ANNUAL MEETING - Home │ psychiatry.org Library/Psychiatrists/Meetings/Annua… · ANNUAL MEETING May 14-18, 2016 • Atlanta S ñ í ð î - W ] u Ç ^ l ] o o ( } W Ç Z ] ] Co

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ANNUAL MEETINGMay 14-18, 2016 • Atlanta

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5/10/2016

1

PRIMARY CARE SKILLS FOR PSYCHIATRISTSAmerican Psychiatric Association Annual Meeting

Atlanta, Georgia

May, 2016

Primary Care Skills for Psychiatrists

APA/AMP 2014: Primary Care Skills for Psychiatrists 2

a collaboration of:

APA Workgroup on Integrated CareLori Raney, MD (chair)Medical Director, Axis Health Systems Dolores, Colorado

Aniyizhai Annamalai, MDInternal Medicine/Psychiatry

Jae Han, MDFamily Medicine/Psychiatry

Robert McCarron, DO Internal Medicine/Psychiatry

Jeffrey Rado, MD Internal Medicine/Psychiatry

Erik Vanderlip, MD MPHFamily Medicine/Psychiatry

Martha Ward, MD Internal Medicine/Psychiatry

Faculty

Disclosures…

New resources are available now!

&

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Agenda

• 9-9:50:

• 10-1020 hr:

• 1020-1040hr:

• 1040-1100 hr:

• 1100 to 1200 hr:

• 1200 to 1 PM hr:

• 100 – 120

• 120 - 140 hr:

• 140-200 hr:

• 2-3 PM hr:

• 3-4 PM hr:


• Introduction, background

• HTN

• Obesity

• Cholesterol

• Cases on HTN, Obesity, Cholesterol

• Lunch

• Diabetes

• Tobacco

• Preventive Medicine

• DM, Tobacco, Prevention cases

• Collective group discussion

First: Survey!


Lastly: Survey!


Same Number!!!

5/10/2016

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INTRODUCTION AND BACKGROUNDLori Raney, MD Medical Director, Axis Health Systems Dolores, Colorado

Erik R. Vanderlip, MD MPHUniversity of Oklahoma School of Community [email protected]

Integrated Care is a Two-Way Street

Mental Health Services

Mental Health Services

Primary Care Services


“reverse integration”

This Talk Focuses on Part II

1. Why?

2. What?

3. When?

4. Where?

5. Who?

Mental Health Services Primary Care Services


5/10/2016

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Why?

1. History

2. Morbidity

3. Access

DECADE OF THE BRAIN

1990 – 1999July 17, 1990

Now, Therefore, I, George Bush, President of the United States of America, do hereby proclaim the

decade beginning January 1, 1990, as the Decade of the Brain.

Decade of the Brain from the Trenches

AntidepressantsSecond Generation

Antipsychotics

• 1987 –fluoxetine

• 1989 – citalopram

• 1989 - bupropion

• 1992 – sertraline

• 1992 - paroxetine

• 1993 – venlafaxine

• 1993 – fluvoxamine

• 1991 – clozaril

• 1994 – risperidone

• 1994 – olanzapine

• 1995 – quetiapine

• 2001 – zisprazidone

• 2002 – aripiprazol

5/10/2016

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“First, Do No Harm”

*4–6 week pooled data (Marder SR et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Allison DB,Mentore JL, Heo M, et al. Am J Psychiatry. 1999;156:1686-1696; Jones AM et al. ACNP; 1999.

Estimated Weight Change at 10 Weeks on “Standard” Dose

6

We

igh

t C

ha

ng

e (

kg

)

54

3

21

0

-1-2

-3

13.2

We

igh

t Ch

an

ge

(lb)

11.08.8

6.64.42.20-2.2-4.4-6.6

*

ADA/APA Screening Guidelines for Second Generation Antipsychotics

American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27:596–601

History: The Beginning

Circa: 2006

5/10/2016

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History: The Beginning

National Association of State Mental Health Program DirectorsOctober 2006

Why?

1. History – How we got here…

2. Morbidity

3. Access

Cardiovascular Disease Is Primary Cause of Death in Persons with Mental Illness

*Average data from 1996-2000. Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited].

Per

cen

tag

e o

f d

eath

s

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Nasralla, et al Schizophrenia Research 2006

Rates of Non‐treatment

Cardiometabolic Risk in Patients With First‐Episode Schizophrenia Spectrum Disorders: Baseline Results From the RAISE‐ETP StudyChristoph U. Correll, MD et al.JAMA Psychiatry. Published online October 08, 2014.

• 394‐patients with schizophrenia, prospective enrollment

• – mean age 24 –

• half were overweight or obese,

• nearly 60% had abnormal lipid levels,

• half had above‐normal blood pressure or overt hypertension,

• Even though “some of these factors were likely related to antipsychotic medications patients had taken, the researchers concluded that the illness itself and associated ‘unhealthy lifestyles’ also played major roles.”

Predicting Cardiovascular Risk

PRIMROSE: Osborn et al JAMA Psych 2015 72(2): 143‐51.

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High Medical Burden of Disease

• Persons with SMI have an accelerated mortality and medical burden compared with the general population– Some estimates are 10-25 years (Colton & Manderscheid, 2006)

– For all adults with any mental illness, it is 8 years (Druss, Zhao, & Esenwein, 2011)

• This mortality gap between those with SMI appears to be widening over time in some groups– In Sweden they’ve found an overall 1.7 fold increase from 1976 to

1995 for men, and 1.3 fold increase for women with schizophrenia (Osby, Correia, Brandt, Ekbom, & Sparén, 2000)

Mental Illness and Mortality

Mortality Risk:

2.2 times the general population

10 years of potential life lost

8 million deaths

annually

Walker, E.R., McGee, R.E., Druss, B.G. JAMA Psychiatry. Epub, doi:10.1001/jamapsychiatry.2014.2502

• The leading causes of this w i d e n i n g g a p are:1. Cardiovascular/ischemic heart disease (Osby 2000), (Crump

2013)

2. Cancer (Crump 2013)3. Suicide (Obsy 2000)4. Accidental death (Osby 2000)

• Persons suffering with SMI are at risk for a number of other medical co-morbidities– High risk of infectious/communicable disease (McQuistion 1997,

Pirl 2005)– High risk of respiratory illness (DeHert 2011)– High risk of dental disease (DeHert 2011)

• Very nice review available from DeHert, 2011 and NASMHPD 2006 Mind the gap.

High Medical Burden of Disease

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Why?

1. History

2. Morbidity

3. Access to quality care

Patient Level Factors

Lack of motivation,apathy

Cognitive Impairment Lack of perceived

need for health care

Fear and DistrustPoor social, communication skills

Comorbidity

Provider Level Factors

Lack of Knowledge about specific disorders

Attribute physical sx to mental illness and miss the problems

Why bother?“Just treat the Schizophrenia and leave the rest”.

Fear and Distrust Discomfort

Lester HE. BMJ, doi.1136/bmj.38440.418426.8F 2005

Take too long, high no-show, impacts bottom line

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The Need for Better Medical Care• Persons with SMI frequently do not get the care they

require– CVD:

• Those with schizophrenia post-MI were significantly less likely to get reperfusion therapy or evidence-based pharmacotherapies, accounting for a significant portion of their 1-year mortality (Druss 2001)

• Adults with schizophrenia admitted to a hospital with confirmed MI were 41% as likely to receive a catheterization (Druss, JAMA, 2000)

– Cancer:• Lower screening rates of colorectal, breast, prostate than cervical, but

all low overall (Xiong 2008)

– Infectious Disease:• Lack overall screening (Goldberg 2004)

• Lack overall vaccinations (Druss 2010)

Crump 2013

Women, Schizophrenia WITH a diagnosis of CAD

Women, Schizophrenia WITHOUT dx of CAD

Gap due to recognition

The quality of care may contribute to a significant portion of this mortality gap.

Average Life Expectancy in US: 78.2 years

Life Expectancy in US of those with any Mental Illness: 70 years

Life Expectancy with SMI: 55 years Mortality Gap

Care

Portion of Gap Attributable to Access and

Quality Care

~12 Years

Putting it Together

Intervention


1. Why?

2. What?

3. When?

4. Where?

5. Who?



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What?

1. Overcoming Access Issues to…

2. Lower morbidity

Improving Access to Care: Models

1. PCARE study

2. PBHCI Grantees

3. 2703 Medicaid State Plan Amendments -Missouri

4. HOME study

5. Certified Community Behavioral Health Clinics (Excellence in Mental Health Act)

32

Programs Generally Contain 3 Major Components:


Care Management and Tracking

Health Behavior Change

33Kern, in Integrated Care: Working at the Interface of Primary Care and Behavioral HealthLori E. Raney, MD, editor. American Psychiatric Publishing, October 2014

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PCARE: Care Management Roles

• RN/LCSW

• Facilitates patient engagement

• Identification and targeting of high-risk individuals

• Monitoring of health status and adherence –tracking outcomes in registries

• Staff and patient education

• Development of treatment guidelines

• Individualized planning with patients

• Tracks care transitions

PCARE: PC Access, Referral and Eval.

Usual CareIntervention

Group

Preventive Services 21.8% 57.8%

CardiometabolicInterventions 27.7% 34.9%

Have Primary Care Provider 51.9% 71.2%

Framingham Risk Index 9.8% 6.9%

Druss BG, et al. Am J Psychiatry. 2010;167(2):151-159.

PCARE: RCT, Atlanta, GA: 407 SMI over 1 year


1. PCARE study

2. PBHCI Grantees


4. HOME study


36

5/10/2016

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UT(1)

AZ(1) NM

WY

MT ND

SD

NE (1)

KS

OK(4)

TX(3)

LA(1)

AR

MO

IA

MN

WIMI(1)

IL(5)

IN(6)

KY (1)

WV(2)

OH(7)

MD (1)

OR(2)

CA(11)

AK(2)

HI

NV

ID

WA(3)

CO(4)

NJ (4)

DE

MA (4)

NH (1)

CT (3)

VT

PA (2)

NY(8) RI (3)

ME (2)

ALMS

TN (1) SC (1)

NC (1)

VA(3)

FL(7)

GA(4)

DC

Region 85 Grantees

Region 519 Grantees

Region 415 Grantees

PBHCI Grantees by HHS RegionsRegion 107 Grantees

Region 912 Grantees

Region 212 Grantees

Region 113 Grantees

Region 71 Grantee Region 3

8 Grantees

Region 68 Grantees

As of 03/01/14

PBHCI Approach in CMHC Settings

PCP

Patient

CareManager

Psychiatrist

Core Team

Other Behavioral Health Clinicians Substance Treatment, Wellness Coach

Vocational Rehabilitation

CaseManager

Grant-funded additions to the BH team

Health/and Wellness

Peers, Wellness Coaches

PBHCI RAND Evaluation #1

Lessons Learned from Early Implementation1.Registries not simple to construct – data gathering difficult

2.Recruiting and retaining qualified staff – high primary care provider turnover

3.Patient recruitment

4.Space and licenses to do primary care

Sharf DM, et al. Psychiatric Services. 2013;64(7):660-665

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PCPs who are a “good fit” for this work• Flexible, sense of humor• Adapts well to behavioral health environment• Likes working with patients with mental illnesses –compassion and passion

• Enjoys being part of a team – no lone rangers• Want to make a difference in a health disparity group• Prefer to use data to drive care including utilizing a ‘treat-to-target” approach to meet goals

“My observations are that the key variable is a seasoned/experienced, confident provider who may not fully understand but isn't frightened or put off by issues of mental illness.”

- CMHC PBHCI Grantee

Curriculum designed to to be taught by Psychiatrists or PCPs

30 slides per module• Downloadable• Updateable• Modifiable• Pre and post test questions• Resources

http://www.integration.samhsa.gov/workforce/primary-care-provider-curriculum

Make your own PCP-guide!

Modules

• Module 1: Introduction to Primary and Behavioral Heath Integration

• Module 2: Overview of the Behavioral Health Environment

• Module 3: Approach to the Physical Exam and Health Behavior Change

• Module 4: Psychopharmacology and Working with Psychiatric Providers

• Module 5: Roles for PCPs in the Behavioral Health Environment

• Pre and Post test

• Reflective exercise

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PBHCI RAND Evaluation #2

• Integrated systems of various kinds created

• Limited use of Evidence Based Practices for smoking, obesity in particular

• Not able to identify centers which functioned best

• Small clinical evaluation did not show significant effect on physical health.

43Scharf, et al. 2013 Report to HHS. http://aspe.hhs.gov/daltcp/reports/2013/PBHCIfr.shtm

PBHCI Clinical Outcomes – N of 3, 12 months

Scharf, et al. 2013 Report to HHS. http://aspe.hhs.gov/daltcp/reports/2013/PBHCIfr.shtm

RAND Recommendations

• Needs Assessment - include systematic efforts to understand the types and extent of consumer physical health care needs, preferences, attitudes, and beliefs about integrated care; barriers anticipated, number of clients in need of care, etc

• Improve Program performance through continuous quality improvement initiatives – use data to drive care, PDSA cycles

• Use Evidence-based practices and measure fidelity to the practice if appropriate

• Provide ongoing education to staff about the primary care services being offered to improve recruitment into the program

• Hire staff that are a good fit for Integrated Care

Scharf, et al. 2013 Report to HHS. http://aspe.hhs.gov/daltcp/reports/2013/PBHCIfr.shtml

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Behavioral Weight Loss Interventions

Most likely to be effective:

• Longer duration (24 weeks)• Manualized• Combined education and

physical activity• Both nutrition and physical

exercise• Evidence-based (proven

effective by RCTs)

Less likely to be successful:

• Briefer duration interventions • General wellness or health

promotion education only• Non-intensive, unstructured,

or non-manualized interventions

46

Bartels, Steve

HEALTH PROMOTION RESOURCE GUIDESept 2014, SAMHSA


1. PCARE study

2. PBHCI Grantees


4. HOME study


48

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2703 Medicaid State Plan Amendments

• Mechanism of Federal funding through the ACA

• Targets care coordination of vulnerable populations• Many states use for SMI/SED

• 90% Federal Match for first 2 years

• Doesn’t cover actual delivery of primary care

• First awards in 2011, Missouri

2703 Medicaid State Plan Amendments

www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-MAP_v34.pdf. Accessed July 19, 2014.

Health Home Focus

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Six Required Services (no direct Primary Care, More Care Coordination)

Individual and Family Support

Comprehensive Care

Management

Care Coordination

Referral to Community and Social Support

Services

Health Promotion

Comprehensive Transitional

Care

52

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Integrating-Care/Health-Homes/Health-Homes.html

“Consultant” PCP (Missouri Model)

ConsultantPCP

Patient

Nurse Care

Manager

Psychiatrist

Other Behavioral Health Clinicians, Substance Tx, Vocational Rehabilitation

Other Community Resources

Case Manager

PCP

New Role

Offsite

Education, tracking

Core Team

OtherResource

Consultant PCP Duties

• Case Consultation

• Collaboration

• Population management

• Education

**Does this look familiar?

• Looking over your shoulder to make sure adequate care is being provided

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Outcomes

Reducing Hospitalization

Primary Care Health Homes CMHC Healthcare Homes

dmh.mo.gov/docs/mentalillness/18MonthReport.pdf

M5

131.19

121.12

116

118

120

122

124

126

128

130

132

Pre Post

LDL Changes in PCHH Patients with Initially High

Levels

p<.0001

9.89

9.17

8.8

9

9.2

9.4

9.6

9.8

10

Pre Post

HA1c Changes in PCHH Patients with Initially High

Levels

p<.0001

149.75

142.94

138

140

142

144

146

148

150

152

Pre Post

Systolic Blood Pressure Changes in PCHH Patients with

Initially High Values

p<.0001

87.84

83.85

81

82

83

84

85

86

87

88

89

Pre Post

Diastolic Blood Pressure Changes in PCHH Patients with Initially High

Values

p<.0001

dmh.mo.gov/docs/mentalillness/18MonthReport.pdf

Primary Care Provider

Establish Priorities Education

Develop Collaborative Relationships

Case Consultation

Psychiatrist

Medical Leadership

Shared Medical

Oversight

Collaboration with other Team Members

in Comprehensive Care Management

Medical Staff SummitsMissouri 2012 and 2013

Slide 55

M5 Paul and Kit would rather not use this slide based on updated methodology.MUZAC7Y, 12/31/2013

5/10/2016

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1. PCARE study

2. PBHCI Grantees


4. HOME study


58

HOME (Health Outcomes Management and Evaluation) Study

• An RCT Permutation of PCARE

• 300 patients with SMI and at least one chronic condition: DM, HTN, Dyslipidemia, Heart Disease

• Randomized 150/150 usual care or intervention

• Partner with FQHC on site

• ICC: Integrated Community Care• Medical outcomes and budget analysis

Druss, NIMH funded. http://clinicaltrials.gov/ct2/show/NCT01228032

Certified Community Behavioral Health Clinics (CBHC)

Excellence in Mental Health Act – passed March 31, 2014

Scope:

•Primary Care Screenings and Monitoring of Key Health Indicators and Risk

•Care Management

•Partnerships with FQHCs for physical health

•Evidence-Based Practices

•Robust evaluation of 8 pilots – CMS in rule writing phase – due Sept 2015

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Integrating Primary Care Into Behavioral Health Settings: What Works For Individuals with Serious

Mental IllnessMillbank Report 2014

• The use of fully integrated systems or enhancing collaboration through care management enhances outcomes

• The interventions required additional staffing, training and support of care managers

• Cost savings is not clear but early reports from HH is this will be effective

• Integrated data and population health tracking

61

Gerrity, et al: Integrating Primary Care Into Behavioral Health Settings: What Works For Individuals with Serious Mental IllnessMillbank Memorial Fund, NY, 2014

What?

1. Overcoming Access Issues to…2. Lower morbidity

• Evaluation is ongoing• Overall weaker evidence for

exact model of “reverse integration”

• Some patients will not get access.


Toronto, Canada

May, 2015

5/10/2016

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1. Why?

2. What?

3. When?

4. Where?

5. Who?



US?

US?

• A Framework for Intervention

• Basic Requirements• First, do no harm

• Second, do KNOW harm screen appropriately, limit risk

• Counsel to mitigate risk

• Tobacco Cessation in everyone

• Be aware of basic chronic disease guidelines for evidence-based management

• Intervene when necessary

Pro

gre

ssiv

e in

tens

ity,

risk

Nature of Problem

Access to Care

Medical Training, Medico‐

Legal Scope

System Capacity of

BHO

Patient Preference

Routine

Domain Spectrum Action

Urgent EmergentEmergent Referral

Poor/Refuses

Inconsistent Good

Sufficient, CoveredInsufficient, Not

Covered

Adequate Systems in Place, Monitoring and Follow‐Up

Limited Systematic Capacity

Prefers BHO, Psychiatrist

Prefers Traditional Primary Care

Psych Manages with PCP Support

Refer to PCP, Triage Barriers to Access to Care

1

2

3

4

5

5/10/2016

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Roles for Psychiatrists

Co-Management

• Each provider has their own caseload

• PCP manages all medical problems

• Psychiatrist manages all mental health problems

• Work together to re-enforce treatment plans

• Psychiatrist screens for medical problems

• Same site or different• Facilitated referral

Manage with Primary Care

Consult

• Psychiatrist works with a nurse care manager

• Manages a caseload of patients for BOTH mental health and basicmedical problems

• Utilize protocols from PCP

• PCP available for consultation and stepped care as needed

• Outside PCP care continued

Comprehensive Management

• Typically dually trained psychiatrist

• One provider manages both medical and mental health problems

• Limited number of providers have this expertise

All psychiatrists are responsible for “not making people sicker”.

Basic Requirements• Knowledge of Management and Screening of Chronic Diseases, Modifiable CVD Risk Factors

• Treatment of Tobacco Use Disorders• Evidence-based Health/Wellness Activities:• Diet• Exercise

• Knowledge of Recommended Preventive Health Screening Practices as patient advocates at the very least

US?








Pro

gre

ssiv

e in

tens

ity,

risk

5/10/2016

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Do No Harm: Psychiatrists Prescribing SGAs

Agents with higher cardiometabolic risk were prescribed to over 75% of individuals with cardiometabolic disorders

• Primary Reasons Cited Upon Interview included:• *Efficacy• *Less sedation/more sedation• *Patient preference• Low incidence of extra pyramidal symptoms• Low incidence of tardive dyskinesia• Cannot tolerate alternatives

Psych Services, 2013, Hermes, et al. Prescription of Second Generation Antipsychotics: Responding to Treatment Risk in Real World Practice

US?








Pro

gre

ssiv

e in

tens

ity,

risk

ADA/APA Guideline Revised for Non-fasting Labs

72

Monitoring Protocol For Patients on Atypical Antipsychotics

Assessment Parameter

Cut-offs Baseline 4 wks 8 wks 12 wks Quarterly Annually

Medical and Family History, Including CVD

n/a x

Weight, BMI (kg/m2)

>7% gain over baseline or >25

kg/m2 x x x x x

Waist Circumference

Men: 40 in., Women: 35 in.

x x

Hemoglobin A1cPre-DM: >5.7%,

DM: >6.5%x x x

Random Plasma Glucose

Pre-DM: > 140 mg/dL, DM: > 200

mg/dLx x x

Blood Pressure >140/90 mmHg x x x

Non-Fasting TC and HDL

Non-HDL: >220mg/dL; or 10-yr

risk > 7.5%x x X

Nonfasting Screening for Cardiovascular Risk Among Individuals Taking Second Generation Antipsychotics. Vanderlip et al. Psychiatric Services, Vol. 65 No. 5. 573 - 576

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Non-Fasting Labs: Detail

APA/AMP 2014: Primary Care Skills for Psychiatrists73

US?








Pro

gre

ssiv

e in

tens

ity,

risk

• Smoking contributes to half the deaths in SMI population, DSM V diagnosis

• Psychiatrists counsel patients less frequently regarding cessation – <15% vs 90% for PCPs

• Education issue? Reluctance? Belief not interested in quitting?

Williams, et al Psychiatric Services Oct 2014

5/10/2016

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US?








Pro

gre

ssiv

e in

tens

ity,

risk

Psychiatric Oversight of all Health“Doctor Up”

77

Section

Obesity

Hypertension

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter

Aniyizhai Annamalai, MD

Robert McCarron, DO

Erik Vanderlip, MD MPH

Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

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Nature of Problem

Access to Care

Medical Training, Medico‐

Legal Scope

System Capacity of

BHO

Patient Preference

Routine

Step Spectrum Action

Urgent EmergentEmergent Referral

Poor/Refuses

Inconsistent Good

Sufficient, CoveredInsufficient, Not

Covered

Robust Systems in Place, Monitoring and Follow‐Up

Limited Systematic Capacity

Prefers BHO, Psychiatrist

Prefers Traditional Primary Care

Psych Manages with PCP Support

Refer to PCP, Triage Barriers to Access to Care

1

2

3

4

5

Build the Team and the Supports

• Consider the models presented earlier

• Find your PCP friend and “take them to lunch”• Roger Kathol, MD

• Be systematic, and prepared to follow-up and treat to target

• Remember that everyone needs good primary care – working on collaborations/partnerships is essential

Programs Generally Contain 3 Major Components:


Care Management and Tracking

Health Behavior Change

81Kern, in Integrated Care: Working at the Interface of Primary Care and Behavioral HealthLori E. Raney, MD, editor. American Psychiatric Publishing, October 2014

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Registry for Tracking and Analyzing

Psychiatrist as Behaviorist

Two Cultures, One Patient84

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Integration Scores for 53 PBHCI Grantees

Collaboration on Tx Plans

Collaboration on Goals

Overall Leadership Collaboration

Overall Provider Collaboration

Psychiatrists as Leaders

• Champions of improving all medical care• Training non-medical workforce

• Help design programs with strong medical component

• Perform needs analysis

• Determine quality metrics

• Use of registries

• Targeted educational efforts

Psychiatrist’s Duty

• “A forerunner of integration, leading discussions on both physical and behavioral health risks at team meetings, monitoring health indicators in addition to BH progress, promoting wellness and smoking cessation, looking for drug interactions and metabolic side effects. We are trained to be integrated providers but many may have left this calling. “

Psychiatrist in PBHCI grantee site2014

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PCP responses

• “If psychiatrists have buy-in it will trickle down more freely to the patients in terms of full participation in visits and health improvement groups “

• “I would like to have a better relationship with the other psych providers as I often have questions related to side effects of medications and interactions. “

PCP SurveyPBHCI Grantee Summit2014

Resources

• APA Website: www.psych.org and list serve [email protected]

• AIMS Center: http://aims.uw.edu

• Center for Integrated Health Solutions: http://www.integration.samhsa.gov/

• ARHQ Integration Academy: http://integrationacademy.ahrq.gov/

• Books/E-books: Integrated Care: Working at the Interface of Primary Care and

Behavioral Health – edited by Lori Raney, MD

Prevention in Psychiatry – Edited Robert McCarron et al


Toronto, Canada

May, 2015

5/10/2016

31



a collaboration of:








Faculty

Agenda

• 9-9:50:

• 10-1020 hr:

• 1020-1040hr:

• 1040-1100 hr:

• 1100 to 1200 hr:

• 1200 to 1 PM hr:

• 100 – 120

• 120 - 140 hr:

• 140-200 hr:

• 2-3 PM hr:

• 3-4 PM hr:



• HTN

• Obesity

• Cholesterol


• Lunch

• Diabetes

• Tobacco




• Preventive Medicine Curriculum for Psychiatrists

• 25% Royalties go to APA RFM support

• Preventive Medicine in Psychiatry: General Principles

• Cardiovascular and Pulmonary Disorders

• Endocrine and Metabolic Disorders

• Infectious Disorders

• Oncologic Disorders

• Special Topics– Pain

– Geriatric

– Child Psychiatry

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Section

Hypertension

Obesity

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter

Robert McCarron, DO



Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

HYPERTENSION

Edited by:Robert McCarron, DOAssociate Professor Director, Integrated Medicine and PsychiatryDirector, Pain Psychiatry Departments of Anesthesiology, Division of Pain Medicine, Psychiatry and Behavioral Sciences and Internal MedicineUniversity of California, Davis

APA/AMP 2014: Primary Care Skills for Psychiatrists

Presented by:Robert McCarron, DO

1

Nothing to disclose


5/10/2016

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Meet Bill…

• 46 yo single, white, male w/ schizophrenia

• Stable psychiatrically w/

• Intensive case management

• Long acting Risperidone shot

• Olanzapine 20mg (added s/p his hospitalization 18m ago)

• Eats at local fast food restaurants

• Smokes cigarettes and marijuana

• Sees his psychiatrist monthly but refuses to see a primary care doctor


With regards to Bill…

• Upon further investigation, you notice Bill’s blood pressure on three prior clinic visits ranged between:

• Does Bill need treatment for his blood pressure???


155-174

93-105

HYPERTENSION


5/10/2016

34

HYPERTENSION


Cardiovascular Risk Factors: Overview

BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension.Wilson PWF et al. Circulation. 1998;97:1837–1847.

0

2

4

6

8

10

12

14

HTNDMSmokingBMI >27 TC >220

Single Risk Factors

Multiple Risk Factors

Odds ratios

Smoking+ BMI

2

Smoking+ BMI

+ TC >220

3

Smoking+ BMI

+ TC >220+ DM

4

Smoking+ BMI

+ TC >220+ DM + HTN

5

The Framingham Study



5/10/2016

35

Mental Illness and Hypertension

• Those with severe mental illness (SMI) are more likely to be obese and therefore more likely to have HTN

• Those with SMI are more likely to have HTN and not be diagnosed or treated

• People who are chronically depressed are more likely to have HTN

• HTN is a key contributor to the significant decreased life span in those who have SMI!

Schizophrenia Research 2006(86)


Schizophrenia Research 2006(86)

Hypertension --- We Are Missing the Target


Hypertension…Past Definitions (JNC 7)


5/10/2016

36

How We Treat NOW…

General Population

(no diabetes or CKD)

≥ 60 years

SBP <150 mmHgDBP <90 mmHg

< 60 years


Diabetes or CKD present

All agesDiabetes present

No CKD


All agesCKD present with

or without diabetes


Set BP Goal and Treat

(JNC-8 2013 Guidelines)


CKD: Chronic Kidney Disease

The Best Treatment is Prevention…

•Screen if normal blood pressure every 2 years

•Consider checking blood pressure at every visit

•Diagnosis of hypertension is made after 3 abnormal readings, made on separate visits


Initiate BP Lowering-Medication

No CKD

Nonblack

Thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination

Black

Thiazide-type diuretic or CCB,

alone or in combination

CKD present

ACEI or ARB, alone or in

combination with other drug classes

JNC-8 JAMA Dec 2013

Based on Age, Diabetes, CKD


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37

Drug treatment titration strategy

A. Maximize first medication before adding second or

B. Add second medication before reaching maximum dose of first medication or

C. Start with 2 medication classes separately or as fixed-dose combination.

JNC-8 JAMA Dec 2013


Common Medication DetailsMedication Class Dose

RangeFreq. Common Side

EffectsLab Monitoring

Amlodipine CCB 5-10 mg QDSwelling, constipation

None

HCTZ Thiazide 12.5-50 mg QDIncreased urination

Hypokalemia

Chlorthalidone Thiazide 12.5-25 mg QDIncreased urination

Hypokalemia

Lisinopril ACE 5-40 mg QD CoughHyperkalemia,Renal Function

Enalapril ACE 2.5-40 mgQD to BID

CoughHyperkalemia, Renal Function

Losartan ARB 25-100 mg QD --Hyperkalemia, Renal Function

Atenolol BB 25-100 mg QD Bradycardia --


Class 1Class 1

Class 2Class 2

Class 3Class 3


5/10/2016

38



Common Drug Class Interactions Antihypertensive Medication Class

Psychotropics Caution

Diuretics Lithium Watch for dehydration and increased serum lithium level

Multiple taken at the same time

Venlafaxine Potential for increased blood pressure

Multiple taken at the same time

Psychotropics with high α‐1 blockade

Potential for hypotension

Any class MAOI’s 1)Hypotension (α‐1 block)2)Hypertension (food with tyramine might cause a catecholamine surge and hypertensive crisis)

Any class Stimulants Potential for increased blood pressure


5/10/2016

39

For Bill’s Blood Pressure

• You decide to:• Start Hydrochlorathiazide (HCTZ) 12.5mg

• If he had DM, you would have started an ACE Inhibitor

• Two weeks later his BP is 148/93• Increase his HCTZ to 25mg

• One month later, his BP is 141/90 but his K+ is 3.3mg/dL• Add in an ACE inhibitor to help w/ BP control and help spare his

potassium

• Two weeks later, BP is 130/85- Goal!• Creatinine and Potassium are normal

• He uses a pill box to help him manage his new medications


Any Questions…?


Thank You For Listening…

[email protected]

5/10/2016

40

Section

Hypertension

Obesity

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter

Robert McCarron, DO



Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

OBESITY

Edited by:Aniyizhai (Ani) Annamalai, M.D.Assistant ProfessorYale UniversityDepartment of Psychiatry

Presented by:Ani Annamalai, M.D.Yale University


2

Nothing to disclose


5/10/2016

41

Today in clinic…

• Looks like Bill has been gaining weight

• Currently 287lbs w/ BMI of 37.9

• On chart review, you see he was 210lbs b/f starting Olanzapine w/ BMI of 27.7 (18 mo ago)

• You ask yourself:

• Just how bad is his BMI?

• What can I do to help Bill with his weight?


Review impact of obesity among persons with SMI

Understand the efficacy of behavioral and pharmacologic treatment of obesity among persons with SMI

Consider risks and benefits for bariatric surgery for patients with SMI--given the evidence for the health benefits of bariatric surgery in the general population

Objectives


Allison DB et al. J Clin Psychiatry. 1999;60:215-220.

< 18.518.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34

0

10

20

30

No schizophrenia

Schizophrenia

Obese Overweight Acceptable Underweight

BMI Range

BMI Distribution


5/10/2016

42

Obesity Related Complications


• CMHC populations• Dyslipidemia

• 45% with TG > 150 mg/dl;

• 35% with cholesterol > 200

• Diabetes• 33% with Impaired Fasting Glucose

• Hypertension• 51% with BP > 130/85

Correll CU et al. Psychiatr Serv 2010; 61(9): 892-898

Screening for Obesity

Measure weight and calculate BMI Every 4 weeks initially and then at least every 6 months*

Measure waist circumference(independent risk factor for diabetes and other metabolic complications)

At least yearly*


*APA/ADA 2004 guidelines but clinical situation often warrants more frequent monitoring

Weight Classification by BMIAPA/AMP 2015: Primary Care Skills for Psychiatrists

Ideal 18.5-24.9

Overweight 25-29.9

Class I Obesity 30-34.9

Class II Obesity 35-39.9

Class III Obesity >=40

5/10/2016

43

Waist CircumferenceAPA/AMP 2015: Primary Care Skills for Psychiatrists

Males 102cm*

Females 88cm*

* Cut-off for metabolic syndrome criteria

Management of Obesity

Prevention

• Patient education

• Periodic screening

• Choice of antipsychotic


Treatment

• Behavioral counseling• Peer support

• Weight loss interventions

• Pharmacologic

• Surgical

Behavioral Weight Loss Interventions

Most likely to be effective:

• Longer duration (24 weeks)• Manualized• Combined education and

activity• Both nutrition and physical

exercise• Evidence-based (proven

effective by RCTs)

Less likely to be successful:

• Briefer duration interventions • General wellness or health

promotion education-only• Non-intensive, unstructured,

or non-manualizedinterventions


Bartels S, et al. SAMHSA-HRSA Center for Integrated Health Solutions, 2012

5/10/2016

44

ACHIEVE

RCT (n= 291) 18 months: individual + group exercise and nutrition 57% with schizophrenia; 82% on SGA Baseline BMI = 36.3

% >

5%

Wt l

oss

Daumit GL et al. N Engl J Med 2013; 368: 1594-1602

37.8% lost >5% IBW at 18m(compared to 22.7% of control, p = 0.0009)

STRIDE

• RCT (n = 200)• 12 months (6 +6

months): physical exercise, food records, personalized plans, cognitive strategies

• 69% bipolar disorder and affective psychoses

• Baseline BMI 38.3• 40% lost >5% BW c/w

17% controls (p=0.001) at 6 months

131

Green CA et al. Am J Psychiatry 2014; Epub ahead of print

Other Health Promotion Programs


5/10/2016

45

Mean Weight Change With Antipsychotic Medications

*4–6 week pooled data (Marder SR et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Allison DB,Mentore JL, Heo M, et al. Am J Psychiatry. 1999;156:1686-1696; Jones AM et al. ACNP; 1999.

Estimated Weight Change at 10 Weeks on “Standard” Dose

6

We

igh

t C

ha

ng

e (

kg

)

54

3

21

0

-1-2

-3

13.2

We

igh

t Ch

an

ge

(lb)

11.08.8

6.64.42.20-2.2-4.4-6.6

†

*


Switch to Reduce Metabolic Risk (CAMP)

-4

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

StaySwitch

0

-0.5

-1.0

-1.5

-2.0

-2.5

-3.0

-3.5

-4

Week of visit

Wei

ght

chan

ge (

kg)

4 8 12 16 20 24

Stroup TS, et al. Am J Psychiatry 2011; 168: 947-956


Pharmacotherapy

Agent Evidence in schizophrenia

Metformin 3 kg weight loss at 16 weeks1

*Phenteramine-Topiramate

Topiramate: 5 kg weight loss

*Orlistat +/-

*Lorcaserin None*Naltrexone/Bupropion +/-

* FDA approval for weight lossJarskog LF, et al. Am J Psychiatry 2013; 170:1032-1040Das C, et al. Annals of Clinical Psychiatry 2012; 24(3): 225-239


5/10/2016

46

Bariatric Surgery

• Indications based on current guidelines1

• Class III obesity (BMI > 40 kg/m2)

• Class II obesity (BMI = 35-39.9) with medical complication (DM, Sleep apnea)

• Class I obesity with poorly-controlled T2 DM


1 NHLBI, NIH Publication No. 98-4083, 1998

Adjustable Gastric Band (AGB)

Sleeve Gastrectomy (SG)

Roux-en-Y Gastric Bypass (RYGB)

Bariatric Surgery ProceduresAPA/AMP 2015: Primary Care Skills for Psychiatrists

Benefits: Weight Loss


-12

-10

-8

-6

-4

-2

00 3 6 9 12

MedicalRYGBSG

Cha

nge

in B

MI

Months

Schauer PR, et al. N Engl J Med 2012; 366: 1567-1576

5/10/2016

47

Benefits: Diabetes

• Improved diabetes control among those with A1c > 7• 12-months: 42% vs 12% of control had A1c < 6 (p=0.002)1

• Higher rates of remission of diabetes at 6 years • (62% vs 8% and 6%); OR = 16.5 (95% CI 4.7-57.6)2

• Prevention of Type 2 Diabetes (15 year follow-up) • Adjusted HR =0.17 (0.13, 0.21)3


1Schauer PS et al. N Engl J Med 2012; 366: 1567-15762Adams TD et al JAMA 2012; 308 (11): 1122-11313Carlsson LMS et al. N Engl J Med 2012; 367: 695-704

Bariatric Surgery and Bipolar Disorder

Surgical Outcomes

• Retrospective study of Roux-en Y at single site (n=120)

• Bipolar (n=33) compared to other psych (n= 45) compared to no psych (n= 42)

• 1 year: no difference in follow-up, mean weight,% weight loss, mean BMI

Psychiatric Outcomes

• N= 144 severely obese patients with bipolar disorder who underwent bariatric surgery (compared to 1440 patients with bipolar disorder who met criteria for referral)

• Hospitalization 9% vs 10.6%; HR = 1.03 (95% CI 0.83-1.23)

• Outpatient psychiatric service utilization also not different


Steinmann WC, et al Obesity Surgery 2011; 21(9): 1323-1329Ahmed AT et al. Bipolar Disord online Aug 5 2013

• Effectiveness with respect to health benefits in this vulnerable population

• Maintenance of weight loss with use of SGA How assess for appropriateness of surgery? No uniform guidelines

• Impact on course of psychiatric illness after bariatric surgery

• Impact of fat malabsorption on medication dose

• Impact on cognition and functional status

• Impact of body image and altered social role

Unique Considerations

Steinmann WC et al. Obes Surg 2011; 21: 1323-1329


5/10/2016

48

• Individuals with SMI are at greatly increased risk of obesity and related complications

• Mental health providers can and should provide treatment for obesity• Regular screening

• Counseling/lifestyle modification

• Switching to antipsychotic medications with lower metabolic liability

• Metformin?

• Consider bariatric surgery for class III obesity

Summary


What You Can Do As A PsychiatristWeigh all patients!

Provide office based counseling Specific targets for behavior change with periodic monitoring more helpful than general advice

Develop weight loss intervention programs in your center

Models exist and lay educators are effective

Choose antipsychotics with lesser metabolic risk

Start appropriate agent and switch when feasible

Consider medications to promote weight loss

Ex. Metformin, especially if other metabolic risks

Assess for appropriateness of bariatric surgery in all severely obese patients

Can be effective for seriously mentally ill patients

Monitor for complications from obesity! Screen periodically for diabetes, hypertension, lipid disorders


So… For Bill’s BMI of 37

• Consider switching his olanzapine

• Encourage lifestyle modifications• Ask him to walk to his CMHC visits

• Stress substituting soda pop with low or no calorie beverages

• Encouraging cooking or healthy options at the fast food restaurant


5/10/2016

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Questions?


Section

Hypertension

Obesity

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter

Robert McCarron, DO



Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

CHOLESTEROL

Edited by:Erik Vanderlip, MD MPHAssistant ProfessorUniversity of OklahomaSchool of Community Medicine


3

Presented by:Erik Vanderlip, MD MPH

5/10/2016

50

Nothing to disclose


What to look for.


4 40 1

Cholesterol Objectives

1. Properly assess cardiovascular (CVD) risk in patients

2. Apply appropriate screening guidelines to patients

3. Interpret a fasting and non-fasting lipid panel

4. Utilize the non-fasting lipid profile for screening

5. Select the appropriate cholesterol-lowering therapy based on CVD risk

6. Monitor and follow-up that therapy to ensure risk is lowered


5/10/2016

51

2013: Out with the old, in with the new


NCEP ATPIII:

• LDL (bad cholesterol) was the focus

• Treat to pre-specified target LDL based on risk

• Calculate risk on Framingham cohort

• Add drugs to treatment regimen until the target was met

ACC/AHA

• Appropriate placement on a statin is target

• Calculate risk based on pooled cohort equations

• Ensure that therapy is effective (patients adherent) by checking cholesterol panels

• No evidence for alternative lipid-lowering treatments

2013!

Screening: Who and When?

• US General Population at Average Risk

• Males: Every 5 years, beginning age 35

• Females: Every 5 years, beginning age 45

• Those at elevated risk could be screened beginning at age 20

CVD Risk Equivalents (10-year risk of CVD ~20%, risk-class high):Diabetes Mellitus

Previous personal history of CVDAbdominal Aortic AneurysmPeripheral Arterial Disease

Carotid Artery Stenosis

Major Risk Factors:

Family history of CVD in 1st deg relative (male < 55, female < 65)Cigarette smokingHypertension, treated or untreated

Age (male > 45, female > 55)

HDL < 40 mg/dL

Risk for CVD

USPSTF 2008


Screening: Atypical AntipsychoticsMonitoring Protocol For Patients on Atypical Antipsychotics

Assessment Parameter

Cut-offs Baseline 4 wks 8 wks 12 wks Quarterly Annually

Medical and Family History, Including CVD

n/a x

Weight, BMI (kg/m2)

>7% gain over baseline or >25

kg/m2 x x x x x

Waist Circumference

Men: 40 in., Women: 35 in.

x x

Hemoglobin A1cPre-DM: >5.7%,

DM: >6.5%x x x

Random Plasma Glucose

Pre-DM: > 140 mg/dL, DM: > 200

mg/dLx x x

Blood Pressure >140/90 mmHg x x x

Non-Fasting TC and HDL

Non-HDL: >220mg/dL; or 10-yr

risk > 7.5%x x X

ADA, APA 2004, Vanderlip et al 2014


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52

Bill– Lipid Profile Interpretation• 46 YO white male with:

• Schizophrenia, controlled with Atypical Antipsychotics

• Hypertension, (last 155/94)• Smoker• Non-diabetic


Lipid Profile• Total Cholesterol: 260 mg/dL• HDL Cholesterol: 33 mg/dL• Triglycerides*: 258 mg/dL• LDL Direct Measure: 185 mg/dL• LDL Calculated*: 175 mg/dL

*Non-fasting

Non-Fasting Lipid Profile• Total Cholesterol: 260 mg/dL• HDL Cholesterol: 33 mg/dL• Non-HDL: 227 mg/dL• Triglycerides*: 258 mg/dL

Note: Both Total Cholesterol and HDL vary by less than 2% with respect to fasting status (Sidhu 2012).

Calculated LDL is artificially low if non-fasting (slide).

Non-HDL is much more reliable with respect to fasting vs. non-fasting, cut-offs are set 30 pts higher than LDL

Since Non-HDL is greater than 220 mg/dL, that is considered extremely high and alone

warrants high-intensity statin (slide)

Bill – Cardiovascular Risk


http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

What you need to calculate risk:

1. Gender2. Age3. Race (w/nw)4. Smoking Status5. Recent BP and +/-

tmt6. DM status7. Total Cholesterol8. HDL Cholesterol

You do not need LDL values for this

calculation.This uses the newer pooled cohort equations.

Bill – Cardiovascular Risk, 10 Yr.


1. Would lowering cholesterol improve his risk?

2. How should it be lowered?

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

This uses the newer pooled cohort equations.

5/10/2016

53

Treatment of Dyslipidemia

• Low saturated fat• No trans fat• < 300 mg chol/day• Fish oil• Tree nuts• Soy• Fiber

• Aerobic exercise• 30 min/day• 120 min/week

• Statins• Statins• Statins

Switching Antipsychotics?

DietExercise

Meds


Treatment: Switching?

Weiden 2007, J Clin Psych

Switching may be effective when:1. Weight gain is directly

related to AP2. Long-term therapy with

weight neutral agent can be maintained

Weiden 2003

Newcomer 2008

How clinically relevant is this?What is the role of funding?

How do these compare to FGA’s?


Treatment: 4 Types of Statin Candidates


ClinicalCharacteristic

TypeofPrevention

ApplicableAgeRange

PreferredStatinIntensity

PotentialActions

ClinicalPresenceofASCVD*

Secondary 21 to75 High ‐‐

SerumLDL>190mg/dLOR

non‐HDL>220mg/dL

Primary 21to75 High

Work‐uppotentialsecondarycauses

TypeIIDiabetes

Primary 40to75Moderate to

High‐‐

10‐yearriskgreaterthan

7.5%Primary 40to75 Moderate

High: ~50% cholesterol reduction Moderate: 30-50% reduction

1

2

3

4

*ASCVD: prior MI, PVD, stable or unstable angina, AAA or ischemic strokeStone 2013, ACC AHA Guidelines

5/10/2016

54

High Cholesterol: Secondary Causes


Class Details

Disease/Medical/Genetic

Diabetes mellitus

Hypothyroidism

Chronic kidney disease

Nephropathy, proteinuria

Familial (genetic) hyperlipidemia

Pregnancy*

Substance Use Excessive alcohol intake

Medications

Estrogen

HIV Anti-retroviral therapy

Anti-psychotic medications

Steroids, immunosuppressants

DietExtreme obesity

High saturated and trans-fats(Stone et al. 2013; Vodnala, Rubenfire, and Brook 2012)

Treatment: Not all Statins are Equal

Source: www.effectivehealthcare.ahrq.gov Published online: May 16, 2013

Low

Moderate

High

High potency, AM dosing possible


Treatment: Statin Details• Monitoring:

• LFT’s should be checked at baseline and 3 mos. if concern about compromised liver exists

• Safe with liver co-morbidities, don’t let transaminases elevate > 3-fold over baseline

• Myalgias are ~10%• If present, hold statin and check CK• Myositis/rhabdomyolysis is rare, CK should be

> 10-fold above baseline• If CK OK, may consider fluvastatin/pravastatin

• Diabetes risk really for those already on the verge

• 0.3/100 cases of DM due to high-potency• 0.1/100 cases of DM due to low-potency


5/10/2016

55

Treatment: Statin Details

• Pregnancy category X• Many psych meds go through CYP450

• Consider pravastatin (generic, dual metabolism)

• Only rosuvastatin (Crestor) and atorvastatin (Lipitor) may be dosed regardless of time


Follow-Up1. Recheck lipid profiles periodically (at 3-12 mo.

Intervals) to ensure adherence / therapeutic effects• High Potency 50% Reduction• Moderate Potency 30-50% Reduction• Low Potency 30% Reduction

2. Maintain therapy until >75 years, then consider moderation of dose or discontinuation

3. If intolerant of statin, try lower dose or lower potency

• (OK to start on highest recommended dose – titration not necessary)

4. If general cholesterol goals not met and adherent, consider secondary causes and referral


Q: Bill – Statin Candidate?


1. Statin Category 4: 10-yr risk >7.5%2. Moderate Intensity Statin OK

• Consider atorvastatin 40 mghttp://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

Statin Candidacy Classes

Statins by Potency

A:

5/10/2016

56

What do you do for Bill’s Cholesterol?

• You decide to start Bill on Atorvastatin 40 mg

• Once a day

• In the morning w/ his Aripiprazole

• Moderate-dose statin (vs weaker Pravastatin) for aim of 30% reduction

• Monitor for interactions due to cytochrome P450 inhibition w/ Risperidone (which you are considering titrating down over time)


• Age >40• SGA therapy?• Smoker?• HTN?• DM?

• Obese?• CVD already?• Significant

family history of CVD?

(Does this person need testing?)

• TC• HDL• TG• ALT• Glucose• HgB A1c if not avail.

Lipid panel

(non‐fasting)

1. TG ≥ 500 mg/dL (confirm

fasting, consider referral)

2. Secondary Cause (Slide 18), if none, screen for FH

3. Unexplained ALT > 3x ULN

If very high…

(evaluate and treat abnormalities)

yes

(4)LDL ≥ 190 mg/dL or

non‐HDLb ≥ 220 mg/dL

(3)Clinical

Atherosclerosis/CVD*

HIGHIntensity

(2)Diabetes 1 or 2

Age 40‐75

(1)No DiabetesAge 40‐75

(estimate 10‐year riska)

10‐yr risk ≥ 7.5% 10‐yr risk ≥ 7.5% Age < 75

ModerateIntensity

No pharmacotherapy

(determine statin intensity)

(re‐check non‐fasting lipid panel in 4‐12 weeks)

Treatment Working?**

1. Monitor Adherence2. Eval. Secondary Causes3. Intensify Therapy4. Modify Diet/Lifestyle

no

eval. secondary cau

ses

no

yes

(Determine Next Interval to Screen or Reassess)Range: 1‐5 years

(categorize into 4 treatment groups)

(diet and lifestyle counselin

g for all)

Questions?


5/10/2016

57

Agenda

• 9-9:50:

• 10-1020 hr:

• 1020-1040hr:

• 1040-1100 hr:

• 1100 to 1200 hr:

• 1200 to 1 PM hr:

• 100 – 120

• 120 - 140 hr:

• 140-200 hr:

• 2-3 PM hr:

• 3-4 PM hr:



• HTN

• Obesity

• Cholesterol


• Lunch

• Diabetes

• Tobacco




Cases on HTN, Obesity, Cholesterol

• Break into small groups and use the workbook handout.


Section

Hypertension

Obesity

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter

Robert McCarron, DO



Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

5/10/2016

58

DIABETES

Edited by:Martha Ward, MDAssistant ProfessorEmory UniversityDepartment of Psychiatry and Behavioral Sciences


4

Presented by:Martha Ward, MD

172

Back to the Case

• You decide to do some lab work to check Bill’s sugars• Non fasting glucose 194

• HbA1C 6.1%

• You wonder:• Does Bill have diabetes?

• What can be done to help Bill avoid further medical complications in the future?


Screening: Does this sound like any of your patients?

• Screen at baseline, 12 weeks and 12 months on anyone started on atypical antipsychotic.

• Screen every 1 to 3 years IN THOSE AT RISK:• Sustained Blood pressure 135/80

• hypertension or hyperlipidemia

• Risk factors: Gestational diabetes, over 45 years old, BMI >25, family history, sedentary lifestyle, acanthosis nigricans, PCOS, clozapine and olanzapine.

• Risk calculator: http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/


5/10/2016

59

Diabetes: DiagnosisRandom glucose >200 with symptoms

polyuria, polydipsia, polyphagia, weight loss

OR


American Diabetes Association. Diabetes Care. 2012;35(Supp 1):S12, table 2.

Non-fasting, simplest

Nonpharmacologic Treatment

• Diet

• Exercise

• treatment of comorbid conditions

• Foot care

• Dilated eye exam

• Smoking cessation

• Immunizations


Pharmacologic Treatment

•Metformin is first line • Works well if HbA1c < 9

• Some nausea and diarrhea 1st week

• Start at 500mg bid and titrate slowly to 1000mg bid (Max dose 2550mg daily)

• Contraindications • Pregnancy • Creatinine > 1.4 mg/dL in women, > 1.5 mg/dL in men• During and for 48 hours after major surgery or

radiologic contrast use


5/10/2016

60

Pharmacologic Treatment

• After metformin (or not tolerated): start sulfonylurea

• Glipizide (glucotrol)• Start 5mg daily (2.5mg in elderly)

• Optimal dosing BID

• Max daily dose 40mg

• Risk of hypoglycemia

• Avoid long-acting formulas

• Caution w hepatic or renal insufficiency but no absolute cutoff



Goals of Care

• A1c 7-8

• BP less than 140/90

• ACE-I for proteinuria

• Statin

• Aspirin?

• Eye exam/foot exam


5/10/2016

61


Monitoring

• Every 6 months (2-3 months if changing therapy)• HbA1c

• Yearly• Lipids • Creatinine • LFTS• Electrolytes • Urine microalbumin, Urine Cr, U/A • TSH


Self-Monitoring of Glucose

• Metformin: No need to monitor

• Sulfonylurea: 1-2 times daily while titrating

• Insulin: QID

• For sulfonylureas and insulin monitor for:• Heavy exercise• Illness


(e.g. glargine (Lantus), humalog, novalog, NPH, etc…)

5/10/2016

62

Self-Monitoring of Glucose: Sample Schedule

DateBefore

BreakfastAfter

BreakfastBefore Lunch

After Lunch Before Dinner

After Dinner Before Bed

1/18 X X1/19 X X1/20 X X1/21 X X1/22 X X1/23 X X1/24 X X


Case

• You start to wonder: does Bill have diabetes?

• You draw an A1c

• 6.1%

• Random glucose on BMP: 115 mg/dL• His renal function is normal (Cr = 0.9 mg/dL), GFR nl

• You start Bill on metformin 500 mg BID


Questions?


5/10/2016

63

Section

Hypertension

Obesity

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter

Robert McCarron, DO



Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

TOBACCO

Edited by:Jaesu (Jae) Han, MDAssociate Clinical ProfessorAssociate Training Director, Family Medicine/Psychiatry Residency ProgramDepartments of Psychiatry and Family/Community MedicineUniversity of California, Davis


5

Presented by:Jae Han, MD

Nothing to disclose


5/10/2016

64

What about Bill’s tobacco use?• Rolls his own q 20-30min while awake

• Approximately 28/day

• Started at age 16, you estimate 60 pack yr hx

• Tried quitting several times

• Went “cold turkey” for 6 months when he was in a state hospital

• He’s not sure what he’d do to pass time if he didn’t smoke

• You wonder:• Can Bill successfully stop smoking?

• Will smoking cessation impact his mental illness, or have an effect on his medications?

• Are cessation medications safe or even effective for Bill?


TOBACCO DEPENDENCE:A 2-PART PROBLEM and MANAGEMENT

Tobacco Dependence

Physiological Behavioral

Treatment Treatment

Addiction to nicotine

Medications for cessation

Habit of using tobacco

Behavior change program

(APA 2006, US PHS 2008, Fiore 2000)

National guidelines recommend ALL smokers should be screened, advised to quit and offered treatment that

address both aspects of dependence


• 234 inpatients with MDD, Bipolar, schizophrenia• Intervention: access to NRT, computer delivered intervention with personally

tailored report and manual, up to 30 minute counseling session, letter to PCP• Primary outcome: 7 day point prevalence abstinence• 18 month f/u

Active Group = 18 month quit rate 20 vs 7.7%OR = 3.15 (CI = 1.22)

Usual Care = greater risk of rehospitalization OR = 1.92 (CI = 1.06)

(Prochaska 2013)


5/10/2016

65

1. ASSESS readiness on “stages of change”

Precontemplation Action Contemplation Maintenance

Motivational Interviewing

Assist

Behavioral Modification: In-Office• Educate on withdrawal symptoms• Set a quit date• Cognitive- identify / modify reinforcing

thoughts• Behavioral- Modify routine, Identify

triggersOR

Behavioral Modification: Community Know your community resources!


ASSIST: Ready to QuitFDA Approved Pharmacotherapy LONG-TERM QUIT RATES

Silagy et al. (2004). Cochrane Database Syst Rev; Hughes et al., (2004). Cochrane Database Syst Rev.; Gonzales et al., (2006). JAMA and Jorenby et al., (2006). JAMA

Per

cen

t q

uit

> 6

mo

nth

s

19.5

14.6

11.5

8.6

16.4

8.8

23.9

11.8

17.1

9.1

20.0

10.2 9.4

22.5


TRANSDERMAL NICOTINE PATCH

DISADVANTAGES

• Cannot titrate the dose.

• Allergic reactions to adhesive may occur.

• Taking patch off to sleep may lead to morning nicotine cravings.

ADVANTAGES Consistent nicotine

levels.

Easy to use and conceal.

Fewer adherence issues


5/10/2016

66

Patch Dosage and Schedule

BrandSuggested Dosage

Suggested Plan

Nicoderm CQ or generic

> 10 cig / dStart with 21 mg

6 wks on 21 mg2 wks on 14 mg2 wks on 7 mg

< 10 cig / dStart with 14 mg

6 wks on 14 mg2 wks on 7 mg

Typically begin therapy ON quit day

However…SMI patients (especially Schizophrenia) more likely to smoke > 1 packs per daySo what if I…

(Dickerson 2013)


Compared to Standard Patch…

• 25-44 mg (6 studies)• Mixed evidence on long-term quit rate

Increased Dose NRT (Patch)

Increased Dose NRT (Patch)

• (9 studies)• Modest benefit for all forms on short-term quit

rate

Combo NRT (Patch + gum, lozenge, spray, or inhaler)

Combo NRT (Patch + gum, lozenge, spray, or inhaler)

• 6-12 months (4 studies)• Weak evidence on long-term quit rate

Extended NRT (Patch or Gum)Extended NRT (Patch or Gum)

• 2-4 week pre-quit patch (9 studies)• Mixed evidence 6 month quit rate

Pre Quit NRT

(Patch or Gum)

Pre Quit NRT

(Patch or Gum)(Carpenter 2013)


FDA Label Change: decreased safety concerns, increased flexibility

Safe to use before quit daySafe to use > 12 weeks

May use during a lapse or relapse and improve outcome

(FDA 2013)

(Zapawa 2011)


5/10/2016

67

BUPROPION SR

DISADVANTAGES

• Avoid if risk for seizures, eating d/o, unmanaged bipolar

• Common side effects:dry mouth, anxiety, insomnia (avoid bedtime dosing)

ADVANTAGES Can be used with NRT

May be beneficial in patients with depression and schizophrenia

Taper not necessary


BUPROPION SR: DOSING for SMOKING CESSATION

Begin therapy 1 week PRIOR to quit date

Initial treatment 150 mg po q AM x 3 days, then: 150 mg po qam & qafternoon x 7–12 weeks

If 300 mg is not well tolerated: Reduce dose to 150 mg and reassure that 150

mg dose is still efficacious

(Swan 2003)


VARENICLINE: MECHANISM of ACTION

Effects

symptoms of nicotine withdrawal

Blocks DA stimulation associated with smoking

Binds 42 neuronal NIC Ach receptors

Low-level agonist activity

Competitively inhibits binding of nicotine


5/10/2016

68

VARENICLINE: DOSING

• Begin therapy 1 week PRIOR to quit date

• Take after eating, with full glass of water to reduce nausea.

Treatment Day Dose

Days 1–3 0.5 mg qd

Days 4–7 0.5 mg bid

Day 8 – Week 12 1 mg bid

Can simply write for “Month Starter PAK,” then 2 months of 1 mg bid


Varenicline:Warning label in package insert “Serious neuropsychiatric events including, butnot limited to, depression, suicidal ideation, suicide attempt, and completed suicide”•Based on case reports, Led to FDA alert in 2/08

Since then…

•No association in most retrospective studies (Stapleton 2009, Williams et al 2011)

•No association in prospective cohort (Thomas et al 2013) and prospective DB randomized studies (Anthenelli et al 2013) and may actually improve mood (Cinciripini 2013)

•No association in reanalysis of 17 RCT’s and Dept of Defense observational data (Gibbons et al 2013)


COMBINATION THERAPIES: EFFECTIVE

• Combination NRT

Long-acting (patch) + Short-acting (gum, inhaler, nasal spray)

• Allows for acute dose titration prn nicotine withdrawal symptoms

• Bupropion SR + Nicotine Patch

• 3 RCT have shown higher abstinence at 6 m

• Varenicline + Nicotine Patch

• PI advises against: risk of increased SE’s

• RCT 2014: combo with higher continuous abstinence at 3 m and 6 m (OR 1.85 p= 0.07 and 1.98 p=0.04) Well tolerated.

(Koegelenberg 2014)

(Fiore 2008)


5/10/2016

69

COMBINATION Therapies: Effective• Varenicline + Bupropion SR

• RCT showed combo with greater abstinence at 3 and 6 months (OR 1.49 p= 0.03 and 1.52 p=0.03) Combo with less weight gain at 3 months, but more anxiety and depressive symptoms


(Ebbert 2014)

Towards and Evidence-Based Algorithm for Stepped Care

Basal Nicotine

Replacement (Patch, 21mg OR 42 mg**)

Wellbutrin SR or XL, Titrated to

goal of minimum 300 mg daily over

a month*

Breakthrough Nicotine

Replacement (Gum,

Lozenge, Inhaler)**

Initial Pharmacotherapy for Tobacco Cessation

3!

Combo

1 Intervention

OR… Chantix…

EMERGING BIOMARKER: Nicotine Metabolite Ratio (NMR)

3-Hydroxycotinine : Cotinine

•2015 RCT: Varenicline vs NRT Patch n=1246

•Normal metabolizers (NMR ≥ 0.31)• Varenicline > NRT Patch at 11 wk, 6 m

•Slow metabolizers (NMR < 0.31)• Varenicline = NRT patch at 11 wk, 6 m

• More side effects to varenicline3-Hydroxycotinine3-Hydroxycotinine

CotinineCotinine

CYP 2A6

NicotineNicotine

CYP 2A6


Unanswered questions: • Cost effectiveness: why not just start all with varenicline? • Option for patients concerned about varenicline side effects?• Needs to be replicated (Lerman 2015)

5/10/2016

70

Medication Coverage

• American Lung Association has state by state tobacco cessation coverage listed

http://lungusa2.org/cessation2/

• Specifically discusses which NRT, pharmacotherapy and counseling options are covered

• Medicaid coverage

• State employee health plan coverage

• Private insurance resources

• What NRT 1-800-QUIT-NOW can dispense


Management for specific SMI diagnoses?

Major Depression• NRT, Bupropion, Varenicline: Good evidence of long term

abstinence

Schizophrenia• NRT Insufficient data

• Bupropion Good evidence of long term abstinence

• Varenicline Early evidence for but unclear at 6 m

(Thomas 2013, Gierisch 2012, Hughes 2007)

(Gibbons 2013, Tsoi 2013)


Management for specific SMI diagnoses?

Bipolar Disorder• NRT, Bupropion: Insufficient data

• Varenicline• Case reports of mania, 2 retrospective studies of smokers with mental

illness (some with bipolar) showed safety

• First adequately powered study (n=60) showed varenicline vs placebo: 48.4% vs 10.3% at end of treatment (3 months) and 19.4% vs 6.9% at 6 months.


(Stapleton 2008, McClure 2010, George 2012)

(Chengappa 2014)

5/10/2016

71

Pharmacotherapy SummaryNRT (Patch) Bupropion SR Varenicline

Initiation On quit date 1-2 w before quit date 1 w before quit date

Dosing < 10 cigs/d: 14 mg x 6 w, 7 mg x 2 w> 10 cigs/d:21 mg x 6 w, 14 mg x 2 w, 7 mg x 2 w

150 mg qam x 3 d, then 150 mg qam and qafternoon (8 hours later)

0.5 mg qd x 3 d, then bid x 4 d, then 1 mg bid

Duration 12 w 12 w 12 w

Precautions Local Reaction Eating disorderSeizure disorderUnmanaged bipolar

Monitor for adversemood and behavior changes

RCT Data specifically for:

NRT Bupropion SR Varenicline

Depression (history of) ++ ++ ++

Schizophrenia ? ++ +

Bipolar ? ? +

? Insufficient data + limited data ++ RCT data support use NRT Nicotine Replacement Therapy


Electronic Cigarettes “Vaping”

• Controversial!!• Helps quitting smoking vs “gateway” to smoking

• Harm reduction vs yet unknown risks

• Not cheap

• WHO 7/14 calls for ban in work, restaurants

and public places

• FDA proposing rules: pending…

• First RCT with e cigarettes vs NRT patch: similar but low efficacy (Bullen 2013)


Psychiatrists Should Take the Lead in Tobacco Cessation in Public Mental Health Settings


5/10/2016

72

Back to the case

• Bill is smoking approximately 28 roll-your-own cigarettes a day

• You ask him about smoking cessation, and he reports that he’d like to give it a try again, and is ready to quit in the next month

• You set a quit date of June 17th and you both agree to • Start Bill on varenicline 1 week prior to the quit date

• Discuss potential barriers to cessation and triggers to relapse

• “Rescue” Bill if he hasn’t reduced his smoking by half (14 cigarettes) on his quit date by prescribing NRT

• You consider both long-acting NRT and breakthrough

• You consider adding bupropion to his varenicline and NRT if he is still motivated but having difficulty


Any Questions…?


Section

Hypertension

Obesity

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter

Robert McCarron, DO



Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

5/10/2016

73

PREVENTION

Edited by:Jeffrey Rado, MDAssistant Professor Departments of Internal Medicine and Psychiatry Rush University


6

Presented by:Jeff Rado, MD

Nothing to disclose


Education Objectives

1. Understand different types of prevention

2. Become familiar with current disease screening and prevention guidelines:• Cancer

• Infectious Diseases

• Vaccines

• Cardiovascular and Endocrine Disorders

3. Utilize office-based or web-based tools that aid with adherence to evidence-based screening guidelines.


5/10/2016

74

Why prevention?


Types of Prevention

• Primary Prevention: Prevent disease in individual with no symptoms or diagnosed disease (e.g. sunscreen, vaccines).

• Secondary Prevention: Goal is to find and diagnose disease early (before symptoms are evident) so that treatment can be initiated as early as possible (mammography, PAP smears).

• Tertiary Prevention: Disease is diagnosed and patient exhibits symptoms; goal is to prevent complications or progression of disease.


What makes a good screening test?

• Disease:• Common condition with significant morbidity and mortality (important public health problem).

• Effective treatment available.

• Screening tool:• Available at a reasonable cost.

• Safe and tolerable to patient.

• Capable of identifying the disease and shown to lead to improved outcomes.


5/10/2016

75

Where do recommendations come from?• U.S. Preventive Services Task Force (USPSTF)• American Academy of Family Practice (AAFP)• American College of Physicians (ACP)• American Academy of Pediatrics (AAP)• American College of Obstetrics and Gyn (ACOG)• American Psychiatric Association (APA)• American Academy of Child and Adolescent Psych• American Medical Association (AMA)• Centers for Disease Control (CDC)• Insurance Companies (CMS, Commercial etc.)• Special Societies ( American Cancer Society, American

Heart Association)


U.S. Preventive Services Task Force Grading Recommendations• A There is high certainty that the net benefit is substantial. Offer this service.

• B There is Moderate certainty that the net benefit is moderate to substantial. Offer this Service.

• C “It depends” May be a benefit depending on the individual patient and there symptoms, presentation.

• D No benefit and possible harm. Discourage using this service.

• I Statement: We don’t know.• Also quality statement: Good, Fair and Poor


jr7

Breast Cancer• Mammography:

• Age 40-49: Individualized discussion of risk/benefits

• Age 50-74: Every two years

• Age 75+: benefit of screening uncertain.

• ONLY 70% of eligible women receive mammograms—most common reason women give is that their doctor never told them to get one.

Self Breast Exam: no benefit

Unknown if beneficial:• Breast MRI

• Clinical Breast Exam


Slide 224

jr7 I'm assuming that the presentation will highlight primarily the USPSTF recs. May help to mention why we chose to highlight these (a slide of the USPSTF background and how the recs come to be? so others viewing this later will be able to ID where the recs are coming from and why we chose these?) I will talk about whyUSPSTF is used primarily but did not think it needed an entire additional slide devloted toit. hope that is okay. jrado, 1/30/2014

5/10/2016

76

Cervical Cancer

• PAP Cytology• Up to age 21: do not screen

• Age 21-65: every 3 years (usually with reflexive HPV testing).

• Age 30-65: every 3 years or every 5 years with high-risk HPV testing

• Over age 65: do not screen

• Do not screen high-risk HPV before age 30.


jr8

Colon Cancer

• No screening recommended prior to age 50 for average risk persons.

• Age 50-75:• Fecal-Occult Blood Testing (FOBT) yearly

• Flexible Sigmoidoscopy every 3-5 years

• Colonoscopy every 10 years

• Age 75+: no screening • There may be considerations that support colorectal

cancer screening in an individual patient between age 75 and 85.


Lung Cancer

• Low dose CT scan of Chest for individuals age 55-80 with a 30 pack-year history who currently smoke or quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.(new December 2013—Grade B recommendation)• Ex: “Bob” is 57 years old. He started smoking at age 16, 1 packs per day.

For last 15 years he reduced his use to 1/2 pack per day. • 1 ppd X 26 years = 26 pack-years PLUS

• ½ ppd X 15=7.5 pack-years

• Total=33.5 pack-years.


jr9

Slide 226

jr8 can we add the specifier that the HPV testing here is the testing for the more invasive types w pap smear? people may be confused by the last bullet

DONE. I was going to explain the reasoning for this as well.jrado, 1/30/2014

Slide 228

jr9 This one is particularly relevant to the CMHC population.

Would it be helpful for a quick side-bar example of how to calculate the pack-years so the members canget a sense of who would be screened for this? Also - I imagine there are questions about coverage and how to order - I haven't yet ordered this. Have you? The ACA should cover all USPSTF preventive services - would it be helpful to add some on that? just thoughts...

I have NOT ordered this yet so actually not sure it is even covered yet. I added a pack year example.jrado, 1/30/2014

5/10/2016

77

Other Cancers

• No benefit from screening:• Pancreatic

• Ovarian

• Testicular

• Prostate

•Unknown benefit from screening:• Bladder

• Skin

• Oral


Cardiovascular Disease

• Hypertension: every 2 years in adults.

• Hyperlipidemia: every 5 years in men age 35 or older and women age 45 and older.

• Abdominal Aortic Aneurysm (AAA): single screening ultrasound in MEN age 65-75 who have ever smoked.

• Tobacco: ask at every encounter.

• Screening for peripheral artery disease or carotid artery disease not recommended.


Endocrine Disorders

•Diabetes: screen every three years only if Blood pressure is >135/80 (Grade B).

•Thyroid Disorders: not recommended due to unclear benefit.

•Osteoporosis: DEXA scan in women >65 years older with out known fractures or secondary causes of osteoporosis (Grade B).


jr10

Slide 230

11 Would organizing this slide into a quick table be helpful? Erik Vanderlip, 1/27/2014

Slide 231

jr10 can we add how often (once, once yearly, etc.?) I can't remember myselfNo consensus guidelines (no evidence) on how frequently to screen plus it depends on so many factors (dexa results, bisphosphonates, what other RF's do they have, etc.) I think this is too complicated to add.jrado, 1/30/2014

5/10/2016

78

Infectious Diseases

• HIV: all individuals age 15-65 should be screened.

• Hepatitis C: All adults born between 1945 and 1965 should receive one time testing.• More regular screening may be indicated for HIV and Hepatitis C if

risk factors are present.

• Chlamydia and Gonorrhea: screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors).


jr11

Vaccines

• Influenza: Yearly for everyone age 6 months and up.• Pneumococcal polysaccharide 23: One dose after

age 65 and one or two doses prior to age 65 for individuals with chronic medical illnesses (including smokers, asthmatics).

• Pneumococcal 13 valent conjugate (Prevnar): One dose <65 with chronic medical illness or one dose >65.

• Zoster (Shingles): single dose at age 60 or older.• Tetanus/Diptheria (Td): every 10 years. One dose booster should be TDAP.

• Hepatitis B: Recommended if risk factors present.• HPV: three doses before age 26 in females and before age 21 in males.


jr12

Disease Recommended Screening or Vaccine

Breast CA 50-74: MGM q 2 years

Cervical CA 21-65: q 3 years 30-65 q 3 yrs or q 5 with high risk HPV test.

Colon CA 50-75: c-scope q10 yrs OR FOBT q1yr OR flex sig q 3-5 yrs.

Lung CA 55-80 30 pack-yrs: low dose CT chest

AAA Male smokers 65-75 : abdominal US

HIV 15-65: once ---------------------------------------------------------------------------------

Hepatitis C Birth years 1945-65: once----------------------

Osteoporosis

>65: dexascan

Diabetes Q3 yrs if BP>135/80-------------------------------------------------------------------------

Influenza Yearly---------------------------------------------------------------------------------------

Pneumovax Once <65 if chronicillness

Once >65.

Prevnar-13 Once<65 if chronic illness or once >65

Tet/dipth Q 10 yearsAPA/AMP 2015: Primary Care Skills for Psychiatrists

Slide 232

jr11 bullets 1 and 2 - this is the general population recommendation but I think that we could also consider saying something along the lines of yearly sreening is justified if risk factors persist

I added a sentence. Did not specify yearly only because there is no consensus on how frequently to screen. There may be cases where you screen every 6 months.jrado, 1/30/2014

Slide 233

jr12 Let's add that this includes smokers and asthmatics, which is at least 1/2 of patients that we see

DONEjrado, 1/30/2014

5/10/2016

79


Resources: http://healthfinder.gov/myhealthfinder/


Resources: http://epss.ahrq.gov/ePSS/search.jsp


Also available on mobile devices.

5/10/2016

80

After reviewing the guidelines…• You decide to screen Bill for HIV, syphilis, hepatitis B and

C, and tuberculosis with a skin test

• You administer a flu shot, TDaP and Hepatitis A and B

• He has no family history of cancers so he is not due for screening until age 50 • At 50, recommend colon cancer screening and discuss prostate

cancer screening

• At age 55, you would consider the low dose CT scan of chest to screen for lung cancer (given < 15 yrs since smoking cessation)


Any Questions…?

THANK YOU!!!!


Section

Obesity

Hypertension

Cholesterol

Diabetes

Tobacco Use

Prevention

Presenter


Robert McCarron, DO


Martha Ward, MD

Jae Han, MD

Jeff Rado, MD



123456

5/10/2016

81

Agenda

• 9-9:50:

• 10-1020 hr:

• 1020-1040hr:

• 1040-1100 hr:

• 1100 to 1200 hr:

• 1200 to 1 PM hr:

• 100 – 120

• 120 - 140 hr:

• 140-200 hr:

• 2-3 PM hr:

• 3-4 PM hr:



• HTN

• Obesity

• Cholesterol


• Lunch

• Diabetes

• Tobacco




DM, Tobacco, Prevention cases

• Break into small groups, get out handbook of cases.


Collective Discussion, Roles and Boundaries


5/10/2016

82

Lastly: Survey!


Same Number!!!



a collaboration of:








Faculty


Atlanta, Georgia

May, 2016

5/10/2016

1

PREVENTION

Edited by:Jeffrey Rado, MDAssistant Professor Departments of Internal Medicine and Psychiatry Rush University


6

Presented by:Jeff Rado, MD

Nothing to disclose


Education Objectives

1. Understand different types of prevention

2. Become familiar with current disease screening and prevention guidelines:• Cancer

• Infectious Diseases

• Vaccines

• Cardiovascular and Endocrine Disorders

3. Utilize office-based or web-based tools that aid with adherence to evidence-based screening guidelines.


5/10/2016

2

Why prevention?


Types of Prevention

• Primary Prevention: Prevent disease in individual with no symptoms or diagnosed disease (e.g. sunscreen, vaccines).

• Secondary Prevention: Goal is to find and diagnose disease early (before symptoms are evident) so that treatment can be initiated as early as possible (mammography, PAP smears).

• Tertiary Prevention: Disease is diagnosed and patient exhibits symptoms; goal is to prevent complications or progression of disease.


What makes a good screening test?

• Disease:• Common condition with significant morbidity and mortality (important public health problem).

• Effective treatment available.

• Screening tool:• Available at a reasonable cost.

• Safe and tolerable to patient.

• Capable of identifying the disease and shown to lead to improved outcomes.


5/10/2016

3

Where do recommendations come from?• U.S. Preventive Services Task Force (USPSTF)• American Academy of Family Practice (AAFP)• American College of Physicians (ACP)• American Academy of Pediatrics (AAP)• American College of Obstetrics and Gyn (ACOG)• American Psychiatric Association (APA)• American Academy of Child and Adolescent Psych• American Medical Association (AMA)• Centers for Disease Control (CDC)• Insurance Companies (CMS, Commercial etc.)• Special Societies ( American Cancer Society, American

Heart Association)


U.S. Preventive Services Task Force Grading Recommendations• A There is high certainty that the net benefit is substantial. Offer this service.

• B There is Moderate certainty that the net benefit is moderate to substantial. Offer this Service.

• C “It depends” May be a benefit depending on the individual patient and there symptoms, presentation.

• D No benefit and possible harm. Discourage using this service.

• I Statement: We don’t know.• Also quality statement: Good, Fair and Poor


jr7

Breast Cancer• Mammography:

• Age 40-49: Individualized discussion of risk/benefits

• Age 50-74: Every two years

• Age 75+: benefit of screening uncertain.

• ONLY 70% of eligible women receive mammograms—most common reason women give is that their doctor never told them to get one.

Self Breast Exam: no benefit

Unknown if beneficial:• Breast MRI

• Clinical Breast Exam


Slide 8

jr7 I'm assuming that the presentation will highlight primarily the USPSTF recs. May help to mention why we chose to highlight these (a slide of the USPSTF background and how the recs come to be? so others viewing this later will be able to ID where the recs are coming from and why we chose these?) I will talk about whyUSPSTF is used primarily but did not think it needed an entire additional slide devloted toit. hope that is okay. jrado, 1/30/2014

5/10/2016

4

Cervical Cancer

• PAP Cytology• Up to age 21: do not screen

• Age 21-65: every 3 years (usually with reflexive HPV testing).

• Age 30-65: every 3 years or every 5 years with high-risk HPV testing

• Over age 65: do not screen

• Do not screen high-risk HPV before age 30.


jr8

Colon Cancer

• No screening recommended prior to age 50 for average risk persons.

• Age 50-75:• Fecal-Occult Blood Testing (FOBT) yearly

• Flexible Sigmoidoscopy every 3-5 years

• Colonoscopy every 10 years

• Age 75+: no screening • There may be considerations that support colorectal

cancer screening in an individual patient between age 75 and 85.


Lung Cancer

• Low dose CT scan of Chest for individuals age 55-80 with a 30 pack-year history who currently smoke or quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.(new December 2013—Grade B recommendation)• Ex: “Bob” is 57 years old. He started smoking at age 16, 1 packs per day.

For last 15 years he reduced his use to 1/2 pack per day. • 1 ppd X 26 years = 26 pack-years PLUS

• ½ ppd X 15=7.5 pack-years

• Total=33.5 pack-years.


jr9

Slide 10

jr8 can we add the specifier that the HPV testing here is the testing for the more invasive types w pap smear? people may be confused by the last bullet

DONE. I was going to explain the reasoning for this as well.jrado, 1/30/2014

Slide 12

jr9 This one is particularly relevant to the CMHC population.

Would it be helpful for a quick side-bar example of how to calculate the pack-years so the members canget a sense of who would be screened for this? Also - I imagine there are questions about coverage and how to order - I haven't yet ordered this. Have you? The ACA should cover all USPSTF preventive services - would it be helpful to add some on that? just thoughts...

I have NOT ordered this yet so actually not sure it is even covered yet. I added a pack year example.jrado, 1/30/2014

5/10/2016

5

Other Cancers

• No benefit from screening:• Pancreatic

• Ovarian

• Testicular

• Prostate

•Unknown benefit from screening:• Bladder

• Skin

• Oral


Cardiovascular Disease

• Hypertension: every 2 years in adults.

• Hyperlipidemia: every 5 years in men age 35 or older and women age 45 and older.

• Abdominal Aortic Aneurysm (AAA): single screening ultrasound in MEN age 65-75 who have ever smoked.

• Tobacco: ask at every encounter.

• Screening for peripheral artery disease or carotid artery disease not recommended.


Endocrine Disorders

•Diabetes: screen every three years only if Blood pressure is >135/80 (Grade B).

•Thyroid Disorders: not recommended due to unclear benefit.

•Osteoporosis: DEXA scan in women >65 years older with out known fractures or secondary causes of osteoporosis (Grade B).


jr10

Slide 14

2 Would organizing this slide into a quick table be helpful? Erik Vanderlip, 1/27/2014

Slide 15

jr10 can we add how often (once, once yearly, etc.?) I can't remember myselfNo consensus guidelines (no evidence) on how frequently to screen plus it depends on so many factors (dexa results, bisphosphonates, what other RF's do they have, etc.) I think this is too complicated to add.jrado, 1/30/2014

5/10/2016

6

Infectious Diseases

• HIV: all individuals age 15-65 should be screened.

• Hepatitis C: All adults born between 1945 and 1965 should receive one time testing.• More regular screening may be indicated for HIV and Hepatitis C if

risk factors are present.

• Chlamydia and Gonorrhea: screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors).


jr11

Vaccines

• Influenza: Yearly for everyone age 6 months and up.• Pneumococcal polysaccharide 23: One dose after

age 65 and one or two doses prior to age 65 for individuals with chronic medical illnesses (including smokers, asthmatics).

• Pneumococcal 13 valent conjugate (Prevnar): One dose <65 with chronic medical illness or one dose >65.

• Zoster (Shingles): single dose at age 60 or older.• Tetanus/Diptheria (Td): every 10 years. One dose booster should be TDAP.

• Hepatitis B: Recommended if risk factors present.• HPV: three doses before age 26 in females and before age 21 in males.


jr12

Disease Recommended Screening or Vaccine

Breast CA 50-74: MGM q 2 years

Cervical CA 21-65: q 3 years 30-65 q 3 yrs or q 5 with high risk HPV test.

Colon CA 50-75: c-scope q10 yrs OR FOBT q1yr OR flex sig q 3-5 yrs.

Lung CA 55-80 30 pack-yrs: low dose CT chest

AAA Male smokers 65-75 : abdominal US

HIV 15-65: once ---------------------------------------------------------------------------------

Hepatitis C Birth years 1945-65: once----------------------

Osteoporosis

>65: dexascan

Diabetes Q3 yrs if BP>135/80-------------------------------------------------------------------------

Influenza Yearly---------------------------------------------------------------------------------------

Pneumovax Once <65 if chronicillness

Once >65.

Prevnar-13 Once<65 if chronic illness or once >65

Tet/dipth Q 10 yearsAPA/AMP 2015: Primary Care Skills for Psychiatrists

Slide 16

jr11 bullets 1 and 2 - this is the general population recommendation but I think that we could also consider saying something along the lines of yearly sreening is justified if risk factors persist

I added a sentence. Did not specify yearly only because there is no consensus on how frequently to screen. There may be cases where you screen every 6 months.jrado, 1/30/2014

Slide 17

jr12 Let's add that this includes smokers and asthmatics, which is at least 1/2 of patients that we see

DONEjrado, 1/30/2014

5/10/2016

7


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