Transcript James B. Broadhurst, MD, MHA - University of Massachusetts

Maintenance of Health:
Check In & Check Up
James B. Broadhurst, MD, MHA
25th Annual Public Sector Psychiatry Conference
June 17, 2009
Relevant Program Objectives
To learn the role of prevention and
health maintenance in the care of
persons with serious mental illness
 To learn what resources are available in
all formats, e.g., print, online, local,
national, and international to improve
the health and wellbeing of persons with
serious mental illness
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Pediatric Obesity - Intervention
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breastfeeding (SOR A)
no television or computer screen time (SOR C)
avoiding premature introduction of solid foods (SOR C)
limiting intake of juice to less than 6 oz/day (SOR C)
avoiding high-calorie beverages with low nutritional
value (SOR C)
educating parents to be role models of healthy lifestyles
(SOR C)
switching to reduced-fat milk during the preschool years
and beyond (SOR A)
Pediatric Obesity - Prevention
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Low or high birth weight
low socioeconomic level
poor eating
a change >3–4 BMI units per year
Depression
>2 hours/day of sedentary activity such as
watching television or playing computer
games
minority status (all are SOR C)
Behavioral Therapy in Weight Loss
self-monitoring
 stress management
 stimulus control
 problem-solving
 contingency management
 cognitive restructuring
 social support
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Exclusions from Weight Loss
Therapy
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most pregnant or lactating women
Serious uncontrolled psychiatric illness such
as a major depression
variety of serious illnesses and for whom
caloric restriction might exacerbate the illness.
Refer for specialized care
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active substance abuse
history of anorexia nervosa or bulimia
…self-efficacy - a patient’s
report that she or he can
perform the behaviors required
for weight loss - is a modest but
consistent predictor of success.
Obesity: The Practical Guide: Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. NHLBI Obesity Education Initiative, North
American Association for the Study of Obesity, 2000, NIH pub no 00-4084, p21.
Look AHEAD Trial
(Action for Health in Diabetes)
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Multicenter, randomized trial (n=5,145)
Effects of intensive lifestyle interventions on
cardiovascular morbidity and mortality on obese (BMI
> 30 kg/m2) patients with Type 2 diabetes
Randomized to:
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DSE – diabetes support and education with regular medical
care
ILI – intensive lifestyle interventions with regular medical care
Baseline: 58 yrs, BMI 36, Wgt 100kg, 60% ♀
Projected trial ends in 2013-2014
Interim Results presented at the American Diabetes Association
69th Scientific Session, New Orleans, LA, 6/7/09
Intensive Lifestyle Interventions
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Meal replacements
Monthly maintenance visits – individual or group
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Months 1-6: weekly contact 3 group and 1 individual
Months 7-12: 2 group and 1 individual per month
Years 2-4: 1 individual visit per month, 1 phone/e-mail per
month, periodic refresher courses/campaigns 2-3 times per
year lasting 6 to 8 weeks
Resource toolbox including orlistat
Encourage physical activity for 175 min/week
Look AHEAD at 4 years
DSE
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1.1% weight loss
18% had 7% weight
loss
Weight loss not
“clinically significant”
No CV endpoints
ILI
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4.7% weight loss
35% had 7% weight
loss
“clinically significant
weight loss”
Look AHEAD Messages
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Meal replacements helpful in weight loss
Physical activity is key
More frequent patient contact appears to
enhance likelihood of success
BUT…
Given current provider supply (MA health
reform lesson) and access issues is the trial
frequency of contact achievable or costeffective?
BARI 2D Trial*
Patients with type 2 diabetes referred for
evaluation of CAD
 N=2368
 Randomly assigned to
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 CABG
v PCI
 Medical therapy v revascularization
 Insulin provision v insulin sensitization
Bypass Angioplasty Revascularization Investigation 2 Diabetes
NEJM, 360:2503-2525, June 11, 2009
BARI 2D Trial Conclusions
Followed for 5 years
 No significant difference medical v
revascularization and insulin provision v
sensitization
 Note - initial Rx strategy for patients with
diabetes and CAD rarely remains
constant over a 5 year treatment period
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BARI 2D Trial - Secondary
Secondary endpoints: death, MI, CVA
 Insulin-sensitizing rx associated with
fewer secondary endpoints than insulin
 CABG group (not PCI) fewer major
cardiac events than optimal medical
therapy group
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BARI 2D Trial – Take Home
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For many patient with diabetes and CAD,
optimal medical therapy is an excellent firstline strategy
When revascularization is indicated several
studies now support CABG over PCI
Comparative effectiveness of rapidly evolving
treatments is a moving target
Older Adults – Fall Prevention
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1/3 of adults >65 will fall annually
Leading cause of non fatal injuries in this age
group
Risk factor for premature death
Tai chi reduces fall risk (SOR A)
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Balance
Strength training
Well controlled HTN – OK to initiate exercise
Calcium intake -  bone density
The Prevention Gold Standard
US Preventive Services Task Force
(USPSTF)
USPSTF Background
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Department of Health & Human Services
Agency for Healthcare Research and Quality
1st convened by US Public Health Service in 1984
Moved to AHRQ in 1998
to evaluate the benefits of individual services
based on age, gender, and risk factors for disease
which preventive services should be incorporated
routinely into primary medical care and for which
populations
USPSTF Ratings 1
Grade
Definition
Suggestions for Practice
A
The USPSTF recommends the service.
There is high certainty that the net
benefit is substantial.
Offer/provide this service.
B
The USPSTF recommends the service.
There is high certainty that the net
benefit is moderate or there is
moderate certainty that the net benefit
is moderate to substantial.
Offer/provide this service.
C
The USPSTF recommends against
routinely providing the service. There
may be considerations that support
providing the service in an individual
patient. There is at least moderate
certainty that the net benefit is small.
Offer/provide this service only if other
considerations support the offering or
providing the service in an individual
patient.
USPSTF Ratings 2
D
The USPSTF recommends against
the service. There is moderate
or high certainty that the
service has no net benefit or
that the harms outweigh the
benefits.
Discourage the use of this
service.
I Statement
The USPSTF concludes that the
current evidence is insufficient
to assess the balance of
benefits and harms of the
service. Evidence is lacking, of
poor quality, or conflicting, and
the balance of benefits and
harms cannot be determined.
Read the clinical
considerations section of
USPSTF
Recommendation
Statement. If the service
is offered, patients should
understand the
uncertainty about the
balance of benefits and
harms.
USPSTF – Breast Cancer
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The USPSTF recommends screening mammography,
with or without clinical breast examination (CBE),
every 1-2 years for women aged 40 and older.
Grade: B Recommendation.
The USPSTF concludes that the evidence is
insufficient to recommend for or against routine CBE
alone to screen for breast cancer.
Grade: I Statement.
The USPSTF concludes that the evidence is
insufficient to recommend for or against teaching or
performing routine breast self-examination (BSE).
Grade: I Statement.
USPSTF – Cervical Cancer 1
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The U.S. Preventive Services Task Force (USPSTF)
strongly recommends screening for cervical cancer in
women who have been sexually active and have a cervix.
Grade: A Recommendation.
The USPSTF recommends against routinely screening
women older than age 65 for cervical cancer if they have
had adequate recent screening with normal Pap smears
and are not otherwise at high risk for cervical cancer (go to
Clinical Considerations). Grade: D Recommendation.
The USPSTF recommends against routine Pap smear
screening in women who have had a total hysterectomy for
benign disease. Grade: D Recommendation.
USPSTF – Cervical Cancer 2
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The USPSTF concludes that the evidence is
insufficient to recommend for or against the
routine use of new technologies to screen for
cervical cancer. Grade: I Statement.
The USPSTF concludes that the evidence is
insufficient to recommend for or against the
routine use of human papillomavirus (HPV)
testing as a primary screening test for cervical
cancer. Grade: I Statement.
USPSTF – Colorectal Cancer
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The USPSTF recommends screening for colorectal cancer (CRC)
using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in
adults, beginning at age 50 years and continuing until age 75
years. The risks and benefits of these screening methods
vary. Grade: A Recommendation.
The USPSTF recommends against routine screening for
colorectal cancer in adults age 76 to 85 years. There may be
considerations that support colorectal cancer screening in an
individual patient. Grade: C Recommendation.
The USPSTF recommends against screening for colorectal cancer
in adults older than age 85 years. Grade: D Recommendation.
The USPSTF concludes that the evidence is insufficient to assess
the benefits and harms of computed tomographic colonography
and fecal DNA testing as screening modalities for colorectal
cancer.
Grade: I Statement.
USPSTF – Prostate Cancer
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The USPSTF concludes that the current
evidence is insufficient to assess the balance
of benefits and harms of prostate cancer
screening in men younger than age 75 years.
Grade: I Statement.
The USPSTF recommends against screening
for prostate cancer in men age 75 years or
older. Grade: D Recommendation.
USPSTF – Vitamins (Ca & CAD)
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The U.S. Preventive Services Task Force
(USPSTF) concludes that the evidence is
insufficient to recommend for or against the
use of supplements of vitamins A, C, or E;
multivitamins with folic acid; or antioxidant
combinations for the prevention of cancer or
cardiovascular disease. Grade: I Statement.
The USPSTF recommends against the use of
beta-carotene supplements, either alone or in
combination, for the prevention of cancer or
cardiovascular disease. Grade: D
Recommendation.
Vitamin C is finally good
for more than Scurvy…
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Cohort trial of ~47,000 Men
Surveyed Vitamin C & new onset Gout
20 Years Follow up
Compared to < 250 mg/d
500-999 mg/d
RR= 0.83
1000-1499 mg/d
RR= 0.66
>/= 1500 mg/d
RR = 0.55
p<0.001
Arch Intern Med 2009 169(5): 502
USPSTF – Hormone Replacement
Therapy
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The U.S. Preventive Services Task Force
(USPSTF) recommends against the routine
use of combined estrogen and progestin for
the prevention of chronic conditions in
postmenopausal women.
Grade: D recommendation.
The U.S. Preventive Services Task Force
(USPSTF) recommends against the routine
use of unopposed estrogen for the prevention
of chronic conditions in postmenopausal
women who have had a hysterectomy.
Grade: D recommendation.
USPSTF – Osteoporosis
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The U.S. Preventive Services Task Force (USPSTF)
recommends that women aged 65 and older be
screened routinely for osteoporosis. The USPSTF
recommends that routine screening begin at age 60
for women at increased risk for osteoporotic fractures
Grade: B Recommendation.
The USPSTF makes no recommendation for or
against routine osteoporosis screening in
postmenopausal women who are younger than 60 or
in women aged 60-64 who are not at increased risk
for osteoporotic fractures. Grade: C
Recommendation.
Osteoporosis Risk Factors
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Lower body weight (weight <70 kg ) is the single best
predictor of low bone mineral density
no current use of estrogen therapy
Age
Less evidence
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smoking, weight loss, family history, decreased physical
activity, alcohol or caffeine use, or low calcium and vitamin D
intake) as a basis for identifying high-risk women younger
than 65
At any given age, African-American women on
average have higher bone mineral density (BMD)
than white women
SOME words are better
than others…
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Comparison 20 FPs; 224 Pts; P/P survey
“Is there anything else you want..”
“Is there something else you want..”
37% had > 1 concern
Intervention % Concerns Met
ANY
53.1%
SOME
90.3%
All Visit Ave: 11.4 Min +/- 5.0 Min
Ask: “Is there SOMETHING else you want to
discuss”
Heritage; JGIM 2007; 22(10): 1429
Number of New Non-Medical Users
of Medications
NSDUH
2002
Prescription Opiates
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Prescription Opioids now cause more drug
overdose deaths than cocaine and heroin
combined.
40% of teens and an almost equal number of
their parents think abusing prescription
painkillers is safer than abusing "street" drugs
FDA Fact Sheet 2008
Unintentional Pain Med Fatalities
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Opioid overdoses are
driving up the number of
accidental poisoning
deaths. Here is the
annual number of
deaths associated with
inadvertent narcotic or
hallucinogenic drug
overdoses among those
ages 15-64:
30 deaths per day by 2005
12000
8
10829
7
9615
9066
9000
6
8125
5
6000
5921 6048
3.2
3.3
6398
5
4.7
4.3
4
3.4
3
3000
2
1999
CDC National Center for Health Statistics
5.5
Deaths
2000
2001
2002
2003
2004
2005
Age-Adjusted rate per 100,000 population
What Puts Me At Risk?
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Smoking
Diabetes
High Blood Pressure
High Cholesterol
Physical Inactivity
Overweight
Family History
OK
How Do I Lower My Risk?
Don't smoke, and if you do, quit
 Aim for a healthy weight
 Get moving
 Eat for heart health
 Know your numbers. Ask your doctor to
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check your blood pressure, cholesterol (total, HDL, LDL,
triglycerides), and blood glucose.
The American Heart Association's
Nutrition Committee strongly
advises these fat guidelines for
healthy Americans over age 2:
AHA Fat Dietary Guidelines - 1
Limit total fat intake to less than 25–35
percent of your total calories each day;
 Limit saturated fat intake to less than 7
percent of total daily calories;
 Limit trans fat intake to less than 1
percent of total daily calories;
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AHA Fat Dietary Guidelines - 2
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The remaining fat should come from sources
of monounsaturated and polyunsaturated fats
such as nuts, seeds, fish and vegetable oils;
and
Limit cholesterol intake to less than 300 mg
per day, for most people. If you have
coronary heart disease or your LDL
cholesterol level is 100 mg/dL or greater, limit
your cholesterol intake to less than 200
milligrams a day.
LDL Targets
160 mg/dL is considered a high LDL.
 130 mg/dL and lower is a good target for
most healthy people.
 100 mg/dL is the target if you have other
risk factors for heart disease.
 70 mg/dL is the target if you already
have heart disease.
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True statements regarding the consumption of transfatty acids include which of the following?
1.
2.
3.
4.
5.
In the United States the main sources are
meats and dairy products
They result in a rise in LDL-cholesterol and
a reduction in HDL-cholesterol
They have been linked to vascular
inflammation and elevation of C-reactive
protein
Consumers can avoid them by consuming
foods with zero trans-fatty acids listed on
the nutrition label
Consumers should be advised to avoid
foods containing hydrogenated oils
0%
1
10
0%
0%
0%
2
3
4
0%
5
Trans Fatty Acids
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Linked their consumption to both sudden cardiac
death and the development of diabetes (Level 2
Evidence)
Increase LDL-cholesterol, reduce HDL-cholesterol,
increase serum triglycerides, and reduce the size of
the LDL particle (Level 3 Evidence)
Systemic inflammation has also been linked to the
consumption of TFAs, with increased activity of the
tissue-necrosis factor system and increases in
interleukin-6 and C-reactive protein
TFAs are formed during partial hydrogenation of
vegetable oils
Saturated
fat
Cis - Unsaturated
fat
Trans
Unsaturated
fat
http://www.badfatsbrothers.com/BFB.html
How to Lower Cholesterol
Follow a low saturated fat, low
cholesterol diet
 Be more physically active
 Lose weight if you are overweight
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Monounsaturated Fat
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remains liquid at room temperature but
may start to solidify in the refrigerator.
Foods high in monounsaturated fat
include olive, peanut and canola oils.
Avocados and most nuts also have high
amounts of monounsaturated fat.
Polyunsaturated fat
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is usually liquid at room temperature and
in the refrigerator. Foods high in
polyunsaturated fats include vegetable
oils, such as safflower, corn, sunflower,
soy and cottonseed oils.
Omega-3 fatty acids
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are polyunsaturated fats found mostly in
seafood. Good sources of omega-3s
include fatty, cold-water fish, such as
salmon, mackerel and herring.
Flaxseeds, flax oil and walnuts also
contain omega-3 fatty acids, and small
amounts are found in soybean and
canola oils.
Can measuring CRP help?
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C-reactive protein
Non-specific measure of inflammation
The infamous JUPITER trial
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Can you spell B-I-A-S?
Not routine in primary care
Limited role now
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Asymptomatic patient with strong family history
and borderline high total cholesterol and LDL
An aspirin a day…
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81mg daily recommendation dates from
primary prevention studies such as the
Framingham Heart Study
Risk reduction then in the order of 30 events
per 10,000 treated
Recent review in the Lancet (5/09) showed
nearly equal benefit and risk
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Reduce non-fatal MI by 5 per 10,000
Cause 4 bleeds per 10,000 (1 CVA, 3 GI)
Aerobic Exercise 1
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Group exercise was found to be superior to other group
activities in treating older depressed patients already on
similar pharmacotherapy (SOR B)
In a study of older men with established coronary heart
disease, light and moderate levels of physical activity (e.g.,
walking, gardening, and recreational activity) were
associated with a significant reduction in all-cause and
cardiovascular mortality rates. The benefit was seen in
men both younger and older than 65. Even those with
chest pain or severe breathlessness achieved significant
benefit from these lighter activities (SOR A)
Aerobic Exercise 2
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The American Heart Association recommended target
heart rate range for adequate aerobic exercise intensity
is 50%–75% of a patient’s maximum heart rate, or 75–
113 beats/min for 70-year-old adults. The formula used
to derive this range is 220 (maximum heart rate in young
adults) minus patient age times 0.55–0.75 (SOR C)
Data from the Centers for Disease Control and
Prevention indicate that about 28%–34% of adults aged
65–74 and 35%–44% of adults age 75 or older are
inactive, meaning they engage in no leisure-time
physical activity. Inactivity is more common in older
people than in middle-aged men and women. Women
were more likely than men to report no leisure-time
activity (SOR C).
AHA Choose To Move Program
Manage stress and weight
 Feel better about yourself
 Aim for 30 min a day
 That is about 10,000 steps!
 Lowers your risk of heart disease
 Lowers your risk of stroke
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Adding Steps!
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Take a walk with your spouse, child, or friend
Walk the dog
Use the stairs instead of the elevator
Park farther from the store
Better yet, walk to the store
Get up to change the channel
Window shop
Plan a walking meeting
Walk over to visit a neighbor
Get outside to walk around the garden or do
a little weeding
What Haven’t I Talked About…
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Vaccines
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Relationships - intimacy
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Tdap
Boostrix®, Adadel®
HPV
Gardasil®
9-26
Zoster
Zostavax® >60
Pneumococcal Pneumovax®
Influenza
many brands
Longevity – deathbed wish
Life in Primary Care in 2009
2009 Life as a “PCP”
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Evidence based care
Pay for performance
Physician scorecards
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Prescribing practices
Carve outs – MH and SA
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GIC in Massachusetts
Quality and Cost
“Black box” thinking
REACH OUT – COORDINATE CARE!
What About
Chocolate?
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A study at Penn State University found
that people who ate lots of chocolate
had higher anti-oxidant levels in their
blood and lower levels of LDLcholesterol – the type that in implicated
in hardening of the arteries
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Cocoa seems to keep down the blood
pressure of the Kuna Indians who live
off the coast of Panama and eat lots of
locally grown cocoa that is high in
flavenoids.
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At Brigham and Women’s Hospital in
Boston, volunteers had less arterial
stiffness after consuming 100 grams of
good quality , plain chocolate.
Researchers speculate that cocoa helps
dilate blood vessels, improves kidney
function, and lowers blood pressure.
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At the University of California,
volunteers ate 25 grams of semi-sweet
chocolate. Two and six hours later, the
platelets of the chocolate eating group
took significantly longer to close an
opening compared with those of a
control group who ate bread.
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Researchers concluded that eating
small amounts of chocolate could have
the same anti-clotting effect as aspirin
and might reduce the risk of deep vein
thrombosis when flying.
Thank You!
[email protected]
Question References - Obesity
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Michigan Quality Improvement Consortium: Prevention and identification
of childhood overweight. Michigan Quality Improvement Consortium, 2006.
Council on Sports Medicine and Fitness; Council on School Health: Active
healthy living: Prevention of childhood obesity through increased physical
activity. Pediatrics 2006;117(5):1834-1842.
Krebs NF, Jacobson MS, American Academy of Pediatrics Committee on
Nutrition: Prevention of pediatric overweight and obesity. Pediatrics
2003;112(2):424-430.
NHLBI Obesity Education Initiative Expert Panel on the Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults; North
American Association for the Study of Obesity Practical Guide
Development Committee: Obesity: The Practical Guide: Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI
Obesity Education Initiative, North American Association for the Study of
Obesity, 2000, NIH pub no 00-4084.
Question References – Falls
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Falls among older adults: An overview. Centers for Disease
Control and Prevention, 2007.
Li F, Harmer P, Fisher KJ, et al: Tai chi and fall reductions
in older adults: A randomized controlled trial. J Gerontol A
Biol Sci Med Sci 2005;60(2):187-194.
Verhagen AP, Immink M, van der Muelen A, et al: The
efficacy of Tai Chi Chuan in older adults: A systematic
review. Fam Pract 2004;21(1):107-113.
Guideline for the prevention of falls in older persons.
American Geriatrics Society, British Geriatrics Society, and
American Academy of Orthopaedic Surgeons Panel on
Falls Prevention. J Am Geriatr Soc 2001;49(5):664-672.
Question References - Exercise
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Mather AS, Rodriguez C, Guthrie MF, et al: Effects of
exercise on depressive symptoms in older adults with
poorly responsive depressive disorder: Randomised
controlled trial. Br J Psychiatry 2002;180:411-415.
Wannamethee SG, Shaper AG, Walker M: Physical
activity and mortality in older men with diagnosed
coronary heart disease. Circulation
2000;102(12):1358-1363.
American Heart Association: Target heart rates. AHA
recommendation.
Agency for Healthcare Research and Quality, Centers
for Disease Control and Prevention: Physical activity
and older Americans: Benefits and strategies. 2002.
Health Maintenance Resources
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What’s New in Preventive Services –AHRQ
www.ahrq.gov/clinic/prevnew.htm
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US Preventive Services Task Force – Home
www.ahrq.gov/clinic/uspstfix.htm
USPDF Topic List
www.ahrq.gov/clinic/uspstf/uspstopics.htm
Oral Health
www.smilesforlife2.org/home.html