1. Overview of Health in Eastern NC

Objectives: To understand the broad patterns of health and illness in Eastern NC

Core Readings:

1. State Center for Health Statistics and Office of Minority Health and Health Disparities. NC Minority Health Facts: African Americans. July 2010. http://www.schs.state.nc.us/SCHS/pdf/AfricanAmer_FS_WEB_080210.pdf 2. State Health Facts: http://www.statehealthfacts.org/profileind.jsp?cat=2&rgn=35 Interactive website that allow you to see a wide range of health statistics for North Carolina 3. Review the following tables and maps, with attention to how Edgecombe and Nash counties and the region surrounding the Bloomer Hill community fit in with the rest of the state. http://www.schs.state.nc.us/SCHS/data/minority.cfm North Carolina mortality statistics by county, 2010: Use this interactive site: http://www.schs.state.nc.us/schs/deaths/lcd/2010 All Causes Heart Disease Cerebrovascular Disease Cancer Diabetes HIV Kidney Disease - Hospitalizations for asthma - North Carolinians without health insurance - Physicians per 10,000 population - Percent of persons in poverty - Unemployment rate

Key points:

1. Residents of eastern NC have high rates of chronic illness such as cardiovascular disease, diabetes, and kidney disease. 2. Many of these illnesses are preventable. 3. Social, political, and economic factors have contributed to poor health, especially among African Americans.

Thought Questions:

1. How do economic and political forces contribute to poor health? 2. What interventions might improve health for the people who come to our clinics? 3. How could we better reach those patients with greatest need? 2. Hypertension

Objectives: To understand the impact of hypertension on health and the ways to reduce the burden of disease.

Core Readings:

1. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 Express). http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf 2. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 2004;114:555-576. PMID 15286277. http://pediatrics.aappublications.org/cgi/reprint/114/2/S2/555

Supplemental Readings:

1. Drugs for hypertension. Treatment Guidelines from the Medical Letter 2009; 7(77). PMID 19107095. (review tables to see comparison of costs of different antihypertensive agents) http://medlet-best.securesites.com.libproxy.lib.unc.edu/restrictedtg/t77.html 2. Fiscella K, Holt K. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med 2008;6:497-502. PMID 19001301. http://www.annfammed.org/cgi/reprint/6/6/497

Key Points:

1. Hypertension is an important cause of heart disease, stroke and kidney failure, particularly in African Americans. 2. Hypertension is usually asymptomatic, so many patients are unaware that they have hypertension. 3. Treatment with lifestyle modification and drugs can improve high blood pressure and reduce its negative consequences.

Thought Questions:

1. What do the patients you meet believe/know about high blood pressure? (ask them) 2. How does the economy of food production/sales contribute to hypertension? 3. How has hypertension affected the patients you meet in clinic? (ask them)

Last updated 8/6/12 3. Diabetes

Objectives: To understand the burden of disease from diabetes.

Core Readings:

1. US Preventive Services Task Force. Screening for Type 2 Diabetes Mellitus in Adults: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2008;148:855-68. PMID: 18519930. http://www.annals.org/cgi/reprint/148/11/846.pdf 2. Rispin CM, Kang H, Urban RJ. Management of blood glucose in type 2 diabetes mellitus. Am Fam Physician 2009;79:29-36. PMID: 19145963. http://www.aafp.org/afp/20090101/29.html

1. Drugs for Type 2 Diabetes. Treatment Guidelines from the Medical Letter 2008; 6(71). PMID: 18583949. (review tables to see comparison of costs of different agents) http://medlet- best.securesites.com.libproxy.lib.unc.edu/restrictedtg/t71.pdf

Key Points:

1. Diabetes is a major health problem in Eastern NC. 2. Diabetes leads to heart disease and stroke, as well as blindness, amputations and kidney failure. 3. Control of blood glucose and other cardiovascular risk factors can reduce the burden of disease.

Thought Questions:

1. How has diabetes affected your patients and their families? (ask them) 2. What more can we do to reduce the impact of diabetes at our clinic? 3. What diabetes care resources are available for low income patients?

Last updated 10/1/12 4. Cholesterol and Global CVD Risk

Objectives:

1. To understand the role of cholesterol disorders in heart disease and stroke. 2. To develop a cost-effective strategy for detecting and treating cholesterol disorders. 3. To understand how estimating global risk of cardiovascular disease can aid in decisions about preventive therapies.

Core Readings:

1. US Preventive Services Task Force. Screening for Lipid Disorders in Adults: Recommendation Statement. 2008.

1. Viera AJ, Sheridan SL. Global risk of coronary heart disease: assessment and application. Am Fam Physician. 2010;82:265-274. http://www.aafp.org/afp/2010/0801/p265.html 2. med-decisions.com cardiovascular risk calculator

Key Points:

1. Heart disease is the leading cause of death in the US. 2. Cholesterol disorders account for 25-33% of heart disease in the US. 3. Screening with non-fasting total cholesterol and HDL is the most effective way to detect lipid disorders. Treating people at high risk (>1% per year) of heart attacks with statin drugs will reduce events by 30%.

Thought Questions:

1. Should we screen all persons who come to our clinic? If not, who should we screen? 2. Who should we treat? 3. Most of the research on effectiveness of lipid lowering drugs was conducted in Whites. Should our approach to screening and treating African Americans be different? Why or why not? 5. Adult Immunizations

Objectives: To understand which immunizations are helpful for adults.

Core Readings:

1. Recommended Adult Immunization Schedule—United States, 2010. MMWR 2010;59 (1) http://www.cdc.gov/mmwr/PDF/wk/mm5901-Immunization.pdf

1. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR 2010: 59. http://www.cdc.gov/mmwr/pdf/rr/rr59e0729.pdf 2. ACIP provisional recommendations for use of pneumococcal vaccines. 3. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and Reports 1997:46;1-24. http://www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htm 4. Kretsinger K, Broder KR, Cortese MM et al. Prevention of tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR Recommendations and Reports 2006;55(RR17):1-33. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm

Key Points:

1. Influenza is an important cause of morbidity and mortality, especially in the elderly and debilitated. 2. Pneumovax is also warranted for the elderly and those with respiratory disease. 3. Tetanus immunization should be given, especially in those who have never been vaccinated. 4. Adults who have never had a pertussis booster should receive one dose of Tdap (tetanus, diphtheria, pertussis).

Thought Questions:

1. Why do patients not want flu shots? What do you say to them? 6. Colon and Prostate Cancer Screening

Objectives:

1. To review the characteristics of a good screening test. 2. To examine the evidence for screening to detect colon and prostate cancer.

Core Readings:

1. US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2008;149:627-637. PMID: 18838716. http://www.annals.org/cgi/reprint/149/9/627.pdf 2. US Preventive Services Task Force. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2008;149:185-191. PMID: 18678845. http://www.annals.org/cgi/content/full/149/3/185

1. Ali S, Tyree S. Colorectal Cancer Incidence, Mortality, Stage at Diagnosis, and Treatment Patterns among Whites and African Americans in North Carolina. NC State Center for Health Statistics, 2010. http://www.schs.state.nc.us/SCHS/pdf/SCHS_161_WEB_021210.pdf 2. Review the “Principles of Screening” reading from the September 15 Clinical Epidemiology seminar on screening. 3. US Preventive Services Task Force. Video: How to Talk with Your Patients When Evidence Is Insufficient 4. Sheridan SL, Harris RH, Woolf SH. Shared decision making about screening and chemoprevention. Am J Prev Med 2004;26:56-66. PMID: 14700714. http://www.sciencedirect.com/science? _ob=ArticleURL&_udi=B6VHT-4B9CGKX- C&_user=130907&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C00000 4198&_version=1&_urlVersion=0&_userid=130907&md5=4b22403307a44693f61b8a208cda9b32 5. Schröder FH, Hugosson J, Roobol MJ et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320-8. PMID: 19297566. http://content.nejm.org/cgi/reprint/360/13/1320.pdf 6. Andriole GL, Crawford ED, Grubb RL 3rd et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360:1310-9. PMID: 19297565. http://content.nejm.org/cgi/reprint/360/13/1310.pdf

Key Points:

1. Prostate and colorectal cancers are important causes of morbidity and mortality in North Carolina. 2. Screening for cancer involves risks and benefits. 3. Patients should be informed about the risks and benefits of screening and allowed to participate in the decision about screening.

Thought Questions:

1. How would you discuss the potential risks and benefits of prostate cancer screening with a patient? 2. How should we screen for colorectal cancer at the Bloomer Hill clinic? 7. Breast and Cervical Cancer Screening and Prevention

Objectives:

1. To review the characteristics of a good screening test. 2. To examine the evidence for screening to detect breast and cervical cancer.

Core Readings:

1. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716-26. PMID: 19920272. http://www.annals.org/content/151/10/716.full.pdf 2. US Preventive Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. 2003. http://www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm

1. Ali S. Female Breast Cancer Incidence, Stage at Diagnosis, Treatment and Mortality in North Carolina. 2006. http://www.schs.state.nc.us/SCHS/pdf/SCHS150.pdf 2. Edwards J, Buesher P. Cervical cancer disparities between African-American women and white women in North Carolina, 1995-1998. 2002. http://www.schs.state.nc.us/SCHS/pdf/SCHS-134.pdf 3. Wright TC, Massad S, Dunton CJ et al. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. American Journal of Obstetrics and Gynecology 2007; 197:346-355. PMID: 17904957. http://download.journals.elsevierhealth.com/pdfs/journals/0002- 9378/PIIS0002937807009301.pdf

Key Points:

1. Breast cancer is an important cause of morbidity and mortality in North Carolina. 2. Racial and ethnic disparities exist in breast cancer mortality. 3. Cervical cancer is preventable through early detection and treatment of cervical dysplasia.

Thought Questions:

1. How should we screen for breast and cervical cancer at Bloomer Hill? What community resources are available to facilitate screening and how should we use them? 2. Why do disparities exist in breast cancer mortality? 8. Screening and Treating Depression

Objectives:

1. To understand common symptoms of depression and how to detect them. 2. To develop an effective and efficient treatment strategy for depression, including when to refer to a mental health professional.

Core Readings:

1. U.S. Preventive Services Task Force. Screening for depression in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2009;151:784-92. PMID: 19949144. http://www.annals.org/content/151/11/784.long 2. US Preventive Services Task Force. Screening and Treatment for Major Depressive Disorder in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics 2009;123:1223-1228. PMID: 19336383. http://pediatrics.aappublications.org/cgi/reprint/123/4/1223 3. Adams SM, Miller KL, Zylstra RG. Pharmacologic management of adult depression. Am Fam Physician 2008; 77: 785-796. http://www.aafp.org/afp/20080315/785.html

1. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006;166:2314-21. PMID: 17130383. http://archinte.ama-assn.org/cgi/content/full/166/21/2314

Key Points:

1. Depression is a common and serious medical condition. 2. Depression responds well to proper treatment, but many cases are missed by usual clinical care. 3. When treatment for depression is initiated, response to treatment should be assessed at follow-up visits and treatment intensified if necessary.

Thought Questions:

1. Should we screen routinely for depression? 2. What are special issues for treating depression in our clinic? 3. What resources for mental health treatment are available in the Bloomer Hill community? 9. Smoking and Alcohol Abuse

Objectives:

1. To understand the burden of illness from alcohol and tobacco use. 2. To examine the specific challenges of treating these disorders in rural Eastern NC.

Core Readings:

1. US Public Health Service. Treating Tobacco Use and Dependence: Quick Reference Guide for Clinicians, 2008 Update. http://www.ahrq.gov/clinic/tobacco/tobaqrg.pdf 2. US Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med 2004;140:554-556. PMID: 15068984. http://www.annals.org/cgi/reprint/140/7/554.pdf

1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004; 291:1238-45. PMID: 15010446. http://jama.ama- assn.org.libproxy.lib.unc.edu/cgi/reprint/291/10/1238

Key Points:

1. Alcohol and smoking are important and common causes of morbidity and mortality. 2. Smoking cessation can lower the risk of smoking related disease. Cessation is aided by counseling and medications. 3. Effective tools are available to detect alcoholism; recommending that patients reduce consumption can increase quit rates.

Thought Questions:

1. What special challenges does one face when trying to quit smoking in rural NC? 2. Should we screen regularly for alcohol abuse? What are the pros and cons? 10. Asthma and COPD

Objectives: Understand the diagnosis and management of asthma and COPD

Core Readings:

1. Pollart SM, Elward KS. Overview of changes to asthma guidelines: diagnosis and screening. Am Fam Physician 2009;79:761-767. PMID: 20141095. http://www.aafp.org/afp/20090501/761.html 2. Fanta CH. Asthma. N Engl J Med. 2009;360:1002-14. PMID: 19264689 http://www.nejm.org.libproxy.lib.unc.edu/doi/full/10.1056/NEJMra0804579 3. Rabe KF, Hurd S, Anzueto A et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2007;176:532-555. PMID: 17507545 . http://ajrccm.atsjournals.org/cgi/reprint/176/6/532

Key Points:

1. Asthma management should focus on preventing exacerbations through use of controller medications, such as inhaled steroids, in patients with persistent symptoms. 2. Smoking cessation is a crucial part of preventing morbidity and mortality in patients with COPD. 3. Medication therapy for COPD is important for managing symptoms and maintaining quality of life in patients with COPD but does not alter the natural history of disease.

Thought Questions:

1. Why are rates of hospitalization for asthma higher in Edgecombe and Nash counties than the rest of the state?