September/October 2013 Annals of Family Medicine Tip Sheet

(Press-News.org) One-third of Walgreens Vaccinations Are Administered During Off-Clinic Hours, Implications for Improving Vaccination Access and Convenience With adult and adolescent vaccination rates below national goals, this study of more than six million vaccinations administered in more than 7,500 Walgreens pharmacies across the United States identifies a potentially important public health impact pharmacies can make by providing vaccines during convenient times that expand access to particular groups of people. Analyzing data on 6,250,402 vaccines administered at the pharmacy chain over the course of a year, researchers found 31 percent were provided during off-clinic hours: 17 percent were provided on weekends, 10 percent on weekday evenings and 3 percent on federal holidays. Younger, working-aged, healthy adults, in particular had higher odds of accessing a variety of vaccinations during off-clinic hours when traditional providers are not likely available. Specifically, patients had significantly higher odds of off-clinic vaccination if they were younger than 65 years of age, male, resided in an urban area and did not have any chronic conditions. The authors conclude allowing patients to seek and receive vaccinations at times that are most convenient to them, often when medical offices are closed, could measurably increase immunization rates in the United States. They call for expanding the ability of pharmacists to administer all vaccines in all states by standing orders coupled with expanded hours of operation. Vaccinations Administered During Off-Clinic Hours at a National Community Pharmacy: Implications for Increasing Patient Access and Convenience By Jeffery A. Goad, PharmD, MPH, et al
University of Southern California, Los Angeles Note: Three of the four co-authors are employees of Walgreen Co; Dr. Goad serves on the speaker's bureau for Merck and Co. Inc.

Eligible Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Expansion Are As Healthy or Healthier Than Current Beneficiaries, Expenditures May Not Be As High As Projected The potentially eligible Medicaid population under the Patient Protection and Affordable Care Act-financed Medicaid expansion is similarly healthy as — if not healthier than — the current Medicaid population, according to a new study from researchers out of the University of Michigan. The exception to this general theme is that tobacco smoking and alcohol use patterns are higher among potential Medicaid enrollees than for current Medicaid beneficiaries. Specifically, the analysis of the most recently available nationally representative data on an estimated 13.8 million current and 13.6 million eligible Medicaid beneficiaries indicates eligible adults are expected to have better health status (35 percent "excellent" or "very good," 40 percent "good") than current beneficiaries (34 percent "excellent" or "very good," 32 percent "good"). Additionally, the proportion of potentially eligible beneficiaries who are obese and with depression is significantly lower than current beneficiaries (35 percent vs. 43 percent and 16 percent vs. 22 percent, respectively). They found no significant differences in the expected prevalence of diabetes or hypertension. Current tobacco smoking (49 percent vs. 38 percent) and moderate and heavy alcohol use (22 percent vs. 16 percent and 17 percent vs. 10 percent, respectively) are more common among the potentially eligible population than among current beneficiaries. These findings suggest that federal Medicaid expenditures for newly covered beneficiaries may not be as high as projected by the Congressional Budget Office in the short term, thereby reducing spending anticipated with implementation of the ACA. Given the higher prevalence of tobacco smoking and alcohol use, however, the authors point to the need for broad enrollment and engagement of this potentially eligible population to address their higher prevalence of modifiable risk factors for future chronic disease. Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries
By Tammy Chang, MD, MPH, et al
University of Michigan, Ann Arbor

Editorial: The Full Impact of the ACA Will Not Be Realized Due to Fundamental Problems in the Way the U.S. Health System is Organized and Paid Reviewing the objectives of the Affordable Care Act and analyzing the likely outcomes in light of the imperfect hand of the U.S. health care market, J.B. Silvers, PhD, a health care economist at Case Western Reserve University, concludes it is unlikely the potential for higher value care efficiently provided in the best location at a fair competitive price will be fully realized. He outlines several reasons for this potential shortfall, including problems with how the U.S. health system is organized and paid, the information and choices available, and the pressures and the incentives that persist. He argues that although the ACA will make the insurance market more competitive, open and fair in access and cost, impediments in the provider and supplier sectors will restrict its impact on the structure of the system and the delivery of care. If public policy is to succeed, he asserts, it will be necessary to correct for market failure. The Affordable Care Act: Objectives and Likely Results in an Imperfect World
By J.B. Silvers, PhD
Case Western Reserve University, Cleveland, Ohio

Editorial: ACA Implementation and Three Urgent Tasks for Family Medicine Drawing on his experience researching and drafting health workforce provisions that ended up in the Affordable Care Act, family physician Daniel J. Derksen, MD, highlights three urgent tasks for family physicians and public health advocates that must be accomplished for the ACA to be effective. First, he calls for the development of new health care delivery models emphasizing integrated, community-based care, as well as the expansion of primary care training programs to ensure access as 25 million uninsured gain coverage. Additionally, he calls for active outreach efforts to help the eligible uninsured population enroll for coverage, with particular emphasis on rural and medically underserved areas and populations. Lastly, he calls on policymakers to ensure prevention, public health and primary care are adequately funded. He asserts that family physicians and public health advocates are uniquely positioned to play a key leadership role in addressing these challenges. The Affordable Care Act: Unprecedented Opportunities for Family Physicians and Public Health
By Daniel J. Derksen, MD
Mel and Enid Zuckerman College of Public Health
University of Arizona, Tucson

Essay: Medical Homes Should Play a More Active Role in Helping Patients Obtain and Retain Health Insurance Coverage A family physician reflects on the potential of primary care medical homes to partner with patients to reduce preventable mortality by helping them find and keep health insurance coverage, asserting that ensuring all patients have the best and most continuous coverage available to them under existing and newly expanded programs may be as (or more) important than ensuring all patients have optimal blood pressure control, diabetes control or timely cancer screenings. DeVoe outlines how basic tenets from the chronic care model can be operationalized to build systems that treat the United States' large "uninsurance" problem. Primary care clinicians, she argues, are in a position to see how lack of insurance negatively affects health, and she calls for the development of effective processes and tools within the medical home to help patients obtain health insurance, retain their coverage or make important health insurance coverage decisions. Health care financing, she argues, should no longer be separate from the delivery of health care services. She concludes that by adopting uninsurance and underinsurance as a chronic illness, and applying the tenets and tools of the chronic care model to treat it, medical homes have the opportunity to improve population health and make a positive difference in the lives of patients. Being Uninsured is Bad for Your Health: Can Medical Homes Play a Role in Treating the Uninsurance Ailment?
By Jennifer E. DeVoe, MD, DPhil
Oregon Health & Science University, Portland

Systematic Review: Cinnamon May Be Beneficial for Diabetic Patients but Dosing Uncertain Consumption of cinnamon is associated with a statistically significant decrease in levels of fasting plasma glucose, total cholesterol, low-density lipoprotein cholesterol and triglyceride, and an increase in high-density lipoprotein cholesterol. A meta-analysis of 10 randomized controlled trials evaluating the effects of cinnamon use in 543 patients with type 2 diabetes at doses of 120 mg/d to 6 g/d for four to 18 weeks found reduced levels of fasting plasma glucose (-24.6 mg/dL; 95 percent CI, -40.5 to -8.7), total cholesterol (-15.6 mg/dL, -29.8 to -1.4), LDL-C (-9.4 mg/dL; 95 percent CI, -17.2 to -1.6) and triglycerides (-29.6 mg/dL; 95 percent CI, -48.3 to -10.9). Cinnamon also increased levels of HDL-C (1.7mg/dL; 95 percent CI, 1.1 to 2.2). No significant effect on hemoglobin A1c levels was seen. High degrees of heterogeneity were present for all analyses except HDL-C. Despite the generally positive results, the authors advise caution in applying the results of this analysis to patient care because of the uncertainty of the dose and duration of cinnamon use and uncertainty of the ideal patient population. Cinnamon Use in Type 2 Diabetes: An Updated Systematic Review and Meta-Analysis
By Olivia J. Phung, PharmD, et al
Western University of Health Sciences, Pomona, Calif.

Mindful Physicians Have More Satisfied Patients Physicians rating themselves as more mindful — nonjudgmentally attentive to their own experience, thoughts and feelings — have more patient-centered communication and more satisfied patients. Measuring the mindfulness of 45 clinicians and later assessing the quality of their interactions with patients infected with the human immunodeficiency virus, researchers found mindful clinicians were more likely to be patient-centered in their communications, more positive in their emotional tone with patients and more likely to be rated highly on communication and overall satisfaction by patients. The authors conclude mindfulness may be an important pathway to a more humanistic, effective and satisfying practice of medicine. The highly reciprocal influence of patients and clinicians on one another, they add, is in itself a powerful and positive medical tool — perhaps in some situations more powerful than other interventions that can be offered to patients. They call for future research to determine whether improving clinician mindfulness can also improve patient health outcomes. A Multicenter Study of Physician Mindfulness and Health Care Quality
By Mary Catherine Beach, MD, MPH, et al
Johns Hopkins University, Baltimore, Md.

Pilot Study Shows Promising Effect of Brief Mindfulness Course on Physician Job Satisfaction and Well-Being Given the pervasive problem of physician burnout and low job satisfaction and its negative influence on patient care, researchers evaluate the ability of a short mindfulness training program to increase job satisfaction, quality of life and compassion among 30 primary care clinicians. In this uncontrolled pilot study, they find participating in a brief mindfulness course consisting of a weekend immersion along with two short follow-up evening sessions was associated with reduction in indicators of job burnout, depression, anxiety and stress on three follow-up surveys at one day, two months and nine months post-intervention. Specifically, at nine months post-intervention, participants had significantly better scores on all Maslach Burnout Inventory subscales, emotional exhaustion (P=.009), depersonalization (P=.005), and personal accomplishment (P END