Nicole Klemas, ELS

	When interrelated risk factors such as high blood pressure, elevated fasting blood sugar, dyslipidemia, abdominal obesity, and elevated triglycerides cluster together, the resulting cardiometabolic syndrome can lead to cardiovascular disease and type 2 diabetes. Approximately 47 million Americans currently live with cardiometabolic syndrome and the resulting elevated risk of serious disease and mortality. 

	Minimizing risk factors and preventing disease development and progression represents a critical task for primary care physicians and other healthcare providers. In addition to treating risk factors, clinicians must  counsel patients on lifestyle changes, smoking cessation, and weight management. Finding effective, efficient ways to treat these difficult-to-manage risk factors can result in significant risk reduction for patients.

A wide range of traditional and newly recognized risk factors contribute to cardiometabolic disease, and it is important to review all of them during a patient examination. 

	·      Traditional cardiometabolic risk factors:

	·      Newer cardiometabolic risk factors:

	o   Abdominal obesity (measured by waist circumference)

	o   Inflammation (measured by high-sensitivity C-reactive protein levels)

	o   Lack of consumption of fruits and vegetables

	When clusters of these risk factors are identified, a management plan should be promptly put into place to delay or prevent future complications.

Because patients with cardiometabolic risk factors may be asymptomatic or have no existing conditions, they may not understand the serious risks associated with cardiometabolic syndrome. Primary care physicians must explain the importance of early risk factor control and stress that cardiac disease and diabetes are harder to treat once they are established. However, clinicians must also be cautious not to label patients in a way that makes them feel self-conscious or guilty for their health-related behaviors. Instead, reinforce the concept that lifestyle change, good nutrition, and increased physical activity can substantially reduce their cardiometabolic risk and improve their quality of life overall. 

Lifestyle modification is the primary management strategy for cardiometabolic syndrome. This can be challenging to implement in a primary care practice because it requires simultaneous counseling on physical activity, diet, and smoking cessation with regular follow-up over a long period of time. Clinical guidelines recommend that lifestyle modifications be continued for 3 to 6 months before considering pharmacotherapy unless patients are at high risk. The importance of continuous, lifelong behavior change should be communicated to patients, even if they receive pharmacotherapy. 

Obesity-defined as body mass index (BMI) ≥30 kg/m

-is a regularly measured cardiometabolic risk factor, but body fat distribution is also an important consideration that should be addressed in a patient’s exam. Excess abdominal fat is associated with increased incidence of cardiometabolic disease, and waist circumference measurements of >40 inches in men and >35 inches in women place patients at higher risk. Adding waist circumference measurements to a patient’s chart can help assess body fat and subsequent risk in ways that BMI alone does not allow. It also provides a measureable goal for patients who are tracking their weight loss.    

Because successful patient lifestyle modification requires long-term support, work to build a care team that can commit to being available to the patient over time. In addition to in-office support staff such as nurses and patient educators, it may be appropriate to refer patients to exercise specialists, registered dieticians, counselors or social workers, commercial weight-loss programs, and online or in-person support groups. Individual case managers or coaches can conduct weekly or bimonthly follow-up with patients via phone or email to provide ongoing motivation and reduce the need for office visits. Alternatively, patients within a practice can be organized into small groups that meet with a case manager or coach at regular intervals to discuss their challenges, share their stories, and support each other. Patients at high risk of cardiac disease or diabetes may also require referral to a cardiologist or endocrinologist.

Successful lifestyle modification requires self-monitoring by patients. When patients accurately track their food intake, exercise, weight loss, and change in waist circumference, they can provide valuable information to be discussed during office visits. Reinforce the importance of regular self-monitoring through a written diary, web-based program, or phone app. Patients can read reviews of available apps and choose one that appeals to them at: http://www.healthline.com/health-slideshow/top-iphone-android-apps-weight-loss.

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Patient management tips for treating cardiometabolic syndrome

Clinical Economics: Cardiometabolic syndrome

Rheumatoid arthritis is a systemic inflammatory disease. It is responsible for premature morbidity and disability. Its causes are unknown and there is no cure.

	In addition to the financial burden associated with rheumatoid arthritis, patients suffer from reduced quality of life and increased disability. A self-reported survey found that patients with rheumatoid arthritis were 40% more likely to categorize their general health as “fair” or “poor” compared to patients without arthritis. These patients were also 30% more likely to require assistance with personal care and twice as likely to have limitations on their activities due to their health.

	Patients with rheumatoid arthritis experience more losses in work, leisure, and social function. “Arthritis is a leading cause of disability,” says Stephen I. Katz, MD, PhD, director of the 

National Institute of Arthritis and Musculoskeletal and Skin Diseases

. “With the aging of the population, it will increasingly burden individuals as well as the economy.”

	Because of the chronic nature of rheumatoid arthritis management, and because patients may not have access to specialty rheumatology care, primary care physicians are challenged with the task of providing education, encouragement, and ongoing support to patients and their caregivers.

	Refer when possible, but be prepared to oversee care. Early diagnosis and treatment is important in patients with moderate to severe rheumatoid arthritis to help prevent damage, deformity, and subsequent disability.

	A rheumatologist can not only help confirm the diagnosis, but also establish a treatment plan to maximize the benefits and minimize the risks of therapy. Rheumatologists understand the importance of early diagnosis and would expect to see patients with suspected rheumatoid arthritis expeditiously. A personal call from the referring family physician can be helpful in this regard.

	In some cases, the current shortage of rheumatology professionals can result in prohibitive travel distances or long waiting periods for appointments. Therefore, primary care physicians should be prepared to act as the main care provider for patients with rheumatoid arthritis.

	Whether or not a rheumatologist is available to be a part of patient’s care team, it can be helpful to build a network of additional appropriate healthcare providers.

	Depending on the patient’s needs, these may include:

		nurse practitioners to aid in providing patient education,

		physical therapists to preserve strength and range of motion,

		occupational therapists to determine when assistive devices may be necessary,

		podiatrists to help treat arthritis in the foot or ankle, and

		ophthalmologists or optometrists to evaluate visual complications of rheumatoid arthritis

 It is critical to coordinate effective communication among members of the patient care team, especially when providers from multiple specialties are involved. Physician-patient communication is equally important.

	Patients with rheumatoid arthritis may be older and have trouble remembering subjects that they want to discuss during their appointments or directions given by their physician. Encourage them to make the most of office visits by bringing a list of their latest questions and a notebook for keeping track of instructions.

	It may be appropriate to have a caregiver or family member join the patient during appointments to help facilitate communication. Inform patients of the best way to reach providers between visits and outside of office hours, including via phone and email.

 As with many other chronic conditions, identifying one or more goals that are appropriate for an individual patient and regularly evaluating progress toward those goals based on measurable criteria are key.

	Involving the patient and/or caregiver in goal-setting and treatment selection can help improve understanding, engagement, and adherence.

 Rheumatoid arthritis can significantly impact patients’ sleep patterns and activities of daily living.

	Recommending lifestyle changes, such as the use of assistive devices, regular exercise, a balanced diet, and good sleep hygiene may help provide supportive care and allow patients to manage symptoms. This is especially important because rheumatoid arthritis is associated with increased cardiovascular risk.

	Therefore, clinicians should be cognizant of the potential need to also manage risk factors for heart disease in these patients.

Patient management tips for treating patients with rheumatoid arthritis

Clinical economics: Rheumatoid arthritis

Approximately 1 billion cases of the common cold occur annually in the United States, according to population research estimates. Each year, between 5% and 20% of patients will be diagnosed with influenza. Cold and flu season-which typically peaks between December and February when high levels of viruses circulate-is often associated with increased patient traffic for primary care offices.

	Colds may be common, but viral infections can have serious implications: on average 200,000 Americans are hospitalized annually due to influenza, and flu-related deaths in the United States have been estimated to range from 3,000 to 49,000 over the past 30 years.

	Cold and flu are also associated with significant burdens for patients and physicians. Approximately 28% of all annual over-the-counter medication expenditures are for cold and flu treatments. Viruses are easily spread and many patients experience multiple colds per year, which may result in frequent office visits. Symptoms can linger for up to 2 to 3 weeks, translating into lost work time.

	Seasonal flu outbreaks result in an average of $10.4 billion in direct costs of hospitalization and outpatient visits, according to the Centers for Disease Control and Prevention (CDC). That total does not include indirect costs associated with lost productivity and worker absenteeism. According to the Bureau of Labor Statistics, employee absences on average are up an estimated 32% during the winter flu season compared with the rest of the year.

	Primary care physicians play a key role in patient education, because patients may not know how to protect themselves and their families during cold and flu season, or may misunderstand the role of vaccinations and medications. By teaching patients how to identify influenza versus the common cold, which over-the-counter medications are appropriate, and when vaccination is recommended, primary care physicians can ease the burden of cold and flu season for their patients and staff.

	Educate on prevention. The common cold and influenza are caused by viruses, which can be airborne or spread through close personal contact.

	Although winter and early spring are typically considered cold and flu season, physicians can help patients protect themselves and their loved ones year-round by offering simple, yet effective, educational tips:


		Scrubbing with soap and water for at least 20 seconds, especially after coughing or sneezing; using alcohol-based hand sanitizer when soap and water are not available.


		Patients should be reminded that viruses live on the hands, and these are common entry points to the body.


		Avoid close personal contact with people who are sick, and patients should stay at home while they are sick whenever possible.


		Clean items that are frequently handled, such as phones, toys, and doorknobs, when someone in the household has a cold or the flu.

 Although there is no vaccination that can protect against the common cold, the best way for patients to avoid the flu is to get vaccinated every year. Since 2010 the CDC has recommended that everyone older than 6 months get a flu shot as soon as one becomes available for the season. However, vaccination may be preventative even if patients have waited until the flu season is underway. Those vaccinated miss fewer days of work or school and have reduced rates of hospitalization.

	Vaccination is especially important for patients at increased risk of developing flu-related complications, including young patients, elderly patients, and those with compromised immune system function.

	For families, vaccination of all members may decrease the risk of infection for those at high risk. Getting a flu shot annually results in significantly higher rates of protection compared with that experienced in the initial year, especially against the complications of flu, such as pneumonia, cardiac events, and death.

	Patients should be reminded that there is still a chance they can contract the flu even if they have been vaccinated. Vaccination in such cases leads to cases being milder, however.

Educate patients on the differences between colds and the flu.

 It can be challenging for patients to distinguish between the common cold and a case of the flu, especially because the symptoms of a severe cold can seem flu-like. Patients should understand the difference between the two and the treatment options for each, as well as when an office follow-up may be needed.

 Cold and flu symptoms can be frustrating for patients. Most patients recover within seven to 10 days, but symptoms such as fatigue can last beyond 2 weeks and it can take up to 3 weeks for a persistent cough to completely disappear.

	Patients can be reminded that medication may ease symptoms but may not speed healing, and that they will likely only need to make additional appointments if symptoms become severe or will not resolve. If a patient experiences worsening of symptoms after 7-10 days, this may signal that s/he is developing a bacterial complication such as sinusitis or pneumonia.

		Getting paid for treating the common cold or influenza requires understanding the possible diagnosis codes. See the table at right for a selection of available codes in both International Classification of Diseases-9th Revision (ICD-9) and ICD-10.

			U.S. Centers for Disease Control and Prevention: 

			American College of Chest Physicians: 

How to better manage-and get reimbursed-for treating cough, cold and flu patients.

Clinical economics: Cough, cold, and flu

	Depression is one of the most common mental health conditions in the United States, according to the 

. It has been estimated that this disorder will affect approximately 18% of adults at some point in their lives.

	Patients with depression incur heavy physical, financial, and emotional burdens. Depression is linked to higher rates of obesity, heart disease, stroke, sleep disorders, and other conditions, and it often co-occurs with other illnesses. Symptoms negatively affect energy, concentration, memory, and decision-making.

	Depression accounts for more than $210 billion in annual medical expenditures in the United States. About 40% of this total is directly attributable to depression. The remainder is associated with treatment of related physical and mental illnesses, reduced productivity, and costs associated with suicide, with workplace costs accounting for about 50% of expenditures.

	Despite significant improvements attainable through depression management, an estimated 75% to 80% of patients either do not seek or are not receiving proper treatment. Primary care physicians can address this gap by identifying patients at risk for depression and implementing a multidisciplinary plan of care for those patients requiring treatment and support.

	“The earliest and best opportunities to identify depression are in the clinics of primary care providers,” noted the Prevention Practice Committee of 

the American College of Preventive Medicine

NEXT: Patient management tips for depression

	Screen patients for symptoms. While many patients are diagnosed with depression as adults, symptoms of depression can develop at any age. Up to 1 in 33 children and 1 in 8 adolescents have clinical depression.

	Depression often co-occurs with other conditions, especially cancer, strokes, heart attacks, diabetes, HIV, Parkinson’s disease, eating disorders, and substance abuse. Extensive patient screening tools or questionnaires are not always necessary; focused patient communication can efficiently open the door to further discussion and confirmation of a diagnosis.

	The use of the following screening questions showed a sensitivity and specificity of 97% and 67%, respectively, when used in a primary care setting with patients not receiving psychotropic drugs:

		During the past month, have you often been bothered by feeling down, depressed, or hopeless?

		During the past month, have you often been bothered by little interest or pleasure in doing things?

	If either of these questions is answered in the affirmative, further investigation should be conducted using a validated screening tool.

	Address treatment non-adherence. Up to 80% of patients with depression who receive treatment-including medication, referral to psychotherapy and support groups, or a combination of these methods-show improvement in their symptoms in four to six weeks.

Integrating primary care and mental health key to improving patient care, lowering costs

	However, medical non-compliance is the cause of approximately half of cases of unsuccessful depression treatment. About 25% of patients given an initial prescription for an antidepressant either do not get it filled or never take the first dose.

	Patients often stop taking their medications too early due to adverse effects, financial concerns, fear of addiction, or short-term symptom improvement that leads them to believe it is unnecessary to continue treatment.

	A phone call from a practice assistant to a patient can increase the initial uptake of treatment significantly by asking three questions:

		Do you have any questions or concerns you’d like to discuss?

	Participation in patient-to-patient support groups has been reported to improve treatment compliance by nearly 86%, and can reduce in-patient hospitalization.

	Additionally, support group participants are 86% more willing to take medications and cope with side effects than are patients who do not participate.

	Encourage patient self-care. Effective patient-centered care includes education on self-management techniques to help reinforce treatment adherence. Incorporating activities such as journal-writing and self-monitoring into a treatment plan can inspire patients to take responsibility for their care.

	When appropriate, suggest that a family member or loved one attend appointments to provide advocacy and support, and involve them in the development of patient treatment plans.

	Collaborative care is critical. Collaborative care among primary care physicians and behavioral health specialists is critical for effective treatment of patients with depression. Studies have reported that collaborative care models increase effectiveness of treatment and reduce the cost of care overall.

	Approaches that have been demonstrated to improve patient outcomes in large trials have four common features:

		Use of a validated screening tool such as the Patient Health Questionnaire-9 or the Quick Inventory of Depressive Symptomatology (16-item) Self-Report (QIDS-SR16),

		clinical use of an evidence-based treatment guideline,

		collaboration with a psychiatric specialist.

	A sample collaborative care plan might include maintaining a list of patients receiving treatment for depression, establishing a plan for providing patient education, contacting the patient at established intervals to ensure compliance, and ensuring follow-up visits and outcomes measurements.

	Include continuity of care in your in-office systems. In-office systems can help coordinate care, ensure continuity, and communicate patient status between all treating clinicians.

	Frequent, structured monitoring and follow-up with patients, such as phone or email consultations conducted by a nurse or care manager, should be built into any such system.

	-Reviewed by Larry Culpepper, MD, MPH
	Boston University School of Medicine
	Boston Medical Center, Boston, Massachusetts

Anxiety and Depression Association of America

Depression is one of the most common mental health conditions in the United States, according to the National Institutes of Mental Health.

Author | Nicole Klemas, ELS

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Clinical Economics: Cardiometabolic syndrome

Clinical economics: Rheumatoid arthritis

Clinical economics: Cough, cold, and flu

Clinical Economics: Managing patients with depression