Disparities in Rural Tobacco Use, Smoke-Free Policies, and Tobacco Taxes.

Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing's voice is respected and can be powerful.

Systems change to improve tobacco use identification and referral in the chiropractic setting: a pilot study.

Background: Tobacco use remains a leading cause of death and disability in the United States. Health professionals need to address the use of tobacco products by their patients, but chiropractic clinical systems often remain unsupported and underappreciated in their role to facilitate tobacco use cessation. Methods: This pilot study tested an intervention to assist a chiropractic community to implement sustainable health systems changes for tobacco use based on U.S. Public Health Service guidelines. Chiropractors were educated on the Ask, Advise, Refer (AAR) approach, provided with ongoing guidance, and followed for six months to assess systems change. The study was conducted from March 2016 to July 2017. Results: Evidence of a systematic process in place to conduct AAR was present in all clinics by the end of the fourth month of the intervention period. Although no clinic had sustained health system change for full AAR, all six of the clinics made progress in the individual AAR components. Furthermore, five clinics achieved sustained system change for the Ask component, as after systems change was achieved, the rate of tobacco user identifications did not drop below 50%. For the Advise component, five clinics succeeded in having individual months of ≥50% of tobacco users being advised, and three clinics achieved the formal definition of systems change. For the Refer component, no clinic achieved system change, although four had individual months of ≥50% of tobacco users being referred. The patient quit rate was 13.3% (n = 15) for the 30-day follow-up and 16.7% (n = 6) for the three-month follow-up. Conclusions: This study demonstrates the feasibility of implementing a health systems change in the chiropractic setting to identify tobacco users, to advise them to quit, and to refer users for cessation services.

Description of tobacco use and cessation among Bhutanese refugees participating in a tobacco cessation program.

OBJECTIVES: To compare the tobacco use, exposure, and cessation differences between Bhutanese refugee and non-Hispanic Caucasian tobacco users in a US federally qualified health center tobacco cessation program. DESIGN: A retrospective cohort study reviewing data from 374 patients counseled on tobacco cessation was performed. Demographic information, tobacco use history, exposure to tobacco, and type of tobacco used characterized baseline assessments. The patient record was followed forward in time to evaluate tobacco cessation outcomes as the dependent variable. Data were analyzed using odds ratios and the Mann-Whitney U-test. RESULTS: Data analysis included 318 patients (211 non-Hispanic Caucasian patients and 107 Bhutanese refugee patients). Bhutanese refugees demonstrated a higher likelihood of smokeless tobacco product use than the non-Hispanic Caucasian population (67.3% vs 1%, OR = 214.971, 95% CI 50.429, 916.383), and a greater odds of having household tobacco users (OR = 2.533, 95% CI 1.532, 4.186). Likewise, the non-Hispanic Caucasian population exhibited larger odds of smoking cigarettes vs the Bhutanese population (97.2% vs 26.2%, OR = 96.399, 95% CI 38.449, 241.687), had a higher odds of passive smoke exposure (OR = 12.765, 95% CI 5.36, 30.393), and higher likelihood of a past quit attempt (OR = 9.037, 95% CI 5.180, 15.765). Significant gender differences with regard to type of tobacco used were noted among Bhutanese refugees. Bhutanese refugees demonstrated significantly higher likelihood of tobacco cessation, compared with the non-Hispanic Caucasian population, at all length cutpoints, while showing no difference in number of follow-up visits or median time followed. CONCLUSION: These culture-specific findings, showing unique tobacco use characteristics and increased cessation among the Bhutanese refugee population, provide novel information helpful to professionals identifying and treating these individuals for tobacco cessation. More research is needed to confirm our results and findings.

Depression Screening in Diabetes Care to Improve Outcomes: Are We Meeting the Challenge?

PURPOSE: Evidence-based guidelines recommend regular depression screening among individuals with type 2 diabetes mellitus (T2DM). The purpose of this study is to examine depression screening patterns among a primary care population with T2DM, through use of the Patient Health Questionnaire-9 (PHQ-9). METHODS: In total, 1817 patients with T2DM were analyzed through a retrospective observational study at 2 sites, a regional health center and a federally qualified health center (FQHC). The T2DM sample was divided into those with and without a major depressive disorder (MDD) diagnosis. Depression screening rates and depression severity were assessed through the PHQ-9. RESULTS: Both sites had higher rates of PHQ-9 screening among individuals with a history of MDD (64.82%) vs those without MDD (11.39%). Individuals from the FQHC without a history of depression had a higher mean PHQ-9 score (10.11) than those with a previous MDD diagnosis at both RHS and FQHC (7.16 and 9.85, respectively). CONCLUSIONS: Depression screening rates among individuals with diabetes and no history of MDD were remarkably low. Patients with diabetes but no MDD diagnosis who sought health care at a FQHC clinic had more depressive symptoms than those with a history of MDD at both sites. Individuals with diabetes and who have a MDD diagnosis are much more likely to receive regular depression screening than those without MDD, which leaves a substantial proportion of patients with undetected depression. Depression screening must be enhanced for all individuals with diabetes, particularly for low-income individuals and those without a previous diagnosis of MDD.

Disease Control Among Patients With Diabetes and Severe Depressive Symptoms.

OBJECTIVE: Major depressive disorder and type 2 diabetes commonly co-occur and disease control tends to be poorer when both conditions are present. However, little research has examined the disease characteristics of patients with diabetes and more severe depressive symptoms. METHODS: We report a retrospective observational study of 517 patients with diabetes from 2 primary care centers. Patients with diabetes and moderately-severe/severe depression symptoms (Patient Health Questionnaire [PHQ-9] score >15) were compared with patients with diabetes without moderate or severe depression symptoms (PHQ-9 score <15; the comparison group) with regard to control of diabetes, blood pressure, and lipid parameters. Frequency of HbA1c and PHQ-9 testing were also examined. RESULTS: Patients with diabetes and moderately severe/severe depressive symptoms had higher HbA1c (7.56% vs. 7.09%), diastolic blood pressure (78.43 vs. 75.67 mm Hg), and low-density lipoprotein cholesterol (109.12 vs. 94.22 mg/dL) versus the comparison group. Patients with diabetes and moderately-severe/severe depression underwent HbA1c and PHQ-9 testing with similar frequency to the comparison group. CONCLUSIONS: The presence of moderately severe/severe depressive symptoms was associated with poorer glucose, lipid, and blood pressure control among patients with diabetes. Further research should prospectively examine whether a targeted depression treatment goal (PHQ-9 score <15) in patients with diabetes results in improved control of these important disease parameters.

Use of the 9-Item Patient Health Questionnaire for Depression Assessment in Primary Care Patients With Type 2 Diabetes.

The purpose of the current study was to assess the frequency and distribution of the 9-Item Patient Health Questionnaire (PHQ-9) among individuals with type 2 diabetes with and without depression. The current case-control study used electronic medical record data from two primary care institutions. The sample was divided into cases with coexisting depression and type 2 diabetes and controls without depression. Data included demographics, biomarkers, number of services delivered, and clinic visits in 2013. Similar PHQ-9 use was seen between unique primary care practices. However, less than one third of patients at either site received depression screening with the PHQ-9 in 2013. Male and older adult patients were less likely to receive assessment. Guideline ambiguity and lack of accountability in primary care practice has made the use of depression metrics arbitrary in diabetic populations at risk for depression. To assure adequate care provision, it is imperative that proven tools for assessing depressive symptoms are used.

Evaluation of health literacy tools for correct prescription understanding.

OBJECTIVES: To evaluate two brief health literacy prediction tools for understanding of a prescription label and using a drug correctly. METHODS: Patients who visited the Family HealthCare Pharmacy were asked to complete the Newest Vital Sign (NVS) and Rapid Estimate of Adult Literacy in Medicine (REALM-R) and to interpret a prescription medication label. Each patient received a bottle of amoxicillin suspension with one of four prescription labels randomly varied in directions for frequency and amount. Patients were also asked to calculate the days' supply and demonstrate their ability to draw up the required dose using an oral syringe. RESULTS: A total of 150 patients consented to participate. Only the NVS score was associated with ability to fully interpret the label correctly. Neither tool was related to ability to draw up the correct amount using an oral syringe but both had some correlation to successfully calculating the days' supply provided. The NVS and REALM-R literacy scores had a modest correlation with each other. CONCLUSION: The NVS may be useful in predicting prescription label understanding and a patient's ability to do a simple dosage calculation. Neither the NVS nor the REALM-R correlated well with ability to draw an amount using an oral syringe correctly.

Medication therapy management: teaming with pharmacists for improved patient care.

Medication therapy management (MTM) is a patient-centered, comprehensive method for improving medication use and is required for eligible beneficiaries under Medicare Part D. Physician assistants (PAs) play a pivotal role in reviewing and approving medication recommendations from pharmacists, as well as referring patients for MTM services.

Economic impact of a pharmacy resident in an assisted living facility-based medication therapy management program.

BACKGROUND: Pharmacists now have the opportunity to be reimbursed for providing medication therapy management (MTM) services. With 5% of the elderly population living in senior housing such as assisted living facilities, MTM programs need to be evaluated in this setting. OBJECTIVE: To evaluate the economic impact of a postgraduate year 1 (PGY1) pharmacy practice resident's interventions while performing MTM in an assisted living facility. METHODS: We conducted a prospective, evaluative study at an assisted living facility over 184 days. Patients included in the study were aged 57-100 years. MTM visits were performed by the PGY1 resident, based on the American Pharmacists Association consensus definition of the model of MTM services. The pharmacy resident prospectively collected data, including interventions made and patient demographics. Drug therapy recommendations were categorized and assessed for cost savings and acceptance by a primary care provider. RESULTS: Fifty-three patients were enrolled in the study (mean age 85.3 y). Patients were taking an average of 12 medications (prescription and nonprescription). The pharmacy resident made 125 recommendations to primary care providers; 72 of those were addressed and 90.3% of addressed recommendations were accepted. The largest category to elicit drug therapy recommendations was dose appropriateness. Of the 72 addressed recommendations, 17 (23.6%) resulted in direct cost savings totaling $3774. Costs that accrued as a result of drug therapy recommendations totaled $693. The resultant net cost-benefit was $1550, with a benefit-to-cost ratio of 1.7 and a return on investment of 70%. CONCLUSIONS: Our study demonstrates the positive value that a PGY1 pharmacy resident has on an assisted living-based MTM program, with respect to a positive drug-related cost-benefit and drug therapy recommendation acceptance.