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ASLMBCE > Sect 3: Clinical processes in lifestyle medicine (8%) > Flashcards

Sect 3: Clinical processes in lifestyle medicine (8%) Flashcards

1
Q

List the Vital Signs in LSM

A

Physical activity, diet, stress, sleep, emotional well-being, tobacco use, alcohol consumption, BMI (8)

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2
Q

Which lifestyle medicine Vital Signs are validated

A

BMI
physical activity
audit c (alcohol use)

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3
Q

STRATEGIES FOR TRACKING SCREENING FREQUENCY AND TEST RESULTS AND FOR PROACTIVELY PTOMPTING FLLOW UP

A
  1. ideally include prompts in e-med record itself
  2. At a minimum have a registry of pt stratified by risk level based on absence of healthy LS beh.
  3. Find a method for recording and tracking LSM activities and the “next steps” in the LSTxPlan
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4
Q

Strategies to obtain information about local community resources and strategies for consistent and UTD referrals

A
  1. Maintain an UTD list of resources to assist patients
  2. Refer pt’s to other helath profess. and com resources
  3. Prepare the prim care practice to connect pat w/ resources
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5
Q

PHYS ACT VITAL SIGN:

What are the proportions of daily total energy expenditure? (resting, hysical activity, thermal

A
  1. Resting energ expend = 60-75% total
  2. Phsyical activity = 15-30% total
  3. Thermal (effect of food)= 10% total
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6
Q

What questions do you use to measure daily physical activity?

A
  1. “how many days a week do you engage in mod to stren exercise, such as brisk walk?”
  2. “On average, how many minutes per day do you exercise at this level?”
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7
Q

Why is strength training important? How do you ask about it?

A

Can increase basal metabolic expenditure, improve activities of daily living and reduce the risk of falls, esp in the elderly.
“how many days a week do you engage in strength training or resistance exercise?”

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8
Q

which micronutrients are typically lacking in people on unhealthy diet?

A

Typical shortfall nutrients: vit ADEC, folate, ca, mg, fiber,
potassium
“ Mainly found in veg, fruits, grains, beans, legumes, low fat diary”

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9
Q

BMI calculation (imperial and metric)

A

imp: BMI = (wt (lb) / ht (in)2) x 703
metric: BMI = wt (kg) / ht (m)2

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10
Q

AUDIT-C questions

A
  1. How often do you have a drink containing alcohol?
  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
  3. How often do you have 6 or more drinks on one occasion?
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11
Q

BMI categories

A 
underwt <18.5
Normal 18.5-24.9 (lowest risk 19-22)
OW 25-29.9
 0besity class I 30.0-34.9
 Obesity class II 35-39.9
 Obesity class 40 or more
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12
Q

What are the main characteristics of Frammingham Risk Assessment tool and what is it used for?

A

Risk of mi in next 10 y
Adults >20 NO heart dis or DM
Tot Chol., HDL-C, smoking,BP, meds for HTN
Underestimate risk for those w/ dm
2008 FRA incl. DM, and stroke, TIA, claudication, HF

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13
Q

What are the main characteristics of
2013 American College of Cardiology (ACC) / American Heart Association (AHA) Guideline on Assessment of cardiovasc risk, a prevention guidelines tool

A
  • 10 y and life-time risk of atheroscler cvd
  • Men and wom, 40-79, African-American and non-Hispanic Caucasian
  • Helps determ when to start statin
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14
Q

What are the main characteristics of 2015 MESA risk score?

A
  • Multiethnic, incl. Coronary Ca score
  • Validated as accurate measure of 10-y coronary heart dis risk in men and wom in a multiethnic study (39% non-hisp whites, 12% chinese am, 28% af am, 22% hisp am)
    Online calculator
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15
Q

What are the main characteristics of Reynold’s risk score for women

A
  • Considers fa hx and high sensitivity CRP (hsCRP)
  • predicts risk of global cvd
  • Online calculator
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16
Q

What are the main CVD Risk calculators used in the US

A
  1. Frammingham Risk assessment tool (2008)
  2. 2013 American College of Cardiology (ACC) / American Heart Association (AHA) Guideline on Assessment of cardiovasc risk, a prevention guidelines tool
  3. 2015 MESA risk score?
  4. Reynold’s risk score for women
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17
Q

What tool is used in the US for prediabetes screening and what are the cut-offs?

A

CDC prediabetes screening tool (online)

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18
Q

What are the cut-off values for prediabetes in the US? (ADA)

A

HbA1c: 5.7% to 6.%4
FPG: 100mg/dl to 126mg/dl (5.6-7.7 mmol/L)
2-h 75g OGTT: 140mg/dl-199mg/dl (7.8 - 11.0 mmol/L)

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19
Q

What are the cut-off values for diabetes in the US? (ADA)

A

HbA1c: 6.5% or greater
FSG: 126mg/dl or greater (7.0 mmol/L)
2h SG in 75g OGTT: 200mg/dl or greater (11.1mmol/dl)
- repeat if results equivocal

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20
Q

What tools are used internationally for assessment of risk of DM

A
  1. American diabetes assoc. Risk ass for devel t2diab
  2. Finnish Diabetes Assoc. (10 y risk)
  3. Australian t2 diab risk ass tool
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21
Q

What is considered increased waist circumference in men and women and what does it increase the risk of?

A

Higher risk /t2dm, htn, cvd relative to incr of WC
Men 40inches or more (102 cm)
Wome: 35 inches or more (88cm)

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22
Q

what is considered increased waist/hip ratio and what risk are they correlated with?

A

Men 0.9 or greater
Women 0.85 or greater
correlate w/ risk of metab. complications

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23
Q

what lifestyle factors can cause baseline sinus tachy?

A

physical deconditioning, caffeine, etoh, etc.

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24
Q

What classes of hypertension does the 2017 update of
7th report of the Joint National Committee on prevention, detection, evaluation, and treatment of High Blood pressure (2017) : US Dept of Health and Human services state and what are the cut-off values?

A
  • Normal BP ,120/,80
    • Elevated : 120-129/<80
    • Stage 1: 130-139/80-89
    • Stage 2: >140/>90○ 50% over 69 yo
      ○ Annual Screening
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25
Q

What does HTN increase the mortality of?

A

Mortality: heart dis, strokem other vasc dis

- Prevalence incr w/ age
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26
Q

What does HTN increase the morbidity of?

A

cvd, angina, mi, hf, stroke, pad, aaa

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27
Q

how often should BP be screened?

A

annualy

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28
Q

what is the prevalence of HTN in people of 60yo?

A

50%

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29
Q

how would a reduction in syst bp of 2mmhg reduce mortality from stroke, heart dis and total mortality?

A

6%, 4%, 3%

30
Q

how would a reduction in syst bp of 3mmhg reduce mortality from stroke, heart dis and total mortality?

A

8% 5% 4%

31
Q

how would a reduction in syst bp of 5mmhg reduce mortality from stroke, heart dis and total mortality?

A

14% 9% 7%

32
Q

Name the MEASUREs OF FITNESS used in LM, available in an office setting

A
  1. Step testing for cardioresp fitness
  2. Squats, pushups and sit ups for muscular endurance
  3. Sit and reach test for flexibility
  4. Skin calipers to evaluate body composition
    Note: muscular strength = diff to test in a clinic unless wts or ability to apply load are available ; mey need to refer
33
Q

What is considered a normal value for fasting total cholesterol in the US? What is it associated with?

A

less than 150mg/dl (3.879 mmol/L) = very low risk of overall heart dis

34
Q

How is LDL calculated?

A
  1. LDL= total chol - HDL - (TGs/5) or
  2. LDL = TC-HDL-TG/2.17
    Not valid if TGs >400 (4.516mmol/L)
35
Q

What is the lipid particle size shown to help with? And what does it not help with?

A

stratify risk; does not compl describe the role and function of chol.

36
Q

What physical parameter is elevated TG level often associated with?

A

TG elevation often assoc w/ low HDL and increased girth (WC)

37
Q

Describe the use on HsCRP.

A

High sensitivity CRP (hsCRP) = marker of chronic inflammation used as biomarker for cvd, can help determine the risk of developing MI in people who have CVD or in asymptomatic people who are at risk of developing cvd

38
Q

describe the role of C-PEPTIDE in assessment

A

a stimulated C-peptide measurement may be used to assess endogenous insulin production n order to identify how beta cells are functioning to meeet the demands of insulin production ; hence can help determine whtherthe pt has dmt1, dmt2 or something else

39
Q

How is HOMA-IR measured and what is its role in assessment?

A

HOMA-IR= homeostatic model assessment for insulin resistnce; estimate of insulin sensitivity and beta cell fnct based on the Fasting Blood Glucose, Fasting Plasma Insulin or C-peptide measurements

40
Q

what lab tests are commonly used as part of LSM assessment?

A

Renal fxn+ electrolytes, liver fxn, CBC, fasting lipids, HbA1c, FPG, OGTT, vit D, Thyr fxn

+/- HOMA-IR, Hs-CRP, C-peptide

41
Q

what is the potential disadvantage of HbA1c measurement?

A

identifies 1/3 fewer cases of undiagnosed dm than looking at Fasting Plasma Glucose or Fasting Serum glucose

42
Q

Who should be screened for DM?

A

OW or obese (BMI 25 or more) + any of RF’s below; if no RF’s begin aged 45 and repeat q 3 years:
RF’s:
1. physical inactivity
2. 1st dgr relative w/ t2dm
3. High risk race (asian, black, latino, native american, pi
4. Women who delivered a baby >9 oz (4.1 kg) or a dx of gestational dm
5. Hypertension (BP 140/90 or on meds
6. Women w/ pcos
7. Prediabetes
8. Signs of insulin resistance (eg acanthosis nigricans)
9. Hx of cvd

43
Q

the outcomes of a multidisciplinary LM team should include…

A
  1. Advocating gor LS modification as a primary modality for chron dis.
  2. Supporting high levels of self-efficacy and self management in patients
  3. Attaining higher levels of treatmnet compliance w/ improved health outcomes
  4. Implementing office work flows to effectively identify and address pt’s needs for therapeutic lifestyle change (TLC)
  5. Optimising pt’s time for support, offering counselling if applicable
  6. Using electronic medical records, websites, mobile apps that track ls change progress and that prompt ls interventions
  7. Using patient registries to identify pt’s who are in need of intensive ls interventions; referring them on if needed
  8. Implementing gp visits to provide therapeutic ls change treatments
44
Q

Effective interdisciplinary teams should be able to demonstrate:

A
  1. Positive leadership and management attributes
  2. Communication strategies and structures
  3. Pers. Rewards, training, development
  4. Approp. Resources and procedures
  5. Appropr skill mix
  6. Supportive team climate
  7. Individ characteristics that support interdisciplinary teamwork
  8. Clarity of vision
  9. Quality and outcomes of care
  10. Respecting and undertsanding roles
45
Q

Perceived benefits of group visits by patients

A
  1. . Improved adherence, pt satisfact., lower hosp rates, higher trust in providr, impr access, better monitoring for older&complex pt’s
  2. Greater pt educ (gp discussions and peer support
  3. Improved access to prof’s , better addresses psych needs
  4. Gain additional choices in treatmetn options
  5. Peer support
46
Q

Perceived benefits of gp visits by providers

A
  1. More efficient use of time
  2. Enhances qual of care
  3. Contain cost
  4. Different, can be interesting and fun
  5. Reduced repetition, more contact, longer amounts of time w/ each pt
  6. Documentation
  7. Collaborative care
47
Q

Group visits benefits (system perspective)

A
  1. increased physician productivity

2. reduced health care expenditure

48
Q

types of group visits

A
  1. SMA: Shared medical appt. (chron dis, perinatal care)
  2. DIGMA: Drop-in medical appt; (many applic)
  3. PSMA: physical shared appoitments (can have a private physical exam.)
    a) heterogeneous
    b) homogeneous (similar demographic and prob)
49
Q

what does confidentiality release for group visits cover?

A
  1. pt’s medical information discussed in front of others

2. agree NOT to discuss the pers. info of others outside of gp

50
Q

interdisciplinary team benefits:

A
  1. higher level of treatment compliance
  2. improved health outcomes
  3. enhanced pt engagement & self-management
51
Q

what outcomes are Healthy eating activities and lifestyle progs known to be assoc with?

A
  1. wt reduction
  2. impr BP and physical fitness parametters
  3. maintain beh changes at 5 months after completion
52
Q

what are the potential advantages of Lay Health Educators (LHE)

A
  1. improved implementation of LS intervention

2. rural centers

53
Q

examples of team implement

A
  1. Ornish Spectrum Program

2. MEdical fitness collaboration

54
Q

Ornish spectrum program

A

= intensive cardiac rehab progr.
2. collaborative, synergistic and interdisciplinary team (physicial, ex. physiol, stress management spec., prog director, chef, reg.nurse, gp support specialist, registered dietitian, admin assist, marketing recruiter)

55
Q

what are MEdical fitness collaboration programs?

A
  • medically supervised, integrated, outcomes-and accountability-based fitness prog’s. They include:
    1. active and reg. medical oversight
    2. qualified and credentialed staff
    3. disease management and clin integration prog
    individualised exerc prog.
56
Q

what are the uses for medical fitness collaboration program

A
  • supports transition from a structuruesd clin environment to a home- or community-based exrc prog.
    helpful for pt ho need longer term fitness prog.
57
Q

what is ICCC

A

Innovative Care for Chronic Conditions: report by WHO; expl how healthcare systems can and must update their practices to be able to care for chron dis. at each societal level

58
Q

according to ICCC, what societal levels should health care systems be able to deliver care for chronic disease?

A
  1. micro (patient&fa)
  2. meso (health care organisation and community)
  3. macro (policy)
59
Q

collaborative Care MAnager MOdel by Agency for HEalthcare Research and Quality

A
  1. patient = at the center; pt sets goals, dev planned visit, updates care process, trains residents, provides intensive care elops skills and assumes self-care
  2. nurse preactitioner (NP) or physicial (PA): manages
60
Q

What chronic care models are there and what are their components?

A
  1. ICCC (innovative Care for Chronic Conditions) - WHO
  2. Collaborative Care MAnager MOdel - AHRQ
  3. value-based care
  4. the chronic Care model: McColl Institute& Ed Wagner
61
Q

What are the main characteristics of The chronic Care model: McColl Institute, Ed Wagner

A
  1. helpful in explaining the involvement of the community & healthcare system in chron dis care
  2. centred on INFORMED, activated and engaged pt. & prepared, pro-active 1ry care team; PRODUCTIVE INTERACTIONS + work w/ the LOCAL COMMUNITY(gyms, politicians, comm. centers, organisations and faits systems)
62
Q

what are the main characteristics of value based care model

A
  1. financial incentives for accountable care organizations
  2. patient-centered medical homes
    To achieve standard health goals instead of merely having visits for disease treatment. May provide support systems that rae needed to achieve successful beh. change w/ LSRx
63
Q

What are the main characteristics of CCMM (collaborative care manager model) by AHRQ (Agency for healthcare research and quality)

A
  1. patient at the centre of model; sets goals, develops skills and assumes self-care
  2. nurse practitioner (NP) or physician assistant (PA): manages planned visits, updates care process, trains residents, provides intensive care and engages pat in their care
  3. clinical expert (MD/DO): leads team meetings, provides intensified care, trains residents and assumes accountability
  4. resident; learns to provide intensive care, undergoes coaching for her own self care goals, oversees medical care and learns to work in a team effectively
  5. interdisciplinary care tem: pharmacist, nutritionist, soc worker, psychologist, podiatrist, ophthalmologist; works w/ above to coord and facilitate care
64
Q

benefits of self-management

A
  1. pt’s and fa’s cope w/ the challenges of their illness more effectively
  2. pt’s and fa’s become experts in their own management
  3. reduced complications and symptoms
    improve pat’s overall sense of health and wll being
65
Q

What are the features of effective clinical information systems?

A
  1. timely and useful information
  2. prompts and reminders on patient registry or e-health record
  3. guideline reminders for the care team at the time of a pt. encounter
  4. timely, specific performance feedback feedback for prov. can be extracted for r/v and correction of deficiencies
  5. specific tx targets and goals can be entered in the system for pt. self-management and clin tracking and can be adjusted as needed
66
Q

Main features of “Prescription for Health” model

A
  • Robert Wood Johnson Foundation (RWJF) + Agency for HEalthcare Research and Quality (AHRQ)
  • 22 prim care, practice based research networks (PBRNs)
  • 27 evidence-based strategies to impr delivery and effectiveness of health beh. change services in 1ry care
  • 4 health risk beh. targeted:
    1. tobacco use
    2. risky alc use
    3. unhealthy diet
    4. lack of pys. activity
67
Q

Results of “prescription for health” model

A
  1. 1ry care capable and keen to address health beh. when funding and support available
  2. when implementing health beh. change strategies, a health care delivery model such as patient-centered medical home = imprt.; this involves substancial practice redesign and integration w/ public health and comm. services
  3. Electronic Preventive Services Selector (ePSS) = useful tool
68
Q

What is the Plan-Do-Study-Act (PDSA) cycle useful for?

A
  • quality improvement in health care
  • must include: what, who, where, when
  • root cause analysis for clin errors and near misses
  • typically several cycles need to achieve desired change
69
Q

what are the basic principles of root-cause analysis

A
  • “5 whys” repeatedly ask why to get to the root
  • “so what” - what is the conseq. of s.t. not going as planned (this frames q: “What is important”)
  • draw cause and effect diagrams (e.g. fishbone diagram) :
    1. define the problem
    2. define categories leading to the problem (people/methods/ machines/ material/ environment/ measurement syst., communication/ policies and patients)
  • steps for analysis:
    1. analyse and d/w the team: repeat causes? is there one main problematic category?
    2. research: interview team mebers, conduct pt surveys and cerate process maps
    3. decide to address a few causes; review resolutions w/ team and apply PDSA cycle
70
Q

what is HOMA-IR and what is its use?

A

Homeaostatic Model assessment for insulin resistance (estimate of insulin and beta cell function based on Fasting plasma glucose and fasting plama insulin or C-peptide measurements

71
Q

what is C-peptide and what is it used for?

A

used to assess endogenous insulin production in order to identify how well beta cells are functioning to meet the demands of insulin production; can help determine whether the pt has t1 or t2 m or something else

72
Q

Describe strategies for incorporating a wellness program for providers into a work place for providers?

A
  1. assure access to physical activity (e.g employee wellness programs, gym on site)
  2. implement a culture of wellness (breaks for pa and healthy food)

ASLMBCE (13 decks)

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