Comorbidity and Health Management Save

Hello, everyone. Welcome to Tuesday Night Rheumatology. This is Tuesday Night Rheumatology where we address the issues important to advanced practice providers. As you know, December is our advanced practice provider, APP campaign that has been so far very successful. The title of the campaign is Mission APP Partners in Care.

We have a lot of things we've been featuring this month, content written by APPs for APPs, lot about rheumatology. And specifically, we've been doing these Tuesday night rheumatology webinars on issues important to APPs. And I'll show you those with our first slide here. But we're going to end our series tonight with this last session on comorbidity and management. I'm lucky tonight to be joined by three colleagues who really are interested and concerned about comorbidity and management.

Before I get to introductions, I want to acknowledge our sponsors this month for this APP campaign that includes AbbVie, Lilly, Johnson and Johnson, Novartis, and Sanofi. They've supported this APP campaign and these Tuesday night rheumatologists, thanks to them. Those of you who are tuning in, feel free to ask questions during this webinar by clicking on the Q and A box and submitting your questions. Tonight, final night, our fourth this month, we're focusing on comorbidity and health management, health maintenance. I want to have everyone introduce themselves.

I'm Jack Cush in Dallas, Texas. Vanessa.

I'm Vanessa Hill, Birmingham, Alabama.

Vanessa, you're a nurse practitioner, correct?

Nurse practitioner, yes, sorry.

No, that's good. God forbid, we don't need another rheumatologist on this.

Sixteen years.

Lindsey.

Hi, my name is Lindsey Tom. I am a physician assistant and I'm coming to you from Reston, Virginia.

Excellent. Barbara.

I'm Barb Schlescher, PA in Rural South Carolina adult rheumatology.

Excellent. Tonight we're interested in that thing that I believe APPs are better at than rheumatologists and physicians are, which is identifying and managing comorbidities and health maintenance issues. But that's up to you to decide, and I wanna hear their interest and expertise. We do know that APPs are playing an important role in healthcare delivery. When a recent survey I did of a large number of rheumatology HCPs, I asked them the future of rheumatology and manpower issues is gonna be solved by what?

And they were equally split by saying training more rheumatology fellows, 46% training and hiring more advanced practice providers, 46%. I think that's very telltale. We've had this shift towards incorporating more APPs into our practices and where we work. When we ask, this is a survey we did last week of nearly 200 HCPs. We asked them what are rheumatology APPs best at providing on the left?

They said 58% said collaborative team care, 22% said chronic and preventative care with very few doing specialized care. And then we asked another question is, of all the many things that your APPs are doing, are they doing any niche or specialized things? And they basically said no, 59, almost 60% said no, they're not doing any niche care. But there were 24% doing telemedicine, 9% doing a disease specialty clinic, like 5%, 4% doing satellite clinics, and only 2% doing health maintenance clinics. And I think that's interesting, the sort of dichotomy we have here between very few doing health maintenance clinics, but on the other question, many are doing collaborative clinics and some are doing chronic and preventative care.

What do you guys think about that, Barb?

It's interesting. I really did like the statistics looking at 46% for increasing workforce by physicians and then APPs. I think that's been proven over the last several years. And I kind of agree, I think we do a lot of collaborative team care. I certainly do that where I am now.

I've worked in a couple of different places, Houston and now in rural South Carolina, which is very different. But I think this is pretty accurate.

I think so. Vanessa, do you think that that small number of niche care health maintenance clinics, what does that mean

Well, to I'm torn on this because I do believe probably do a lot more health maintenance than the graph shows but we typically incorporate the health maintenance into our regular rheumatology visits. Right. So, rather than having a special visitor, you know, special clinic for health maintenance, I think that we, especially as APPs end up incorporating health maintenance into our regular appointments. I know I do. I spend probably more time discussing health maintenance and preventative care than I actually use discussing rheumatology condition.

Yeah. I want to know more about health maintenance and comorbidity. If you go down the list of core competencies for physician assistants and NPs, it's all the things that you guys are expert at, what you've been working on for the last, how many dozens of years that you've been doing this. But I don't think that this is a core competency. It's certainly not for us rheumatologists, the MDs they go through fellowship.

When asked about this, I was doing educational programs twenty five years ago on comorbidities in rheumatology, and all the rheumatologists said, Oh, this is incredibly important. This is incredibly important. But no, I'm not going to do it. I don't have time. What I have primary care doctors for.

And then I show them the data that says, but your patients think you're the smartest doctor they see and they don't go to their primary care doctor. And now you're not paying attention to that. So the question is, how do we get around to making this an issue, especially when you look at the comorbidities, a lot of cardiovascular disease, twofold risk of malignancy, a six to ninefold increased risk of serious infections in some cases. Higher rates of chronic lung disease, we had a whole campaign on that two months ago on ILD and that's just devastating. GI disease comes about as a result of the non steroidal era, which is not so much anymore, but clearly life expectancy.

These are things outside of the joints that we have to watch and pay attention to.

From my perspective, I don't think that we could be good at specialized care if we aren't good at health maintenance. And so maybe, you know, more than, maybe it's just more of the issue of who's performing the health maintenance rather than who's thinking about the health maintenance but I know for me, I cannot take care of a rheumatology patient without considering their comorbidities and health maintenance as well. So, to me, it's a building block. If you don't have that, you know, the base building block of understanding health maintenance and comorbid conditions, then, I don't think that you can do your best at taking care of the complex diseases that we take care of in rheumatology.

The diseases themselves are complex enough and deadly enough. They certainly don't need the other problems that comorbidity and health maintenance can bring. Lindsey, how do you manage that in the course of your work?

So I think that's also where APPs also can help play a big role. I think that all rheumatology providers want to be good at health maintenance. We want to take care of these comorbidities. We want to be doing all these screenings. We know it's important.

I think historically it's just been a challenge with where is the time with all of these diseases we're treating. So as we bring APP to help establish more care for patients and be able to give them more time on that rheumatology care team, I think that it allows us to be able to manage those health and comorbidities and health maintenance screenings a little bit better.

Yeah, do any of you have, I hate to ask this question because I know it irritates me, I know it irritates my rheumatologist friends. Do you have an EMR that pings you about health maintenance all the time? Does that happen?

It

happens in Epic and only if your system turns it on. It can be really irritating. But then again, wouldn't it be useful? So I guess the fact that most of us don't have that going on, meaning it means that we either have to be cognizant of this issue and deal with it or wait for the computer to remind us, which is probably a really bad idea.

Now, our EMR, we do have a tab for health maintenance. You can click on it and view it, but there's no alarms or warnings. You have to have to consciously go there.

Right. Okay. That's very similar.

Yeah. Okay. So when I was doing a lot of comorbidity lecturing, as I said, twenty five years ago, I asked the audience all rheumatologists, a few APPs because there was less back then being employed. Do you do these things? And the answer of course is yes to all of them.

Treat complex disease, I examine skin and joints, I assess and quantify disease, I diagnose with certainty, I screen, I monitor, I do follow-up based on their diagnosis or based on their therapy. And yes, because of all these, I have to do all that in either twenty minutes or thirty minutes or God forbid even less time. And I can bill for a complex management, at least a 99,204, if not a $2.14, if not a 99,215. And Then I asked the question, what about this stuff? What if someone's got a blood sugar 148 or blood pressure of 165 over 88 or they're clearly overweight and not exercising, the BMI is over 30.

Do you counsel them on diet, exercise, fitness? What about smoking other than looking for tobacco stained fingers or teeth or the smell on their clothes? Are you asking about that and counseling on it? Should you start blood pressure medicine? Should you start diabetes medicines or a statin in your clinic?

Do you mandate immunizations? And obviously they all say, this is all important, but I don't do this. That's what the primary care does this. My question to you, how does this change where you work?

I think it depends on, I know some patients, at least where I am, I have a wide range. So I have some patients closer to the city, they have their primary care, they see them all the time. They're like, my primary care checks my blood pressure. Yes, it was high. I'm seeding them.

I have a log. They're aware I'm following up with them. Whereas I have other patients who maybe travel over an hour to see me and they say, Oh, my blood pressure's high. Okay, no big deal. And if I ask them about it, nobody's following up on this.

And sometimes they give me like a wishy washy answer of, Yeah, yeah, I'll see somebody, but I know it's not going to happen. And if that's the case, I take over because I know it's just not, they're not gonna have it taken care of and that's so important for their health. So that kind of divides in my situation.

I think it does depend on how your clinic is set up. Where I work now, it's a federally qualified health clinic. So there is primary care that is attached to the care that we provide. So I can definitely respond back to the primary care to ask them to help manage these if it's weight or exercise, but in general, I do bring those up and discuss with patients.

So what I'm hearing is that it kind of depends and it's kind of individualized based on where you work. But I'll then say, and the point being, who's really responsible for this other stuff? The PCP, the rheumatologist or the APP? And I'm gonna say,

We all are.

We all are at every visit.

Yeah. We are. And and, you know, and that that may mean something different for everyone, you know, just because we address it does not necessarily mean we have to manage it. But, I mean, I'm huge on smoking cessation. Over the years, I've had several people quit smoking because they're literally sick of hearing me lecture them every time they come in.

I I address weight. I address the need for exercise and and I have eyes rolled at me in clinic every single day because I have to address these things but I think it's my it's my responsibility to address it because if I recognize there's a problem, I need to bring it up. If we recognize there's a problem but we don't bring it to the patient's attention, then, they may not really realize it's a problem and that it's that important that they address it. So, you know, with the blood pressure, you know, we we talk about the blood pressure. We talk about weight, exercise, smoking.

If I have someone who's hypertensive and they don't have a physician, then, I'm going to start them on on medications. I have started patients on metformin for diabetes in the past because I know that they are not going to follow-up anytime soon. So, I think it's everyone's responsibility to recognize it and make the patient aware and to at least educate the patient on whatever if it's blood pressured or diabetes, etcetera. We, it's our job to educate them and help them to make better choices for themselves. And when it comes down to who's going to manage these things, I think it depends on what the comorbid condition is because I I crossed the line at or I I draw the line at managing diabetes.

I'll start somebody on diabetic medication on metformin, but that's it. They're gonna have to see primary care or endocrinology.

I like that you you you you said that you overwhelm the patient with your, questions about smoking and whatever. I'll give you a little vignette that most doctors don't want to talk, really don't get into weight management with patients because they say they never lose weight. I tell them every time they never do anything about it. And that sort of task inertia or choice. And it's also like, you have so many tasks to do if they don't actually result in an action, why do them?

That's like choice overload. If I give you 95 choices for what movie we're gonna say, go see, then Lindsay is gonna say to me, forget it, I'm not gonna go to the movies with you, too many choices. But the data is very clear about weight loss. And I think it's the same for smoking cessation. While you on your end, the advisor says it doesn't really work.

You look at people who do lose weight, out of the one thousand people who do lose weight, one thousand people who need to lose weight, one hundred and thirty seven did. The number one factor that made them lose weight was their doctor and the counselor. True. That's why you're obligated to do this.

Well and and I'll just lecture them on the need to do something. If I explain to them that something needs to be done such as weight loss, then I also take the time to go you know, I I don't offer them a whole lot of choices there, but I will, you know, will either talk about low carb, we'll talk about intermittent fasting, a couple of more simple things, and then I keep, pamphlets on hand in my office so I can give that to them to to review as well.

And I think patients, like, a lot of times for myself, they want to do what they can to help themselves. They need that guidance though, you know? So in terms of like exercise, fitness, weight loss, even smoking cessation, sometimes like it needs to be brought up to them. You don't want to assume the primary or somebody else has brought them up, brought up these other options, because sometimes they just need someone to take that extra time and explain the importance of how it affects multiple conditions, including their rheumatology stuff and some of the other options we can do to help them.

Right.

And I I'd like to

bring up too, Jack. I don't know if you can go back to the slide with the comorbidities and what the increased risks are. Yeah. With the the one prior to that that had the colors.

Oh, yeah.

Yeah. That's a really beautiful diagram. I love it. So I've recently gotten certified in lifestyle medicine. Lifestyle medicine is a framework where you really look at the key components, what is the underlying disease?

What is the root cause? So when I talk to patients, I do pull in their hemoglobin A1c, I do pull in their lipid panel. I may not be ordering it, but I review it whole in total. I look for any anemia, chronic kidney disease, and I tie it all together under lifestyle medicine. And I teach that if we improve your joints, we're actually making your kidneys better.

If we improve your kidneys, we're actually making your brain better. We make your brain better, we're making your lungs. So I connect it systemically and whole. For lifestyle medicine, it's basically six pillars and it's just a framework for you to put things together for the patients so that when you're educating them and education is a huge component that takes a lot of time, but also you're giving them some steps forward. And I have them pick one of the six pillars, which is either they can do nutrition, activity.

Notice I didn't say exercise, it's activity. Restorative sleep, keyword restorative, risky substances, smoking is included in there, social connection, and then stress management. So I to me, lifestyle medicine fits it all very nicely. For the clinic that I work in, we have patients that have social determinants of health which are very specific and add another layer of complexity to treating our patients. We're looking at probably maybe in July doing shared medical appointments where you bring in 10 or 12 patients in a group together.

They may have the same condition or maybe they don't, but you kind of focus on things as far as lifestyle medicine. Just wanted to tie that all together.

Yeah, I like the six pillar approach. It's very similar. You should cross reference what you do with what Brian England is doing in comorbidity management where he's got these domains that you need to review in managing a chronic inflammatory disease like RA. I want to go to ask this question. PCPs, some have them, some have them don't go to them, some referred and don't go, some refer the PCP.

Do any of you have a rule that says that I'll see you the patient as long as you have a PCP? I had that rule for many years and tried to impose that on my patients and I don't think it worked at all.

We don't have, I was

gonna say, I just feel like I lose certain patients because some of these patients just, they wouldn't go to primary, then I just, I wouldn't see them either and they wouldn't get the care.

So

I encourage it, but we definitely don't have a rule. I mean, some people it's expensive for them to pay a copay also too. So you have to think about like having multiple doctors or time and depending where they're coming, driving, copays, other So that also makes it a challenge for them.

But the consequences of not having a PCP are formidable. Delays in care, delays in diagnosis, delays in institution of lifesaving therapy. Having an algorithm that is immediately evident when the you know what hits the fan with chest pain, fainting, loss of feeling in my right leg, you call your primary care, right?

Yeah.

But if you don't have a primary care, and so this is a big issue because if we're gonna make health maintenance and comorbidity an important part of total patient management for rheumatic patients, The patient needs to know the algorithm and you need to be clear on what they know and you need to be clear if that's gonna involve you. I think the APPs are in line with I can take on this responsibility, but also draw the line like I'm not going to do whatever. Get you started and then I'll make sure that you go to someone. But I think that this PCP issue, it almost should be like a problem on the problem list. Has no PCP, is co managed by a PCP.

Don't know. Well,

our institution, have attempted to implement the rule that you have to have a primary care provider to be seen in our rheumatology clinic. But like Lindsey said, you know, it it it's really a double edged sword though because what you said is is correct. What she said is correct. I have the same fears. I'm afraid if I don't take care of some of these things that that they're not going to follow-up with primary care either because they're just not going to or because they don't have a primary care provider.

So, it really puts us all in a in a tough spot. The biggest thing to me is a relationship with your patient. So, the to me, the better relationship you you have with your patient, the more you understand everything about them, their social status, you know, their home says, the more you know about the patient, the easier it is to care for them but if you understand that your patient is in a very social situation, then, you know, at least for me, I'm going to go above and beyond what I would do for other people who are not in a difficult social situation but understanding everything about the patient helps guide their care, not just rheumatology care but the health maintenance issues as well. If you don't really understand your patient, then, you know, I think that we may be trying to offer patients things that that they don't have access to or they're not gonna they're not gonna address because they have too many other things going on. So I'm just gonna say that the best thing is to to build a good relationship with your patients so you can really understand what's going on in their life.

Yeah. I wanna start to take some notes here that we can share with our audience. Barb, the six pillars of what?

It's the American College of Lifestyle Medicine. So it's lifestyle medicine, and it's looking at the root cause of disease. So we can prevent, reverse, treat. We're using all that terminology.

Right. So We've asked the question about health maintenance measures. Seems like most were following health maintenance parameters. Does anybody do anything different other than hypertension, A1C, lipids, and weight?

Thyroid. I'll check thyroid labs if needed.

Okay. Does it matter whether it's you or the MD rheumatologist doing that?

No.

Right now, a really hot topic in rheumatology and all of medicine is weight loss and obesity management with the advent of know, first generation GLP-one, right? And SGLPT-two drugs as well for diabetes. They both produce weight loss. Where is this going? Let me ask you right now, have any of you prescribed a GLP-one agonist for your rheumatic patient?

I have for some of my patients, it's

not on

a regular basis. I'd say probably my bigger deterrent is just like prior authorization and like time and manpower to get the approval. So it's not because of the challenge with the prescription and, you know, we have so much time we're taking to get our other rheumatology drugs approved. We just don't have the extra time and ability and manpower my office to also add on that effort for these weight loss drugs. So that would be our biggest deterrent, but I have for some patients who just really need it and same thing as I mentioned before, they're not going to get it someplace else and I know it helped, not only their overall health but also their rheumatology health.

Right.

Right. I have prescribed it in the past for patients who knew that their insurance would cover it but their primary care has refused to prescribe it.

Morbid obesity is an indication. Indication is going to continue to grow. The new trials, a recent one in knee osteoarthritis looked really good with a second generation drug from Lilly, so why not? How do you get your patients to change diet or to change activity, Barb?

I really use a lot of the information that comes from the American College of Lifestyle Medicine. And our own American College of Rheumatology and the integrative guidelines recommend the Mediterranean diet. And there are many other medical organizations that recommend the Mediterranean diet, and I just try to explain that in a very simple term. It means that you're crowding out processed foods and you're crowding in more fruits, vegetables, nuts, you know, whole grains. I have probably four handouts that I share with patients that go over how can you get more fiber in your diet because that's the the main issue is fiber.

We're so focused on protein that we forget about fiber. And I would say the majority of our patients are fiber deficient. They are not protein deficient. Right. So that's where I focus mainly.

I do give them an opportunity. I keep the the circle that shows the different lifestyle medicine pillars. And I do ask patients, you know, is there a certain area that you would wanna work on? Sometimes they they may wanna work on smoking cessation. Maybe I feel that they may benefit from nutrition.

But I think overall for sustainable change, you have to start where your patients are. And small is the way to go. Small steps are more sustainable. So even if they're doing small changes, if it's they've lost a few pounds or with diet, I think the first thing that we see is that patients do feel better. They do feel better.

They have less achy joints and they come back and that's a winner. If you can get them for that first step, then after that, they will come back. And we do have to tell ourselves that what we say does make a difference because as you pointed out, you know, a lot of people that stop smoking, they say, well, I stopped smoking because my provider talked about it. So I think just just bringing it up and talking about it. But I do agree with Vanessa.

You have to know where your patient is coming from. What is their culture? Where do they live? I live here in very rural South Carolina. We live in a food swamp.

There is absolutely every fast food restaurant here, but there is very limited access to quality healthy food. So I have to take that into consideration when I'm advising patients.

Do you think patients, whether it's smoking or weight loss or whatever, they need a program to latch onto? Like I was taught a long time ago, smoking cessation is hard and as is alcohol, it's hard to go cold turkey. You need one, the guidance, two, maybe a drug and three, the program, the support program, and then four, to do it with other people. And so is it important that you either lay out a program or have access to a program? Lindsey, how do you handle this kind of stuff?

I think a lot of patients are different. So I think it's a discussion that you need to have with a patient, you know, what have, if have they previously tried quitting smoking, what have they done and what's worked and what hasn't worked? You know, what works within their schedules and their timeframe and what they're interested in. Some patients are very adamant that they don't want to add another medication. They want to try something else first on their own in other ways, as opposed to some patients are very open, like, yes, if that's going to help me, I'll do all the tools.

So I think I bring up all of those as options discussion that these can all be helpful by determining the exact plan per patient, it's individualized of also what works for them.

Yeah, I think that that's really key and most of that is really spending time with the patient to have the conversation, ask the question, to listen, all of those things. Is it different for steroids? Right now steroids continue to be the hottest thing in rheumatology. The best quote that we ever had on steroids was from Peter Merkel, which said steroids are the best drug and the worst drug that we have. And now the argument is, should people be on a little bit of steroids forever or should they be off steroids as quick as possible?

We do know that people on steroids have horrible outcomes. The higher the dose, the worse the outcome. And it's sort of like circular reasoning, of course, as to why that happens. But if the idea is we're gonna counsel on steroids, A, do you have a plan? And then B, how do you handle steroid induced osteoporosis?

Where I think it's more formal and there's guidelines as opposed to what you do on counseling people to get off steroids. Who wants to tackle steroids?

I'll weigh in. I am pretty strict about talking early with patients and talking about how long have you been on steroids. Have you tried to taper before? It's almost the same conversation you have with smoking cigarettes because it it is important to know. And I will try cutting their dose in half.

I'll do a lot of five milligram intermittently with two and a half or depending on if they're starting at ten. Just kinda alternate every other day. And I'll leave them at that dose until they come back next time because then that will that is a true test if they can maintain at that. If they can't maintain at that, then I know I have to go a lot slower. And I explained to patients what the risks are, and I have a printed sheet that goes over steroids so that they know what the side effects are.

Because I think they're confused sometimes that their other biologic medications have much more side effects than the steroids do. So I think part of it is educating them and then letting them know that every milligram makes a difference. So I have patients that are on four milligrams, but it's not five. And if

I have somebody on two and

a half, it's not three. So I tell them that every milligram makes a difference. And I think just, you know, us having that conversation about, you know, how's your joint pain, always checking in with them and letting them know they can go back to that dose if they need to, you know, whatever that highest dose was. But I think if they feel comfortable with us and they have rapport that, you know, they feel comfortable and supported that they can do it. Self efficacy.

I think also when I start, I mean, steroids are great until they're not, you know, and I talk to patients about, you know, these potential side effects, but I also go into, even when we're starting patients dead steroid, sometimes we temporarily have to use it, it's our choice, but, you know, have you had a screening bone density scan? When was the last time have you had it done? You know, do you have diabetes? But even if you don't, like, do you have someone checking your A1C or your blood sugars? It kind of goes back to, we hope that someone has a primary care, but if they don't, and we're putting them on steroids, it's probably good for us to have that baseline to know what we're dealing with too, so it is being monitored.

Not making sure, we're making sure the steroids not causing them more problems, even if we're trying to taper off that steroid. I

think oral prednisone is such a common drug use that patients just have a false sense of security when they're taking it. It's like, it's so common that it must be safe. So I do think that, a lot of it is education. We do have to make sure our patients understand that, you know, it's it's not the safest thing to to take long term. And it's hard to make get patients to really understand that and accept that if they've been taking steroids for a long time.

You know, I always say in my teachings that all steroids come on an expiration date. Meaning, if you're going to start it, you, the person who's starting it needs to know when you're stopping it. If you don't have that mindset and then Barbara's idea of scare them crazy with all the side effects of steroids, they're never going to get off and whatnot. About steroid induced osteoporosis, isn't that different because we have guidelines, do guidelines help? Lindsay?

Yeah, I think guidelines help. Mean, it gives us more direction in terms of making sure we're trying to prevent the osteoporosis if we're having patients on steroids being more aggressive with treatment, but it's also making sure we're still getting even things like screening bone densities, monitoring their baselines, knowing their history, even maybe prior to starting steroids where they are as well.

Yeah, I think that's important. It's important that everyone know those and whatnot. About smoking, Vanessa, do you have a plan that's different than what I said, which is my counsel, a drug, smoke enders program and doing it with someone else. Do you have another way of doing that?

Well, I also offer them, there's a 1800 quit now. You can call, you can also go to the CDC website and get information there. But, patients can actually get free medication to help quit smoking, and they can also get, some counseling through that program as well. But one thing I do with my patients is I try to get them to equate their pain with their cigarette smoking. You know, I mean, literally, you know, just like I do with sugar, sugar's poison, your knees hurt.

The sugar's poison that's causing, you know, this weight issue and causing inflammation and contributing to your pain. I I tell them every time you think about your knee hurting or your elbow hurting or your hands hurting, you know, every time you you you smoke a cigarette, you need to realize that you smoking that cigarette is contributing to these to the pain that you're having, the stiffness that you're having, all this inflammation that you're having. And I do believe that that has helped with a lot of my patients to quit smoking when you really, when you really get it through to them that the cigarette smoking is is very bad for their health. And everybody knows that smoking can cause lung cancer, but patients don't really equate their other diseases as being related to smoking or understanding that smoking can aggravate the disease process and causing them to be a lot sicker than they should be if they weren't smoking.

I would also Go ahead, Barbara.

I would jump in and say that I also educate patients that cigarette smoking is just as addictive as cocaine or heroin so that they understand. And I generally tell them, you will need some kind of help usually to stop smoking if you've already tried and you failed. So I do talk a lot about the data shows that if you use a medication such as Chantix or Zyban, that you can also use the nicotine replacement along with it. And those people who use those combination really do better. And then I also tell them that the cigarette smoke, the nicotine is doing something for you.

It's not that you're just smoking because you enjoy smoking. It really is having an effect in the brain. So I explained that as well so that they I want them to know that I support them and this is serious and I do want them to stop smoking and anything that we can do to help them be successful. I'm in a 100% to help them.

Yep. Does anybody have any insight as to the frustration I have when I tell patients, your rheumatoid arthritis is caused by your smoking. Rheumatoid arthritis is made worse by your smoking or your rheumatoid arthritis was caused and made worse by your obesity, ergo your diet. And I can't get them to make change those things. But if I told them their rheumatoid arthritis would get better if they knocked out red meat, half the people would do that.

So I think it's the difficulty of helping people to manage a new chronic illness that's unexplained and they're looking for easier or mentally digestible solutions and diet can be one of them. Meaning if I can eliminate something on my diet, I don't want to go crazy and try to lose 70 pounds when I need to lose 100. It's just very frustrating that you can't get them to smoke, stop smoking. And I must say rheumatologists are very good at discussing smoking. I don't think we're very good at discussing exercise.

Just increase your exercise. What does that mean? Well,

I actually have a conversation with my patients, especially the ones that tend that seem to be refractory to, to multiple treatments. I have had the conversation before where I literally tell patients that, you know, I've done what I can do. The rest is up to you. You actually have to take responsibility. There's some things that you are going to have to do for yourself that I cannot do for you This disease is not going to be managed optimally if you do not do some things for yourself.

We have to put some of that responsibility on the patient. We can't fix everything.

Exactly. Put responsibility back on the patient when possible.

To me, that's exactly what lifestyle medicine does. But it comes from a different perspective of you standing patient looking at the problem together. So I think it gives a nice package of putting things together. I did wanna say there is a free program that I use, it's called Full Plate Living and it's online, it's free, it's self paced modules that you can do that talk about increasing fiber and looking at your it it's called full plate, but making your plate full so that it's easier to get the nutrients that you need while trying to reduce your weight.

That's useful. I'll put that in the notes. That's I think really great. I want to just talk about a few more of these issues. I think that we do spend a lot of time talking about weight and nutrition, about smoking and smoking cessation and about bone health.

The other things I don't have highlighted on the slide, I don't think that we're doing very much on or anything really great. Anybody want to address what else we should be doing in health maintenance and comorbidity management?

One thing I always talk about is restorative sleep. I always discuss sleep with my patients because most patients come in and one of their number one complaints is, you know, not only not only their joint pain, but fatigue as well, brain fog, just yeah. So I have a very long discussion about restorative sleep. I probably order more sleep, consults than anybody at the institution where I work, because I've recognized how much sleep apnea can affect patients and affect every part of their life but not only sleep apnea. I mean, just patients who have poor sleep hygiene and people getting non restorative sleep for other reasons.

I try to explain to them that, you know, we can fix every problem you have but if you're not getting restorative sleep, you're not going to feel well. Right. You know, the fatigue, brain fog, memory issues, depression, explain how pain, how how not sleeping well can affect their pain. Typically, I have pretty good success getting patients to go to sleep medicine consult and have a sleep study. Using CPAP's a different story, but we have to start somewhere.

I do agree. And Vanessa, there are lots of studies showing that IL-one, IL-six, TNF alpha, CRP are all elevated in people who have sleep deprivation. So we know that it impacts the immune system. I have had some luck talking with patients about their immune system. Look, when you're sleeping, your immune system is recalibrating.

Your brain is cleaning itself. Your gut is cleaning itself. So I try to link all those organ systems together. And especially for lupus patients, I think that's super important. And I agree with you.

I definitely refer for lots of sleep studies.

I'll also use the analogy of how oxygen deprivation can kill cells. You wrap a wrap a rubber band around your finger and see how long it stays on there. You know? If you think about, your entire body going without enough, without adequate oxygenation while you sleep, just imagine what's happening.

What about dentition? There's a lot of data about gingivitis and poor oral hygiene. It's very involved now because we're getting more and more into Sjogren's syndrome, but it's really in all forms of arthritis. This is a big contributor. I don't think I'm very good at looking in mouth and counseling or pushing dental appointments and things like that.

Do any of you have a different perspective on how to better do that? It's a tough one.

I mean, I typically, especially with, my Sjogren's patients or anyone who complains of dry mouth, I try to encourage them to have their teeth cleaned every three months rather than every six months. Of course, that's extra cost, that's not feasible for everyone. I will have to admit that I am not good at looking in mouths. I will ask questions about dentition. Probably not as much as I should though.

You know what? You know what? As I think is a single greatest impediment into looking in someone's mouth is A, the disappearance of the tongue blade and B, cell phones. Because no one can find a penlight anymore. We used to always have them in our pocket.

And now because you have a cell phone that's got a flashlight on it, you think that's good enough. And in fact, it's really poor. Bring back the penlight or you know what, I'm going to give this to you, Barb. You can invent the tongue blade penlight and sell them and tons you'll of money off that.

I'll be on that.

Yeah, what about vaccinations? Do you do them in your clinic? Is it your responsibility?

I mean, I discuss it with all my patients. I think vaccinations are obviously so important, but we don't order and administer them, at least at this point. I know it's been discussion where I work of managing it, but I guess similar to some of the other things, we have so many things we're trying to do, so we just haven't taken it on board as something that we're continuing to do. So it's discussed with patients, but we're not ordering, storing, administering all of these with vaccines.

The point being that vaccines are usually handled by either the primary care doctor or the pharmacist. Again, we have the primary care problem and if you're doing that, you have to do it. We provided, influenza vaccinations, usually starting in September, going all the way through to probably February and both high dose and usual dose. And with great success in having the rules that if you're on methotrexate, you skip methotrexate for one week after the vaccine, that's what you need to make the vaccine work. But then all other drugs in it, that works for pretty much everything.

But if you don't have a strong plan on that, the work at UAB where Vanessa works, it's very strong and showing that rheumatologists are just as bad as primary care doctors, if not worse, in ensuring that their patients have influenza and pneumococcus. Forget about the newer ones like COVID and RSV.

Exactly.

Where I work, we're starting like an in house pharmacy and I know a lot that's common with more rheumatology groups now too. So the question is if you have like an in house pharmacy, will this later help the trend of maybe doing some like vaccinations and stuff? Maybe, I don't know if it'd make it easier with some of these like storage and having another kind of tool, but I guess we'll see.

I go think ahead. Go ahead. Go ahead, Barbara.

I was gonna say, and where I'm working now, I'm shocked at the vaccine hesitancy. So I didn't have to deal with it as much, you know, in Texas as I do here in South Carolina. So I really feel like I'm at a loss sometimes, talking with patients about recommending the flu you know, a simple flu vaccine.

It's made worse by it becoming a political issue that it really shouldn't be. It should be based on the evidence and the evidence is strong for most of the things we're talking about. Patients who have chronic inflammatory diseases have higher rate of cardiovascular disease, have higher risk for serious infections, hospitalizable infections, and are at higher risk for cancer. So how are we handling cancer screens? I think in rheumatology, we only get involved in cancer screening when we get a polymyositis dermatomyositis patients and then we're like all over it.

Should you be recommending and following through on health maintenance as far as cancer screening? These are hard things.

Well, I discuss these things with my patients. And, again, to go back to the lack of primary care, I order mammograms. I have ordered colonoscopies. I have ordered PSAs. Basically, I do what I feel like I need to do.

I do address it in the clinic and I do order what I need to order. I would like to say that I'm pretty good at that but I guess if I went back and audited myself, I'm probably doing it less than I feel like I'm doing it.

Yeah. Do you have anything that you do on this, Barbara?

I bring it up and review it. Again, it's a little bit different because we do have primary care that's attached to our clinic. We do have some patients that say that rheumatology is their primary care. I try to disagree and say, oh no, we're not because I haven't done a prostate exam in many years, I can assure you. But I think it just comes up in conversation.

I particularly, you know, because we cover so many organ systems with review of systems, we'll ask them about bowel and ask them if they have any history for colon cancer. Certainly, you know, I make those recommendations, you know, I may counsel, but I certainly don't manage or order.

All right. So we've covered a lot of things, a lot of topics here and a lot of to dos, if you will, for health maintenance and primary prevention and managing comorbidities. As we end, does anybody wanna bring up one more that we haven't brought up that's not on our list? I liked that we added sleep and the importance of sleep to this list. Is there anything else that we haven't talked about?

Mental health.

Oh, boy.

Now, I really cannot address that. I I do, well, I do address it. I can't help people there. I feel like I need to go back and and add on another degree because I think that most of our patients who have chronic illness have some degree of at least some degree of depression, maybe, you know, when they're first diagnosed, but I do believe that it's very important to address mental health in our patients who have chronic illness.

There is a bidirectional relationship for sleep and mood disorders, inflammatory arthritis and sleep and depression. Yeah. Yeah. Depression can be detected, I think it's like five years. Some of the studies have looked forward five years.

So you can look at patients that are depressed that have an increased risk for developing inflammatory arthritis. So it is truly bidirectional. And I don't know what the mechanism might be there, but it's very interesting. Something that I think we need to watch.

I have always said that rheumatology is one of the I think it's the only specialty that has to address all organ systems. We have to address the entire person. We do not get to pick and choose one organ system.

Yeah.

As one benefit where I I work at an FQHC, we do have very good behavioral health resources. So that is very different than working in a private practice because I can get a same day mental health referral, which is very nice. That's great.

So if you visit New York City and you have the pleasure or fear of going on a subway, you'll hear frequent announcements that say, if you see something, say something. I think that really, really applies to mental health. Yeah. It's organically important and it will kill all outcomes in rheumatology. Doesn't matter the disorder, it will kill all outcomes.

They're untreatable, unmanageable and whatever. So call it what it is and walk them over to this either psychologist office or the psychiatrist office and tell them, it's like getting a rheumatologist, if you don't like one, get another. There are plenty in business who can help you. Want to thank our discussants for a really great session. I think this was really useful to review the many things that we should be talking about this month, especially comorbidity and health maintenance in our patients.

This is the final in this Tuesday night rheumatology series. We'll have other campaigns and other series in 2026. Going forward, I wanna remind the audience that Room Now Live is coming up in Dallas and virtual online February. You can register now at roomnow.live. Folks, thank you.

We hope you enjoyed this TNR podcast devoted to advanced practice practitioners. This podcast was sponsored by AbbVie, Eli Lilly, Johnson and Johnson, Novartis, and Sanofi.