce Program Measure Advances

AFP has again initiated legislation to create an incentive for family physicians to precept students at their clinics. The Preceptor Workforce Program, HB 689, was introduced by Representative Brenda Shields, heard by the House Workforce Development Committee, and voted out of committee earlier this session. Many thanks to Ed Kraemer, MD, University of Missouri Kansas City; Carol Suit, Physician Assistant Program at Saint Louis University; and Shanon Luke, Student, University of Missouri Columbia, for their compelling testimony at the hearing. This testimony was in addition to many letters of support that were sent to the committee emphasizing the importance of this program to the recruitment of preceptors in rural areas. The Preceptor Workforce Program would create a self-funded tax credit for physicians and physician assistants to precept students in a rural area. To be eligible for the tax credit, the physician or physician assistant cannot receive payment from the medical school for precepting. And, for a cumulative 120 hours of precepting, they would be eligible for up to three $1,000 tax credits in one year – which are not applicable to past income due, and cannot be carried over to the next tax year. Funding for this tax credit would come from a $7 per license fee increase for physicians and a $3 per license fee increase for physician assistants. MO-AFP.ORG 25

Leveraging Primary Care Physicians to Accelerate COVID-19 Vaccination

s you know, family physicians are uniquely positioned to combat vaccine hesitancy and ensure efficient, equitable vaccine administration. In a March 5th letter to Missouri Governor Mike Parson, Jamie Ulbrich, MD, MAFP Board Chair, urged the Governor to improve collaboration with primary care physicians and practices, including independent physicians unaffiliated with a larger health or hospital system. Primary care physicians and practices should be explicitly incorporated in our state’s vaccine distribution plans and empowered to administer vaccines across our state. Ulbrich stated that, “Family physicians provide preventive services and comprehensive primary care to patients across the lifespan. As integral members of their communities, family physicians see firsthand how pervasive health inequities contribute to poor health outcomes. As such, they play a critical role in the fight against COVID-19 by diagnosing and treating their patients as well as counseling patients and administering vaccines.” According to data from the 2013-17 Medical Expenditure Panel Survey, primary care physicians provided 54 percent of all clinical visits for vaccinations, which make them more likely to administer vaccines than other stakeholders, such as pharmacies or grocery stores. 1 Family physicians report that their patients are contacting them for information on the COVID-19 vaccines and, in many cases, asking when they can receive the vaccine from their current primary care physician. Unfortunately, 85 percent of independent practices are unable to obtain COVID-19 vaccines for their patients.2 Many small and independent physician practices are in rural and other under resourced areas that lack large retail pharmacies or other mass immunizers. He continued to “call on your administration to take immediate steps to supply community-based primary care physicians with COVID-19 vaccines.” Leveraging health care distributors who already supply physicians with flu and other vaccines could help more health care clinicians access vaccines and ultimately accelerate the pace of immunizations. Data indicate that Black and Hispanic adults under 50, as well as rural residents, are more likely to report vaccine hesitancy or indicate that they will not get the vaccine. 3 However, 85 percent of individuals across demographic groups report that their primary care physician or other clinician is the most trusted source of information about COVID-19 vaccines and they will rely on them when deciding whether to get the vaccine. 4,5 26

References found on page 31

MISSOURI FAMILY PHYSICIAN April - June 2021

Earn Live CME Credits in April

Join us Friday, April 23, 2021 from 12-4:00 p.m. to earn 4.0 live CME credits. These interactive sessions will be presented live via Zoom meetings to encourage learner participation.

Topics Include: • • • •

Cost:

The Impact of School on COVID-19 Transmission Identifying Emotional and Social Trauma in Your Patients How You Can Help Missouri’s Medical Students Getting to Blood Pressure Goal During Quarantine: Team Based Hypertension Care

• MAFP Member Price: $75 • Non-member Price: $100 • Residents & Students: Free Learn more and register: www.mo-afp.org/cme-events/virtual/. Sponsored by Missouri Health Professional Placement Services

Summer Externship Deadline Approaching The Family Health Foundation of Missouri’s annual externship opportunity for medical students is quickly approaching its April 5th deadline. Co-sponsored by the American Academy of Family Physicians Foundation, the four-week summer externship opportunity is offered to Missouri medical students, preferably after their 1st or 2nd year, who are interested in pursuing a career in family medicine. Externships are available at six Missouri family medicine residency programs throughout the state. Participants will receive a $1,000 stipend.

Deadline to apply: April 5, 2021

Learn more and apply at: https://www.mo-afp.org/members/ residents-students/externships/.

WE HAVE THE POWER TO STOP INFECTIONS TOGETHER. Visit cdc.gov/projectﬁrstline to learn more about infection control practices.

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MEMBERS IN THE NEWS Stevermer Earns Appointment to U.S. Preventative Services Task Force James Stevermer, MD, MSPH, FAAFP, the Vice Chair for Clinical Affairs and Professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine, has been appointed to the United States Preventive Services Task Force (USPSTF). “The MU School of Medicine is proud to congratulate Dr. Stevermer on this prestigious new appointment,” said Michael LeFevre, MD, professor and chair of Family and Community Medicine. “His experience in family medicine, dedication to evidence-based care and expertise in guideline development will be a valuable contribution to the task force.” The task force is an independent volunteer panel of national experts in prevention and evidence-based medicine. Members come from primary care and prevention-related fields, including internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology and nursing. Members are appointed to serve four-year terms. “I am pleased to welcome Dr. Stevermer to the task force,” said task force chair Alex H. Krist, MD. “Dr. Stevermer’s experience translating clinical research into practice and serving on multiple guideline-making bodies, in addition to his commitment to improving the health of rural communities, will be an important addition.” In addition to his role at the MU School of Medicine, Stevermer is the medical director of MU Health Care Family Medicine–Callaway Physicians. His scholarship focuses on evidence-based medicine, guideline development and evaluation, and the translation of clinical research into practice. He has written and edited for the Family Physicians Inquiry Network and was an associate editor at the “Journal of Family Practice.” More information on the Task Force is available at www.uspreventiveservicestaskforce.org.

Lichtenberg and Mourad Appointed to AAFP Commissions Kate Lichtenberg, DO, MPH, FAAFP, was appointed to serve as a member of the American Academy of Family Physicians’ Commission on Continuing Professional Development for a four-year term that began in December 2020. This commission helps guide the AAFP’s credit system and its provision of continuing medical education that helps members and other health care professionals demonstrate continuous improvement in knowledge, competence, practice performance, and patient outcomes as well as fulfill educational requirements for licensure and certification. Wael Mourad, MD, MS, FAAFP was appointed to serve as a member of the American Academy of Family Physicians’ Commission on Health of the Public and Science for a four-year term that began in December 2020. Members of this commission help support the AAFP’s strategic objectives: payment reform, practice transformation, family medicine workforce, and clinical expertise. You can find more information about AAFP’s commissions at https://www.aafp.org/about/meet-ourleadership/commissions.html.

Kate Lichtenberg, DO, MPH, FAAFP

Wael Mourad, MD, MS, FAAFP 28

MISSOURI FAMILY PHYSICIAN April - June 2021

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review. We love to hear from our members!

Continuum Family Care Brings a New Approach to Health Care in Maryville

Pictured from left: Helen Smith, LPN; Dr. Fillingane; SaraBeth Fillingane; and Ame Ebrecht, LPN. Credit: The Maryville Forum.

Chip Fillingane, DO, recently opened Continuum Family Care to provide simplified, preventive care for long-term wellness and health for every stage of life, from newborns to seniors, to residents of Maryville and Northwest Missouri. Located along South Main Street in Maryville, Continuum focuses on preventive health care, primary care, full laboratory testing – including screening and diagnostic lab tests – and telehealth appointments, which allow patients to receive the same level of attention and communication as in-person visits

from the comfort of home. “We’re proud to nurture our community, to be a resource for our hometown, to stay with you through the entire continuum of care—because your health is always personal to us,” Dr. Fillingane said. “We’re neighbors helping neighbors manage their health at every life stage through a comprehensive approach to health care.” For more info, visit https://continuumfamilycare.com/.

Lichtenberg Receives FACPM Designation Kate Lichtenberg, DO, MPH, recently received her Fellow designation for the American College of Preventive Medicine. Election as a Fellow of the American College of Preventive Medicine (FACPM) is an honor bestowed upon qualified

candidates by their peers on the ACPM Membership Committee. Fellows of the College are recognized for demonstration of significant efforts to advance the preventive medicine specialty and mission of the College.

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MEMBERS IN THE NEWS

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review. We love to hear from our members!

Miller Receives 2020 Greater St. Louis Community Health Award David Miller, MD, MHA, CHCEF, FAAFP was honored with the St. Louis Academy of Family Physicians’ 2020 Greater St. Louis Community Health Award for “special contributions to the community of public health, health education and providing health services.” A practicing physician for more than thirty years, Miller received the award for his ongoing work coordinating Affinia Healthcare’s free COVID-19 testing program, which has performed over 27,000 tests predominately in underserved communities in St. Louis City, while also continuing to serve as Affinia’s assistant medical director and urgent care clinical director. First given in 1994, the Greater St. Louis Community Health Award recognizes a family physician, family medicine resident or medical student (planning to enter family medicine) for substantial contributions to the health of the St . Louis community through personal efforts in health education, public health, or providing services to those in need. “I am honored to receive this award in recognition of all the hard work we’re doing for the members of the communities we serve,” said Dr. Miller. “It’s my privilege to oversee Affinia’s COVID testing program and help coordinate the overall mission.”

Henderson Elected to Serve on MIC Board Scott Henderson, MD, has been elected to serve on the Missouri Immunization Coalition (MIC) Board of Directors, representing the Central Region District. The Missouri Immunization Coalition was founded in 2020. MIC works to protect Missourians from vaccine-preventable disease. The coalition has more than 100 members consisting of physicians, nurses, pharmacists, public health departments, hospitals, businesses, policy makers, and community organizations in order to fulfill their mission of preventing diseases, promoting vaccinations, and protecting Missourians.

MISSOURI FAMILY PHYSICIAN April - June 2021

Pictured from left: Affinia President and CEO, Dr. Alan Freeman, FACHE; Dr. Miller and Affinia Vice President and CMO, Melissa Tepe, MD, MPH

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13. Missouri Telehealth Network. ECHO: Move Knowledge, Not Patients. https:// showmeecho.org/ Accessed Feb 8, 2021. 14. Becevic M, Greever-Rice T, Wallach E, Sheets LR, Braudis K, Francisco B, Hoffman K, Edison KE. Assessing impact of Show-Me ECHO on the health of Missourians: Two examples. Missouri Medicine. 2020; 117(3): 245-253. 15. American Academy of Pediatrics Arora S. Changing the World of Pediatrics: How Telementoring Can Aid in Reaching Children Globally. Oct 2015. https://www. youtube.com/watch?v=a_JaeYzmekc Accessed Feb 7, 2021. 16. University of Missouri, School of Medicine. Missouri Telehealth Network. 2020. https://medicine.missouri.edu/offices-programs/missouri-telehealth-network Accessed Feb 7, 2021. 17. Puckett HM, Bossaller JS, Sheets LR. The impact of project ECHO on physician preparedness to treat opioid use disorder: a systematic review. Addict Sci Clin Pract. 2021:16:6. https://doi.org/10.1186/s13722-021-00215-z 18. Missouri Telehealth Network. Asthma 1 – Essentials: Impact Asthma. https:// showmeecho.org/clinics/asthma/ Accessed Feb 9, 2021. 19. Missouri Telehealth Network. Asthma 2 – QI/MOC – Asthma Care Accelerator. https://showmeecho.org/clinics/asthma-accelerator/ Accessed Feb 9, 2021. 20. Missouri Telehealth Network. Asthma 3 – Community: Asthma Care and Education. 21. https://showmeecho.org/clinics/ace/ Accessed Feb 9, 2021. 22. Child Asthma Risk Assessment Tool. https://www.asthmacommunitynetwork. org/carat Accessed Feb 10, 2021. 23. National Association of Community Health Centers. Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). https://www. nachc.org/research-and-data/prapare/ Accessed Feb 10, 2021. Inhaler Use and Adherence in Children pages 20-21 1. Asthma and children fact sheet. (2020, October). Retrieved asthma and copd. Respiratory Medicine, 107(10), 1481-1490. doi:10.1016/j.rmed.2013.04.00 2. Asthma - management and treatment. (2018, January 30). Retrieved February 8, 2021, from https://www.cdc.gov/asthma/management.html 3. Boyd, J. (2017, February 28). Inhaler study: How much medicine makes it to lungs? Rice University New and Media. Retrieved February 9, 2021, from https://news.rice.edu/2017/02/28/inhaler-study-how-much-medicine-makesit-to-lungs-2/ 4. Jochmann A, Artusio L, Jamalzadeh A, Nagakumar P, Delgado-Eckert E, Saglani S, Bush A, Frey U, Fleming LJ. Electronic monitoring of adherence to inhaled corticosteroids: an essential tool in identifying severe asthma in children. Eur Respir J. 2017 Dec 21;50(6):1700910. doi: 10.1183/13993003.00910-2017. PMID: 29269577. 5. Ramsey, R. R., Plevinsky, J. M., Kollin, S. R., Gibler, R. C., Guilbert, T. W., & Hommel, K. A. (2020). Systematic review of digital interventions for pediatric asthma management. The Journal of Allergy and Clinical Immunology: In Practice, 8(4), 1284-1293. doi:10.1016/j.jaip.2019.12.013 6. Mosnaim, G. S., Pappalardo, A. A., Resnick, S. E., Codispoti, C. D., Bandi, S., Nackers, L., Malik, R. N., Vijayaraghavan, V., Lynch, E. B., & Powell, L. H. (2016). Behavioral Interventions to Improve Asthma Outcomes for Adolescents: A Systematic Review. The journal of allergy and clinical immunology. In practice, 4(1), 130–141. https://doi.org/10.1016/j.jaip.2015.09.011 Leveraging Primary Care Physicians to Accelerate COVID-19 Vaccination page 26 1. Wilkinson E, et al. Primary Care’s Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care. 2021. Available at: https:// deepblue.lib.umich.edu/bitstream/handle/2027.42/166088/874-20V3_ PP.pdf?sequence=1&isAllowed=y 2. Medical Group Management Association. https://www.mgma.com/ news-insights/press/nation%E2%80%99s-physician-practices-left-out-ofcovid-19?utm_source=ga-organic-st-01.26.21&utm_medium=social&utm_ campaign=ga-vaccine-press-release 3. Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor. February 2021. Available at: https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid19-vaccine-monitor-february-2021/ 4. Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor. December 2020. Available at: https://www.kff.org/coronavirus-covid-19/report/kff-covid-19vaccine-monitor-december-2020/ 5. Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor. January 2021. Available at: https://www.kff.org/report-section/kff-covid-19-vaccine-monitorjanuary-2021-vaccine-hesitancy/ MO-AFP.ORG 31

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