How Physicians Should Respond to Climate Change.

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

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

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

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

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

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

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

A survey of African American physicians on the health effects of climate change.

The U.S. National Climate Assessment concluded that climate change is harming the health of many Americans and identified people in some communities of color as particularly vulnerable to these effects. In Spring 2014, we surveyed members of the National Medical Association, a society of African American physicians who care for a disproportionate number of African American patients, to determine whether they were seeing the health effects of climate change in their practices; the response rate was 30% (n = 284). Over 86% of respondents indicated that climate change was relevant to direct patient care, and 61% that their own patients were already being harmed by climate change moderately or a great deal. The most commonly reported health effects were injuries from severe storms, floods, and wildfires (88%), increases in severity of chronic disease due to air pollution (88%), and allergic symptoms from prolonged exposure to plants or mold (80%). The majority of survey respondents support medical training, patient and public education regarding the impact of climate change on health, and advocacy by their professional society; nearly all respondents indicated that the US should invest in significant efforts to protect people from the health effects of climate change (88%), and to reduce the potential impacts of climate change (93%). These findings suggest that African American physicians are currently seeing the health impacts of climate change among their patients, and that they support a range of responses by the medical profession, and public policy makers, to prevent further harm.

Strategies for expanding colorectal cancer screening at community health centers.

Community health centers are uniquely positioned to address disparities in colorectal cancer (CRC) screening as they have addressed other disparities. In 2012, the federal Health Resources and Services Administration, which is the funding agency for the health center program, added a requirement that health centers report CRC screening rates as a standard performance measure. These annually reported, publically available data are a major strategic opportunity to improve screening rates for CRC. The Patient Protection and Affordable Care Act enacted provisions to expand the capacity of the federal health center program. The recent report of the Institute of Medicine on integrating public health and primary care included an entire section devoted to CRC screening as a target for joint work. These developments make this the ideal time to integrate lifesaving CRC screening into the preventive care already offered by health centers. This article offers 5 strategies that address the challenges health centers face in increasing CRC screening rates. The first 2 strategies focus on improving the processes of primary care. The third emphasizes working productively with other medical providers and institutions. The fourth strategy is about aligning leadership. The final strategy is focused on using tools that have been derived from models that work.

Promoting cancer screening within the patient centered medical home.

While consensus has grown that primary care is the essential access point in a high-performing health care system, the current model of primary care underperforms in both chronic disease management and prevention. The Patient Centered Medical Home model (PCMH) is at the center of efforts to reinvent primary care practice, and is regarded as the most promising approach to addressing the burden of chronic disease, improving health outcomes, and reducing health spending. However, the potential for the medical home to improve the delivery of cancer screening (and preventive services in general) has received limited attention in both conceptualization and practice. Medical home demonstrations to date have included few evidence-based preventive services in their outcome measures, and few have evaluated the effect of different payment models. Decreasing use of hospitals and emergency rooms and an emphasis on improving chronic care represent improvements in effective delivery of healthcare, but leave opportunities for reducing the burden of cancer untouched. Data confirm that what does or does not happen in the primary care setting has a substantial impact on cancer outcomes. Insofar as cancer is the leading cause of death before age 80, the PCMH model must prioritize adherence to cancer screening according to recommended guidelines, and systems, financial incentives, and reimbursements must be aligned to achieve that goal. This article explores capacities that are needed in the medical home model to facilitate the integration of cancer screening and other preventive services. These capacities include improved patient access and communication, health risk assessments, periodic preventive health exams, use of registries that store cancer risk information and screening history, ability to track and follow up on tests and referrals, feedback on performance, and payment models that reward cancer screening.

Colorectal cancer is an Ambulatory Care Sensitive Condition.

Ambulatory Care Sensitive Conditions (ACSC) are conditions where the provision of ambulatory care may affect the probability of hospitalization or the severity of the disease at the time of hospitalization. Population-based measurement of ACSCs can focus attention on aspects of ambulatory care that merit strengthening to improve access, quality, or patient compliance to achieve better outcomes and reduce costs. If colorectal cancer was added to the list of ACSCs, it would highlight the continuum of care that starts in the ambulatory setting and includes risk assessment as well as access to colonoscopy, which is the only means of adenoma removal after a positive screen. Each link in the continuum of care can increase or reduce the rates of colorectal cancer incidence and mortality at the local and national levels. Employing colorectal cancer as an ACSC at the hospital level or state level can provoke policy makers and managers to examine these links for gaps and weaknesses that merit attention and may be addressed.

The effect of HEDIS measurement of colorectal cancer screening on insurance plans in Pennsylvania.

OBJECTIVE: To determine the effect of Healthcare Effectiveness Data and Information Set (HEDIS) measurement of colorectal cancer (CRC) screening on insurance plans in Pennsylvania. STUDY DESIGN: Natural experiment tracking changes in CRC screening policies. METHODS: Survey data were collected in 2006 on screening policies of 13 Pennsylvania commercial insurers offering 37 plans. All companies that met the inclusion criteria were surveyed. Medical directors answered questions about how HEDIS measures affected plan benefit designs. Responses were analyzed using descriptive statistics. RESULTS: All companies responded and focused their responses on a particular plan as requested, including 2 health maintenance organizations, 3 point-of-service plans, 2 fee-for-service plans, and 6 preferred provider organizations. The survey results indicated that 39% of plans revised their screening guidelines, 46% established new or updated reminder systems, and 46% established new systems for tracking screening rates. Although only the health maintenance organization plans were linked to HEDIS with formal reporting, all types of plans reported changes that they attributed to the HEDIS measure. CONCLUSION: The establishment of the new HEDIS measure on screening for CRC has been associated with changes in health plan policies and practices in Pennsylvania.

How to increase colorectal cancer screening rates in practice.

A recommendation from a physician is the most influential factor in determining whether a patient is screened for colorectal cancer. While the vast majority of primary care physicians report that they screen for colorectal cancer, many patients do not receive the recommendation they need. Evidence-based strategies can help the physician ensure that every appropriate patient leaves the office with the needed recommendation. Choosing an office system that can be implemented by the physician or office staff can fuel efforts to achieve higher screening rates. Reminder systems, tracking systems, communication strategies, and policies that reinforce use of evidence-based guidelines may contribute.

Choice of screening modality in a colorectal cancer education and screening program for the uninsured.

BACKGROUND: Starting in 2001, the state of Maryland established a carefully planned and executed multicomponent intervention to reduce mortality and disparities in colorectal cancer. METHODS: In the most populous county, uninsured participants received education and a choice of free screening by fecal occult blood testing (FOBT) or colonoscopy or both. RESULTS: Over 2 years, a group of 1,672 uninsured individuals, of whom 90% were minorities, registered with the program. Overall, screening uptake was 41% with colonoscopy, 10% with FOBT, and 10% with both FOBT and colonoscopy. CONCLUSION: The choices of colorectal cancer screening modalities by a diverse uninsured population demonstrates the importance of maintaining screening options.

Uptake of colorectal cancer screening in an uninsured population.

BACKGROUND: Montgomery County established a colorectal cancer education, screening, and treatment program as part of the Maryland state cancer program. The program removed barriers to screening by providing free endoscopy (predominantly colonoscopy) to uninsured county residents. METHODS: The education component was available to the general public and included distribution of free fecal occult blood cards (FOBTs). The clinical component was available only to the low-income uninsured. Clinical program participants met with a registered nurse who provided education, made endoscopy (colonoscopy) referrals, and provided case management. County residents entered the program in three ways: by direct referral from a physician, after contact with a health educator, or via telephone. RESULTS: Over 2 years, 1672 uninsured individuals registered with the program, of whom 13% had prior screening. In this group, 52% completed screening with at least one modality, the majority by colonoscopy. CONCLUSION: This program is one of the first in the nation to offer uninsured individuals free access to colonoscopy mediated by nurse referral and case management. It provides an experience that can inform interventions of experimental design in which the uptake of the options for colorectal cancer screening are compared; or it can serve as a "benchmark" against which other efforts to screen uninsured minority populations may be compared.

Use of a patient assistant to facilitate medical visits for Latino patients with low health literacy.

In the face of limited resources, evidence-based prioritization is needed to maximize the reach of health services for the underserved. A medical referral project that referred low income uninsured individuals to discounted appointments with office-based doctors found that some Latino patients had difficulty in taking advantage of these appointments. These individuals appeared to face barriers beyond the cultural and linguistic barriers faced by most patients in the project. One additional bilingual staff person, a Patient Assistant, was hired to facilitate doctor visits by these patients. The Patient Assistant performed the duties of a navigator, trouble shooter, and interpreter--and assisted with communications. The project staff derived a screening question to encourage patients to identify themselves as those who would need the help of the Patient Assistant. These patients were subsequently questioned in a waiting room survey designed to characterize them. The characteristics of these patients were compared with a comparison group of project patients. The target group and the comparison group differed in their levels of education. Sixty percent of the target group had less than 4 years of schooling compared to 13% of the comparison group. The target group was comprised entirely of immigrants from South and Central America. This report underscores the conclusions of the recent report of the Institute of Medicine on the problem of health literacy--patients' ability to understand and act in their own interest--and highlights the needs of Latin American immigrants who are burdened by cultural and linguistic barriers, low health literacy, and minimal education.