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Primary care health services filling gap in ‘shortage areas’

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The day paramedics rushed Jeramiah Parsons to the hospital, his lips were so sore and swollen he had trouble talking. A skin-picking habit related to his methamphetamine addiction had permitted a dangerous antibiotic-resistant infection to take up residence in his face. He had no health insurance and no doctor he could call.

“It’s difficult to acquire a primary care physician, especially when your life circumstances are insurmountably daunting,” Parsons explained.

It can be all the more challenging when you have little or no access to primary care due to local physician shortages.

St. Joseph, Mo., where the 36-year-old resides, is the seat of Buchanan County, a so-called “health professions shortage area.” The designation means there are too few primary care, mental health, or dental care providers to adequately serve the population. In Buchanan, all three apply. Primary care doctors who agree to practice in such areas may qualify for loan repayment or scholarships.

After recovering from sepsis, Parsons met Dana Peters, a community health worker who helped him complete a housing application and apply for Medicaid. She connected him with Rachel Lessor, a nurse practitioner at his new primary care provider — St. Joseph-based Northwest Health Services, a nonprofit, federally qualified health center.

Now that he has a team of care providers, Parsons hasn’t had to return to the emergency department. His experience highlights the role health centers play in America’s most underserved communities. “I feel like I have a better shot at it now,” he said.

Filling the primary care gap

Nationally, primary care physicians earn $237,000 on average, according to Medscape’s 2019 Physician Compensation Report. By contrast, family medicine physicians employed by federally qualified health centers make about 25 percent less, based on average salaries reported to the job search engine Indeed.

“You don’t go to a health center if you want to make a bunch of money,” said Dr. Ronald Yee, chief medical officer of the National Association of Community Health Centers, the voice of the nation’s 1,400 health centers, which serve 29 million people at 12,000 locations.

Just to fill existing vacancies, health centers could use 2,500 more primary care clinicians, including physicians, physician assistants, or PAs, nurse practitioners, or NPs, and nurse midwives, said Yee, who worked for a California health center for 20 years. When recruiting primary care providers, he would look for people driven by a sense of mission and try to match their interests with opportunities in the community or the practice.

“I had a PA who did exercise classes every Wednesday night, and that is part of what she loved doing,” he recalled. She came to the center as a National Health Service Corps scholar — it’s kind of like the military for health care — but stayed for multiple years after her commitment had been fulfilled. NHSC scholars receive up to four years of tuition in exchange for serving in a high-needs area after completing their primary care training.

Advanced practice providers’ expanding role

Increasingly, community health centers are relying on non-physician health providers to flesh out their primary care teams. In 2013, health centers employed 0.78 PAs, NPs and nurse midwives for every one doctor, Yee said. Now it’s more like 1.02 to 1.

PAs have masters-level training in all aspects of medicine. They can diagnose and treat illnesses and prescribe medications. NPs are registered nurses with advanced clinical training. DNPs have doctoral-level training in nursing.

These “advanced practice providers” are in demand in all types of patient settings. The number of NPs more than doubled between 2010 and 2017, from 91,000 to 190,000, according to a February report in Health Affairs. Their numbers are projected to grow by 6.8 percent a year through 2030, outpacing growth in the ranks of PAs (at 4.3 percent per year) and physicians (just 1.1 percent).

In some states, there’s a movement to ease regulations so that NPs and PAs can handle more primary care tasks — up to the full extent of their education and training. Twenty-two states and Washington, D.C., for example, allow NPs to perform patient care tasks on their own. The others require physician supervision or collaboration.

In North Carolina, even if nurse practitioners acquire waivers to prescribe the opioid addiction drug buprenorphine, they cannot write those prescriptions without supervision by a physician who also has a waiver.

Not everyone is comfortable with lifting such restrictions. In a Jan. 14 letter to the U.S. Centers for Medicare and Medicaid Services regarding proposed reforms to Medicare, the American Academy of Family Physicians argues that advanced practice registered nurses and PAs “should never independently deliver care without supervision from a physician.” Team-based models of care should be physician-led, the academy stated.

Patricia Pittman, who directs the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University, said it’s not about squeezing out physicians; it’s about how best to configure care teams. With two NPs, a social worker, an RN and a community health worker in a single practice alongside one doctor, “you could cover 30 percent more patients with one physician,” she said, “which would mean that you could reduce estimates of the number of physicians you need in the country.”

As for Parsons, he had nothing but good things to say about his team of providers. “I’m treated in a dignified manner, rather than just kind of thrown away,” he said.

Copyright 2020 HealthDay. All rights reserved.



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‘Green prescriptions’ could cancel mental health benefits for some

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So-called “green prescriptions” may end up being counterproductive for people with mental health conditions, researchers say.

Spending time in nature is believed to benefit mental health, so some doctors are beginning to “prescribe” outdoor time for their patients.

That led researchers to investigate whether being in nature helps actually does help people with issues such as anxiety and depression. They collected data from more than 18,000 people in 18 countries.

The takeaway: Time in nature does provide several benefits for people with mental health conditions, but only if they choose on their own to visit green spaces.

While being advised to spend time outdoors can encourage such activity, it can also undermine the potential emotional benefits, according to the authors of the study published this month in the journal Scientific Reports.

The researchers said they were surprised to find that people with depression were spending time in nature as often as folks with no mental health issues, and that people with anxiety were doing so much more often.

While in nature, those with depression and anxiety tended to feel happy and reported low anxiety. But those benefits appeared to be undermined when the visits were done at others’ urging, the investigators found.

The more external pressure people with depression and anxiety felt to visit nature, the less motivated they were to do so and the more anxious they felt.

“These findings are consistent with wider research that suggests that urban natural environments provide spaces for people to relax and recover from stress,” said study leader Michelle Tester-Jones, a postdoctoral research associate at the University of Exeter in the United Kingdom.

But the findings also show that health care practitioners and loved ones should be sensitive about recommending time in nature for people who have mental health issues.

“It could be helpful to encourage them to spend more time in places that people already enjoy visiting, so they feel comfortable and can make the most of the experience,” Tester-Jones said in a university news release.

More information

For more on the benefits of green spaces, go to the National Recreation and Park Association.

Copyright 2020 HealthDay. All rights reserved.



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Study: Nearly half of ‘essential workers’ in U.S. at risk for severe COVID-19

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Nov. 9 (UPI) — Nearly half of those classified as “essential workers” in the United States are at increased risk for severe COVID-19, according to an analysis published Monday by JAMA Internal Medicine.

This means that more than 74 million workers and those with whom they live could be at risk for serious illness, based on disease risk guidelines developed by the U.S. Centers for Disease Control and Prevention, the researchers said.

“Many parts of the country face high and rising infection rates, [and] we should not think about work exposure and health risks in isolation, given that workers and persons at increased risk often live in the same households,” study co-author Thomas M. Selden told UPI.

“Insofar as we can reduce the prevalence of COVID-19 in our communities, we can reduce the extent to which policymakers have to choose between the economy and keeping the population safe,” said Selden, an economist with the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality.

Since the COVID-19 pandemic spread to the United States in March, states and cities across the country have instituted lockdown measures designed to limit the spread of the disease.

Many of these measures entailed closing schools and non-essential businesses, with only banks, grocery stores, pharmacies and other businesses deemed to provide vital services allowed to stay open.

For this study, Selden and his colleagues analyzed data on the U.S. workforce to examine how many people were in essential jobs, how often they were able to work at home, their risk for severe COVID-19 and the potential health risks for their household members.

Of the more than 157 million workers across the country, 72% are in jobs deemed essential — based on U.S. Department of Homeland Security criteria — and more than three-fourths of all essential workers are unable to work at home, Selden said.

Essential workers include those in the medical and healthcare, telecommunications, information technology systems, defense, food and agriculture, transportation and logistics and energy, water and wastewater industries, as well as those in law enforcement and public works, the DHS criteria stipulates.

The study notes that up to 60% of these workers have underlying health issues, placing them at increased risk for severe COVID-19 if they get infected, as defined by U.S. Centers for Disease Control and Prevention guidelines.

Those with diabetes, heart disease, high blood pressure and chronic respiratory conditions like asthma are considered to be at high risk for serious illness, the CDC says.

Based on these findings, between roughly 57 million and 74 million adults working in on-site essential jobs — and their families — are at increased risk for serious illness, Selden and his colleagues estimated.

“Policymakers face important decisions about how to balance the economic benefits of keeping workers employed and the public health benefits of protecting those with increased risk of severe COVID-19,” Selden said.

“These issues arise in the context of decisions to close segments of the economy and decisions about how to distribute vaccines, which will initially be available only with limited supply, [and] become all the more difficult when the prevalence of infection rises in parts of the country,” he said.



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Study: Hydroxychloroquine no better than placebo for hospitalized COVID-19 patients

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Nov. 9 (UPI) — COVID-19 patients treated with hydroxychloroquine showed no signs of significant improvement in “clinical status” compared with those given a placebo, a study published Monday by JAMA found.

Patients given a five-day course of the drug were scored as “category six” based on the World Health Organization’s seven-category COVID Ordinal Outcomes Scale, the same as those given a placebo, the researchers said.

Also, 28 days after they started treatment, 10.4% of those treated with hydroxychloroquine died, just slightly lower than the 10.6% fatality rate in the placebo group.

“The results show that hydroxychloroquine did not help patients recover from COVID-19,” study co-author Dr. Wesley H. Self told UPI.

“In the study, patients treated with hydroxychloroquine and those treated with a placebo had nearly identical outcomes, [so] I do not foresee any role for hydroxychloroquine in acutely ill patients hospitalized with COVID-19,” said Self, an infectious disease specialist at Vanderbilt University Medical Center.

Hydroxychloroquine is an immunosuppressive and anti-parasitic drug that is used to treat malaria.

Early in the COVID-19 pandemic, it was touted by President Donald Trump and others as a potential treatment for the virus, despite the lack of any scientific data supporting its use.

Given its effectiveness helping those sickened with malaria — a mosquito-borne infection — to recover, “there was a strong rationale for why hydroxychloroquine may have been beneficial for patients with COVID-19,” according to Self.

However, in July, the U.S. Food and Drug Administration warned against the drug’s use in the treatment of those infected with the new coronavirus, due to potentially serious heart-related side effects.

For this study, Self and his colleagues treated 433 COVID-19 patients at 34 hospitals across the United States with either the drug or a placebo for a period of five days.

Patients assigned to the hydroxychloroquine group received 400 milligrams of the drug in pill form twice a day for the first two doses and then 200 mg. in pill form twice a day for the next eight doses, for a total of 10 doses over the five days.

All of the patients were then assessed based on the WHO’s COVID Ordinal Outcomes Scale, which categorizes those infected according to disease severity.

Most of the patients in both the hydroxycholorquine group and the placebo group were in “category six,” meaning they were hospitalized and receiving extracorporeal membrane oxygenation or invasive mechanical ventilation to maintain their breathing, the researchers said.

“Our results, especially when combined from other studies conducted in the United Kingdom and Brazil, are good evidence that hydroxychloroquine does not provide benefit for patients hospitalized with COVID-19,” Self said.



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