How Physicians Should Respond to Climate Change.

Urgent warnings about the existential threat of climate change are coming from leaders in nearly every sector of society, including virtually all climate scientists, notable heads of civil governments around the globe, the world's top religious leaders, prestigious medical journals, as well as principals of the largest financial firms. Surveys show that the majority of U.S. physicians in several specialties are caring for patients who are experiencing direct health harms due to climate change. In public platforms, physicians are expressing their awareness that this public health crisis places everyone at risk, but many people are at greater risk, including children, pregnant women, people with chronic health conditions, elders, and those who experience environmental injustice or live in harm's way. Physicians should respond to this crisis with meaningful activities performed within the context of their current roles. The role of medical care provider is the best known role. But, throughout their careers, physicians have ongoing responsibilities as educators of colleagues, trainees, and patients. They are influential employees of medical institutions, trusted experts who exercise civic responsibility, and sources of guidance for public policymakers. Physicians and other health professionals, individually and through their organizations, also work to influence our societal response to the challenge of climate change. The first annual Lancet Journal Countdown Report in 2016 tracking health indicators of climate change stated that climate change had the potential to wipe out all public health gains of the last half century, but it also presents a tremendous opportunity to save lives and improve health. All physicians should work toward the latter outcome.

Limiting global warming to 1.5 to 2.0°C-A unique and necessary role for health professionals.

In an Editorial, Edward Maibach and colleagues discuss the important role of health professionals in future responses to threats of climate change.

Climate change and health beliefs, knowledge, and educational needs among disaster providers.

INTRODUCTION: Climate change has been called the greatest public health threat of our time. Increasing morbidity and mortality is expected to continue as climate-associated disasters become more prevalent. Disaster health professionals are on the front lines of addressing these health sequalae, making the need to assess their knowledge of climate change and health and their perceived need for a policy response critically important. OBJECTIVE: The purpose of this study is to examine the knowledge, opinions, and educational needs of disaster health providers surrounding climate change and health. METHODS: A web-based questionnaire assessing disaster health professionals' attitudes and knowledge on the health effects of climate change and associated policy recommendations was administered to a sample of disaster health professionals. RESULTS: Among the study's 150 participants, 95% responded affirmatively that climate change exists and is largely caused by humans. Two-thirds (67%) indicated climate change affects their patient's health and 93% indicated climate change will continue to affect patients in the future. Respondents also believed climate change will impact vulnerable populations such as children under four years old (75%), the elderly (72%) and those living in poverty (71%). Three-quarters (76%) indicated educating patients about climate change and its association with health outcomes should be integrated into health professions education. CONCLUSION: Disaster health professionals need access to education on climate-change related health impacts, materials for patients and relevant policy information. This research provides evidence from front-line disaster and emergency health professionals that can inform policy on climate change and health.

It's Time for Medical Schools to Introduce Climate Change Into Their Curricula.

Climate change presents unprecedented health risks and demands universal attention to address them. Multiple intergovernmental organizations, health associations, and health professions schools have recognized the specific importance of preparing physicians to address the health impacts of climate change. However, medical school curricula have not kept pace with this urgent need for targeted training.The authors describe the rationale for inclusion of climate change in medical education and some potential pathways for incorporating this broad topic into physician training and continuing medical education. Reasons include the magnitude and reach of this transboundary issue, the shared responsibility of the U.S. health care sector as a major contributor to greenhouse gas emissions, and the disproportionate effects of climate change on vulnerable populations. The integration of climate-change-related topics with training of essential physician skills in a rapidly changing environment is feasible because many health topic areas already exist in medical school curricula in which climate change education can be incorporated. To fully integrate the health topics, underlying concepts, and the needed clinical and system-wide translations, content could be included across the scope of training and into continuing medical education and faculty development. The authors provide examples of such an approach to curricular inclusion.

Measuring the Cost of the Patient-Centered Medical Home: A Cost-Accounting Approach.

To explore the cost for individual practices to become more patient-centered, we inventoried and calculated the cost of costly activities involved in implementing the Patient-Centered Medical Home (PCMH) as defined by the National Committee for Quality Assurance. There were 3 key findings. The cost of each PCMH-related clinical activity can be classified in 1 of 3 major categories. Cost offsets can be used to defray part of the cost recognition. The cost of PCMH transformation varied by practice with no clear level or pattern of costs. Our study suggests that small- and medium-sized practices may experience difficulty with the financial burden of PCMH recognition.

Exploring Variation in Transformation of Primary Care Practices to Patient-Centered Medical Homes: A Mixed Methods Approach.

The objective was to quantify the activities required for patient-centered medical home (PCMH) transformation in a sample of small to medium-sized National Committee for Quality Assurance (NCQA) recognized practices, and explore barriers and facilitators to transformation. Eleven small to medium-sized PCMH practices in Southeastern Pennsylvania completed a survey, which was adapted from the 2011 NCQA standards. Semistructured follow-up interviews were conducted, descriptive statistics were computed for the quantitative analysis, and a process of thematic coding was deployed for the qualitative analysis. Practices had considerable quantitative variation in their workforce composition and the PCMH-related activities they implemented. Most practices improved access and continuity through staff training and team-based care as well as expanded data collection for population management. The barriers to PCMH recognition were least burdensome for the largest practices. The heterogeneity of the small PCMH practices within the study sample underscore the need to understand the key transformation issues as efforts to disseminate the PCMH model continue.

Survey of International Members of the American Thoracic Society on Climate Change and Health.

The American Thoracic Society (ATS), in collaboration with George Mason University, surveyed international members of the society to assess perceptions, clinical experiences, and preferred policy responses related to global climate change. A recruitment email was sent by the ATS President in October 2015 to 5,013 international members. Subsequently, four reminder emails were sent to nonrespondents. Responses were received from 489 members in 68 countries; the response rate was 9.8%. Half of respondents reported working in countries in Asia (25%) or Europe (25%), with the remainder in South America (18%), North America (Canada and Mexico) (18%), Australia or New Zealand (9%), and Africa (6%). Survey estimate confidence intervals were ± 5% or smaller. A high percentage of international ATS survey respondents judged that climate change is happening (96%), that it is driven by human activity (70%), and that it is relevant to patient care ("a great deal"/"a moderate amount") (80%). A majority of respondents also indicated they are already observing health impacts of climate change among their patients; most commonly as increases in chronic disease severity from air pollution (88%), allergic symptoms from exposure to plants or mold (72%), and severe weather injuries (69%). An even larger majority anticipated seeing these climate-related health impacts in the next two decades. Respondents further indicated that physicians and physician organizations should play an active role in educating patients, the public, and policy makers on the human health effects of climate change. International ATS respondents, like their counterparts in the U.S., observed that human health is already adversely affected by climate change, and support responses to address this situation.

Zika virus: A call to action for physicians in the era of climate change.

In February 2016, the World Health Organization declared the mosquito-borne Zika virus to be a "public health emergency of international concern" as the disease linked to thousands of birth defects in Brazil spreads rapidly. The distribution of the Aedes mosquitos has drastically increased over the past few decades, which have been the hottest decades on Earth in more than 1000 years based on climate proxy measures. Although a combination of factors explains the current Zika virus outbreak, it's highly likely that the changes in the climate contribute to the spread of Aedes vector carrying the Zika virus, the pathogen causing serious birth defects. Physicians, both individually and collectively, as trusted and educated members of society have critical roles to play. In addition to clinical management and prevention of Zika, physicians should communicate about the health benefits of addressing climate change in straightforward evidence-based language to their local communities and policymakers, and make clear their support for policies mitigating climate change.

Developing effective communication materials on the health effects of climate change for vulnerable groups: a mixed methods study.

BACKGROUND: Individuals with chronic health conditions or low socioeconomic status (SES) are more vulnerable to the health impacts of climate change. Health communication can provide information on the management of these impacts. This study tested, among vulnerable audiences, whether viewing targeted materials increases knowledge about the health impacts of climate change and strength of climate change beliefs, and whether each are associated with stronger intentions to practice recommended behaviors. METHODS: Low-SES respondents with chronic conditions were recruited for an online survey in six cities. Respondents were shown targeted materials illustrating the relationship between climate change and chronic conditions. Changes in knowledge and climate change beliefs (pre- and post-test) and behavioral intentions (post-test only) were tested using McNemar tests of marginal frequencies of two binary outcomes or paired t-tests, and multivariable linear regression. Qualitative interviews were conducted among target audiences to triangulate survey findings and make recommendations on the design of messages. RESULTS: Respondents (N = 122) reflected the target population regarding income, educational level and prevalence of household health conditions. (1) Knowledge. Significant increases in knowledge were found regarding: groups that are most vulnerable to heat (children [p < 0.001], individuals with heart disease [p < 0.001], or lung disease [p = 0.019]); and environmental conditions that increase allergy-producing pollen (increased heat [p = 0.003], increased carbon dioxide [p < 0.001]). (2) Strength of certainty that climate change is happening increased significantly between pre- and post-test (p < 0.001), as did belief that climate change affected respondents' health (p < 0.001). (3) Behavioral intention. At post-test, higher knowledge of heat vulnerabilities and environmental conditions that trigger pollen allergies were associated with greater behavioral intention scores (p = 0.001 and p = 0.002, respectively). In-depth interviews (N = 15) revealed that vulnerable audiences are interested in immediate-term advice on health management and protective behaviors related to their chronic conditions, but took less notice of messages about collective action to slow or stop climate change. Respondents identified both appealing and less favorable design elements in the materials. CONCLUSIONS: Individuals who are vulnerable to the health effects of climate change benefit from communication materials that explain, using graphics and concise language, how climate change affects health conditions and how to engage in protective adaptation behaviors.

Population-based programs for increasing colorectal cancer screening in the United States.

Answer questions and earn CME/CNE Screening to detect polyps or cancer at an early stage has been shown to produce better outcomes in colorectal cancer (CRC). Programs with a population-based approach can reach a large majority of the eligible population and can offer cost-effective interventions with the potential benefit of maximizing early cancer detection and prevention using a complete follow-up plan. The purpose of this review was to summarize the key features of population-based programs to increase CRC screening in the United States. A search was conducted in the SCOPUS, OvidSP, and PubMed databases. The authors selected published reports of population-based programs that met at least 5 of the 6 International Agency for Research on Cancer (IARC) criteria for cancer prevention and were known to the National Colorectal Cancer Roundtable. Interventions at the level of individual practices were not included in this review. IARC cancer prevention criteria served as a framework to assess the effective processes and elements of a population-based program. Eight programs were included in this review. Half of the programs met all IARC criteria, and all programs led to improvements in screening rates. The rate of colonoscopy after a positive stool test was heterogeneous among programs. Different population-based strategies were used to promote these screening programs, including system-based, provider-based, patient-based, and media-based strategies. Treatment of identified cancer cases was not included explicitly in 4 programs but was offered through routine medical care. Evidence-based methods for promoting CRC screening at a population level can guide the development of future approaches in health care prevention. The key elements of a successful population-based approach include adherence to the 6 IARC criteria and 4 additional elements (an identified external funding source, a structured policy for positive fecal occult blood test results and confirmed cancer cases, outreach activities for recruitment and patient education, and an established rescreening process).

Does telephone scheduling assistance increase mammography screening adherence?

OBJECTIVES: The 2 objectives were: 1) describe the use of a patient navigation process utilized to promote adherence to mammography screening within a primary care practice, and 2) determine the result of the navigation process and estimate the time required to increase mammography screening with this approach in a commercially insured patient population enrolled in a health maintenance organization. STUDY DESIGN: An evaluation of a nonrandomized practice improvement intervention. METHODS: Women eligible for mammography (n = 298) who did not respond to 2 reminder letters were contacted via telephone by a navigator who offered scheduling assistance for mammography screening. The patient navigator scheduled appointments, documented the number of calls, and confirmed completed mammograms in the electronic health record, as well as estimated the time for calls and chart review. RESULTS: Of the 188 participants reached by phone, 112 (59%) scheduled appointments using the patient navigator, 35 (19%) scheduled their own appointments independently prior to the call, and 41 (22%) declined. As a result of the telephone intervention, 78 of the 188 women reached (41%) received a mammogram; also, all 35 women who had independently scheduled a mammogram received one. Chart documentation confirmed that 113 (38%) of the cohort of 298 women completed a mammogram. The estimated time burden for the entire project was 55 hours and 33 minutes, including calling patients, scheduling appointments, and chart review. CONCLUSIONS: A patient navigator can increase mammography adherence in a previously nonadherent population by making the screening appointment while the patient is on the phone.