Implementation of a Physical Activity Vital Sign in Primary Care: Associations Between Physical Activity, Demographic Characteristics, and Chronic Disease Burden.

INTRODUCTION: Physical activity is important to prevent and manage multiple chronic medical conditions. The objective of this study was to describe the implementation of a physical activity vital sign (PAVS) in a primary care setting and examine the association between physical activity with demographic characteristics and chronic disease burden. METHODS: We extracted data from the electronic medical records of patients who had visits from July 2018 through January 2020 in a primary care clinic in which PAVS was implemented as part of the intake process. Data collected included self-reported physical activity, age, sex, body mass index, race, ethnicity, and a modified Charlson Comorbidity Index score indicating chronic disease burden. We classified PAVS into 3 categories of time spent in moderate to strenuous intensity physical activity: consistently inactive (0 min/wk), inconsistently active (<150 min/wk), and consistently active (≥150 min/wk). We used χ2 tests of independence to test for association between PAVS categories and all other variables. RESULTS: During the study period, 13,704 visits, corresponding to 8,741 unique adult patients, had PAVS recorded. Overall, 18.1% of patients reported being consistently inactive, 48.3% inconsistently active, and 33.7% consistently active. All assessed demographic and clinical covariates were associated with PAVS classification (all P < .001). Larger percentages of consistent inactivity were reported for female, older, and underweight or obese patients. Larger percentages of consistent activity were reported for male, younger, and normal weight or overweight patients. CONCLUSION: Using PAVS as a screening tool in primary care enables physicians to understand the physical activity status of their patients and can be useful in identifying inactive patients who may benefit from physical activity counseling.

Physical Activity in Adults With an Amputation as Assessed With a Self-Reported Exercise Vital Sign.

BACKGROUND: Physical activity (PA) is important for the prevention and treatment of numerous chronic medical conditions. Individuals with a limb amputation face unique challenges for staying physically active. There are few studies evaluating PA of civilians with amputation in the United States. OBJECTIVE: To evaluate self-reported PA in persons with an amputation in the outpatient setting using a standardized exercise vital sign (EVS) and correlate PA with demographic information, amputation characteristics, and disease burden. DESIGN: Cross-sectional observational study. SETTING: Outpatient rehabilitation clinic at a tertiary care institution. INTERVENTIONS: N/A. PARTICIPANTS: Two hundred twenty-nine patients with limb amputation. MAIN OUTCOME MEASUREMENTS: EVS (self-reported weekly participation in moderate to vigorous intensity exercise), disease burden using a modified Charlson Comorbidity Index (CCI), possession of a prosthetic limb, amputation level, time from amputation, body mass index (BMI), gender, race, and age. RESULTS: A total of 28.8% of patients with limb amputation self-reported exercising at or above 150 min/wk as recommended by the United States Department of Health and Human Services (HHS); 31.8% of patients with transfemoral amputations, 27.8% with transtibial amputations, and 36% with upper extremity amputations reported exercising the recommended amount. Those with a prosthesis exercised 0.91 h/wk more than those without a prosthesis (95% CI 0.01, 1.8, P = .047), and female patients exercised 1.09 h/wk less than male patients (95% confidence interval [CI] 1.69-0.49, P < .001). Increasing age (P = .045), CCI (P = .006), and BMI (P = .005) all had a small but significant correlation with lower EVS. There was no statistically significant correlation between EVS and amputation level, race, or time from amputation. CONCLUSIONS: Less than one-third of patients with an amputation meet HHS recommendations for aerobic exercise. Male patients, those with a prosthesis, lower CCI, lower BMI, and younger age reported higher PA rates. Assessing EVS can help clinicians to identify patients with amputation that are not sufficiently active and may benefit from PA counseling and prescription.

Reducing 30-day readmission rates in a high-risk population using a lay-health worker model in Appalachia Kentucky.

This exploratory study aimed to address the effectiveness of a lay-health worker (LHW) model in addressing social needs and readmissions of high-risk patients admitted in a rural community hospital. A quasi-experimental study design assessed implementation of a LHW model for assisting high-risk patients with their post-discharge social needs. Outcome measures included 30-day hospital readmissions rates during a 4-month baseline period compared with a 6-month post-implementation period. The LHW intervention involved assessment and development of a personalized social needs plan for enrolled patients (e.g. transportation and community resource identification), with post-discharge follow-up calls. There was a 47.7% relative reduction of 30-day hospital readmissions rates between baseline and intervention phases of the study. Simple regression analyses demonstrated a 56% decrease in odds (90% confidence interval 0.20-0.98) in being readmitted within 30-days among those in the intervention phase compared with those in the baseline phase. Once adjusting for education, transportation cost and anxiety symptoms, there was a 77% decrease in odds among those exposed to the LHW program. LHWs offer an effective hospital-based model to improve transitions in care from the hospital setting, especially those at high-risk with persistent social needs.

Preceptor teaching tips in longitudinal clerkships.

BACKGROUND: In longitudinal integrated clerkships (LICs), the continuous preceptor and student relationship over time creates opportunities for more in-depth teaching approaches than shorter preceptorships allow. We identify student perceptions of the most effective teaching practices and develop tips for LIC preceptors. METHODS: The first four third-year medical student classes completing the Asheville LIC of the University of North Carolina School of Medicine (UNC SOM) formed the subject group. Between June and August 2013, a trained research assistant (AS) conducted semi-structured interviews with all 27 UNC SOM Asheville LIC students. Interviews were transcribed and coded by thematic analysis. RESULTS: All 27 (100%) students participated in the interviews. We identified seven main themes of successful precepting practices: enhance teaching; create bring-backs (learning topics to bring back to preceptors); support patient ownership; structure clinic; improve feedback; engage learners; and develop a relationship. These themes were condensed into nine preceptor tips for teaching in LICs. CONCLUSIONS: The longitudinal relationship of preceptor and student in LIC models affords specific, important opportunities for teaching and learning. The concise list of LIC preceptor tips can be used by preceptors to further optimise their teaching in the LIC setting. We identify student perceptions of the most effective teaching practices and develop tips for LIC preceptors.

Interprofessional care for patients with osteoporosis in a continuing care retirement community.

OBJECTIVES: To assess the quality of care provided to patients with osteoporosis in a continuing care retirement community (CCRC) after implementation of an interprofessional osteoporosis clinic (OPC). Specifically, quality measures were evaluated, including dual-emission X-ray absorptiometry (DXA) screening, calcium and vitamin D supplementation, and prescription treatment of osteoporosis and low bone mass in an ambulatory independent living community. SETTING: Large family medicine teaching practice that provides primary care for residents in one main practice, 5 rural satellite practices, and 2 CCRCs. An interprofessional OPC was developed at the main practice in 2005. Patients at all of the organization's sites could be referred to the main practice for osteoporosis management. A needs assessment conducted at one of the CCRCs in 2011 revealed that rates of screening and treatment were suboptimal for its residents despite availability of an off-site OPC. PRACTICE INNOVATION: In 2012, a new interprofessional OPC including a physician, medical assistant, and pharmacist was replicated on-site at the CCRC so that residents had access to this service within their medical home. EVALUATION: Quality measures were evaluated after implementation of the team-based OPC on-site at a CCRC and included: 1) DXA screening; 2) calcium and vitamin D supplementation; and 3) prescription treatment of osteoporosis and low bone mass. RESULTS: Twenty-nine patients were seen in the new OPC from January 2012 to August 2013. Ninety-three percent had appropriate DXA testing after OPC implementation. Patients accepted pharmacist recommendations regarding calcium and vitamin D supplementation 90% and 86% of the time, respectively. All but 4 patients received appropriate treatment for osteoporosis or low bone mass. CONCLUSION: Providing a team-based OPC on site in a CCRC improved quality measures for screening and treatment of osteoporosis and low bone mass.

Assessing pharmacist-led annual wellness visits: Interventions made and patient and physician satisfaction.

OBJECTIVES: To quantify the nature and frequency of interventions made by pharmacists during a Medicare annual wellness visit (AWV), to determine the association between the number of medications taken and the interventions made, and to assess patient and physician satisfaction with pharmacist-led AWVs. SETTING: Large, teaching, multidisciplinary family medicine practice in North Carolina. PRACTICE DESCRIPTION: Mountain Area Health Education Center (MAHEC) is a large academic practice that serves rural, western North Carolina. There is a heavy emphasis on team-based care. PRACTICE INNOVATION: Pharmacist-led AWV. EVALUATION: Between April 2012 and January 2013, the following were evaluated for 69 patients: the nature and frequency of interventions made, the association between the number of medications taken and the interventions made, and patient and physician satisfaction scores. RESULTS: A total of 247 medication-related interventions and 342 nonmedication interventions were made during the pharmacist-led AWVs. The majority of medication interventions (69.6%) involved correcting medication list discrepancies. The number of medications taken was positively associated with the total number of medication interventions (r = 0.37, P <0.01). On a 5-point Likert scale, patients strongly agreed that the AWV is important for their overall health (mean 4.8, median 5) and that they would like to see the same provider next year (mean 4.8, median 5). Physicians strongly disagreed that they would prefer to do the visit themselves (mean 1.5, median 1) and strongly agreed that their patients benefited from a pharmacist-led AWV (mean 5, median 4.9). CONCLUSION: Pharmacists addressed both medication and nonmedication interventions during AWVs. Patients taking a greater number of medications required more medication interventions than patients taking fewer medications. Patients and physicians reported satisfaction with the pharmacist-led AWV.

Financial implications of pharmacist-led Medicare annual wellness visits.

OBJECTIVE: To determine if pharmacist-led Medicare Annual Wellness Visits (AWVs) are a feasible mechanism to financially support a pharmacist position in physicians' offices. SETTING: Large, teaching, ambulatory clinic in North Carolina. PRACTICE DESCRIPTION: The Mountain Area Health Education Family Health Center is a family medicine practice that houses a large medical residency program. The Department of Pharmacotherapy comprises five pharmacists and two pharmacy residents providing direct patient care. PRACTICE INNOVATION: In April 2012, pharmacists began conducting Medicare AWVs for patients referred by their primary care physicians within the practice. MAIN OUTCOME MEASURES: Visit reimbursement, annual revenue, number of patients who must be seen to cover the cost of a pharmacist's salary. RESULTS: A small practice requires all eligible Medicare patients to complete an AWV to generate enough revenue to support a new pharmacist position. A medium-sized practice requires a 54% utilization rate, and a large practice requires an 18% utilization rate. Two additional AWVs per half-day of clinic are needed to support an existing pharmacotherapy clinic. A total of 1,070 AWVs per year are required to support a pharmacist's salary, regardless of practice size. CONCLUSIONS: AWV reimbursement may significantly contribute to supporting the cost of a pharmacist, particularly in medium- to large-sized practices. In larger practices, enough revenue can be generated to support the cost of multiple pharmacists.

Integration of pharmacists into a patient-centered medical home.

OBJECTIVES: To define the joint principles of the patient-centered medical home (PCMH) and describe the integration of pharmacists into a PCMH. SETTING: Family medicine residency training program in North Carolina from 2001 to 2011. PRACTICE DESCRIPTION: Mountain Area Health Education Family Health Center is a family medicine residency training program that is part of the North Carolina Area Health Education Center system. The goal of the organization is to train and retain health care students and residents. The practice is recognized as a level III PCMH by the National Committee for Quality Assurance (NCQA) and seeks to provide quality, safe, patient-centered care according to the joint principles of PCMH. Pharmacists, nurses, nutritionists, care managers, Spanish translators, and behavioral medicine specialists work collaboratively with physicians to provide seamless, comprehensive care. PRACTICE INNOVATION: The Department of Pharmacotherapy is embedded in the family medicine clinic. Three pharmacists and two pharmacy residents are involved in providing direct patient care services, ensuring access to community resources, assisting patients with transitions of care, providing interprofessional education, and participating in continuous quality improvement initiatives. The pharmacists serve as clinical pharmacist practitioners and provide medication therapy management services in a pharmacotherapy clinic, anticoagulation clinics, and an osteoporosis clinic and via an inpatient family medicine service. Multiple learners such as student pharmacists, pharmacy residents, and family medicine residents rotate through the various pharmacy clinics to learn about pharmacotherapeutic principles and the role of the pharmacist in PCMH. CONCLUSION: PCMH is a comprehensive, patient-centered, team-based approach to population management in the primary care setting. Pharmacists play a vital role in PCMH and make fundamental contributions to patient care across health care settings. Such innovations in the ambulatory care setting create a unique niche for pharmacists to use their skills.

Preventing Growth of Potentially Toxic Molds Using Antifungal Agents 1.

Mold inhibitors such as sorbates, propionates and benzoates have been used commercially for some time. Recently these and other potential inhibitors have been studied from the standpoint of their effects on growth of potentially toxic molds and mycotoxin production. In addition, other substances such as the antifungal antibiotic natamycin (pimaricin) and plant-derived products such as components of the essential oils of certain herbs and spices have recently been studied for their antifungal properties and effects on mycotoxin production. Some of these inhibitors inhibit mycotoxin production by greater than 70%, while only inhibiting growth of the mold by 25% or less. Of the organic acids, sorbic, propionic and benzoic, sorbic and its sorbate salts seems to be most effective over the widest range of conditions in preventing mold growth and mycotoxin production. Potassium sorbate is effective against toxic molds at levels of 0.10 to 0.15%. The antibiotic natamycin is very effective in preventing mold growth and toxin production at very low (0.001 to 0.005%) concentrations. A number of herbs and spices possess antifungal activity. At a level of 2.0%, in YES agar, cloves, cinnamon, mustard, allspice, garlic and oregano all completely inhibit mycotoxin production by a number of mycotoxigenic molds. Cloves, cinnamon and mustard seem to be the most effective of those tested, with complete inhibition occurring with amounts of spice less than 1%. Essential oils of orange and lemon also have antifungal properties at levels of 0.2 % and higher. Certain insecticides and fumigants also inhibit mold growth and mycotoxin production. The organophosphates naled and dichlorvos are both effective inhibitors at relatively low concentrations (0.002 to 0.01%). Phenolic antioxidants, particularly BHA, also inhibit toxic molds in concentrations of 0.025% and above. Naturally occurring methylxanthines, such as caffeine and theophylline, inhibit growth and aflatoxin production by A. parasiticus in concentrations of 0.1% and above. Chlorine, a commonly used sanitizer, will inactivate spores of toxic Aspergillus and Penicillium species at levels of residual chlorine commonly achieved with most sanitation procedures. Even though considerable information is available on inhibitory effects of a number of substances on mold growth and mycotoxin production, more work is needed to further define the conditions under which commercial antifungal agents are most effective in preventing growth of toxic molds and mycotoxin production.