Osteoporosis is a systemic skeletal disease involving low bone mass and microarchitectural deterioration of bone tissue, resulting in increased bone fragility and fracture risk.

Bone density corresponds to the amount of mineral within a volume, and bone quality depends on architecture, bone matrix composition, bone turnover, damage accumulation, and mineralization.

 Osteoporosis develops silently over years before it becomes apparent through bone mineral density (BMD) screening or fractures. Fragility fractures are the main physical manifestation and occur at diverse sites, such as the distal radius, proximal femur, and vertebral bodies.

Recommend a dual-energy x-ray absorptiometry (DXA) to check BMD and screen for osteoporosis in the following patients at high risk

Adults on chronic glucocorticoid therapy, such as oral prednisone ≥5 mg/day for 3 or more months or an equivalent

Individuals aged 50 years and older with a recent low-trauma fracture

Other patients may also be good candidates for a DXA to check BMD, especially those with multiple risk factors. Assess risk factors to see if BMD testing is warranted with a thorough history in men aged 50 to 69 years or postmenopausal women younger than age 65 years with the following medical concerns

Excessive alcohol intake of 3 or more drinks per day

Radiographic osteopenia (DXA T-score between -1 and -2.5)

Taking medications that decrease BMD, such as aromatase inhibitors, glucocorticoids, GnRH agonists, phenobarbital, or phenytoin

There are 3 different categories of bone health for classification purposes:

: BMD 1 standard deviation or less below that of young white women reference mean (ie, T-score of −1 or greater)

: BMD between 1 and 2.5 standard deviations below that of young white women reference mean (ie, T-score between −1 and −2.5)

: BMD more than 2.5 standard deviations below that of young white women reference mean (ie, 

There are specific indications for pharmacotherapy:

T-score of −2.5 or less (ie, or worse) in distal third of radius, femoral neck, spine, or total hip

T-score from −1 down to −2.5 in distal third of radius, femoral neck, spine, or total hip, and fragility fracture of hip or spine

T-score from −1 down to −2.5 in distal third of radius, femoral neck, spine, or total hip, and FRAX score shows that that 10-year probability of hip fracture is 3% or greater or the 10-year probability of a major osteoporotic fracture is 20% or more

There are different approaches to screening. Some think that it is not necessary to check a DXA in patients who are receiving osteoporosis treatment because women receiving osteoporosis treatment may have reduced fractures, regardless of the impact on BMD. Others recommend continuing to check a DXA during treatment until BMD has stabilized or after 3 to 5 years of bisphosphonate therapy.

There are several pharmacotherapeutic options for osteoporosis treatment. Medications are classified mechanistically as antiresorptive agents that slow bone breakdown or anabolic “bone building” agents.

Antiresorptive medications include intravenous (IV) and oral bisphosphonates; selective estrogen receptor modulators (SERMs), specifically raloxifene and calcitonin nasal spray; and subcutaneous denosumab. Romosozumab-aqqg is a subcutaneously administered monoclonal antibody with anabolic/antiresorptive properties.

Anabolic agents are the subcutaneous parathyroid hormone analogs abaloparatide and teriparatide. Oral bisphosphonates, such as alendronate or risendronate, are generally preferred first-line agents for osteoporosis prevention and treatment in most patients. The choice of osteoporosis medication depends on multiple factors, including cost, osteoporosis fracture risk and severity, route of administration, and tolerability. The 

details the adverse effects (AEs), contraindications, and dosing of osteoporosis medications.

There are specific circumstances for which other osteoporosis medications may be considered.Raloxifene may be an option for women at high risk for breast cancer and in women who cannot tolerate bisphosphonates or denosumab.

 Calcitonin may be an option to reduce acute bone pain associated with vertebral fractures as well.

Patients with severe osteoporosis and very high fracture risk who cannot tolerate or respond poorly to IV and oral bisphosphonates may be candidates for anabolic agents abaloparatide or teriparatide or alternatively romosomuzab.

 Denosumab is an alternative to anabolic agents for high-risk older patients who cannot take or tolerate or respond poorly to bisphosphonates.

AE indicates adverse effect; BMD, bone mineral density; IV, intravenous; PTH, parathyroid hormone; PTHrP, parathyroid hormone-related protein; and SERM, selective estrogen receptor modulator.

Osteoporosis is a common medical condition that increases fracture risk and requires individualized screening and management. Lifestyle management includes adequate vitamin D and calcium intake, increased physical activity, and smoking cessation. Oral bisphosphonates are first line for most patients with osteoporosis. Other agents may be reserved for high-risk patients who are intolerant or poorly responsive to bisphosphonates. Follow-up BMD testing is recommended to monitor response to therapy.

-------------------------------------------------------------------------------------

 is a clinical associate professor at Pace University’s College of Health Professions in New York, New York.

 is a clinical professor at a department chairperson at Pace University’s College of Health Professions.

-----------------------------------------------------------------------------------

Black DM, Rosen CJ. Postmenopausal osteoporosis. 

. 2016;374(3):254-262. doi:10.1056/NEJMcp1513724

 7th ed. Jameson JL, De Groot L, eds. Saunders; Philadelphia, PA: 2016;1184-213.e6.

Allen S, Forney-Gorman A, Homan M, Kearns A, Kramlinger A, Sauer M. Diagnosis and treatment of osteoporosis. Institute for Clinical Systems Improvement. Updated July 2017. Accessed February 11, 2021. 

https://www.icsi.org/wp-content/uploads/2019/01/Osteo.pdf

Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. 

. 2019;104(5):1595-1622. doi:10.1210/jc.2019-00221

Qaseem A, Forciea MA, McLean RM, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. 

 2017;166(11):818-839. doi:10.7326/M15-1361

Adler RA, El-Hajj Fuleihan G, Bauer DC, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. 

Silverman S, Christiansen C. Individualizing osteoporosis therapy. 

. 2012;23(3):797-809. doi:10.1007/s00198-011-1775-y

Cranney A, Papaioannou A, Zytaruk N, et al. Parathyroid hormone for the treatment of osteoporosis: a systematic review. 

. 2006;175(1):52-59. doi:10.1503/cmaj.050929

Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab treatment in postmenopausal women with osteoporosis. 

 2016;375:1532-1543. doi:10.1056/NEJMoa1607948

Forteo [prescribing information]. Indianapolis, IN; Lilly USA: 2020. Accessed February 18, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021318s053lbl.pdf

Ringe JD, Doherty JG. Absolute risk reduction in osteoporosis: assessing treatment efficacy by number needed to treat. 

. 2010;30(7):863-869. doi:10.1007/s00296-009-1311-y

Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. 

 2009;361(8):756-765. doi:10.1056/NEJMoa0809493

Osteoporosis is a common medical condition that increases fracture risk and may require patients to make lifestyle changes.


Osteoporosis Requires Individualized Screening and Management

Jennifer Hofmann, DMSc, MS, PA-C, and Jean Covino, DHSc, MPA, PA-C

The Advisory Committee on Immunization Practices (ACIP) recommends that all Americans 6 months and older who do not have contraindications receive the flu vaccine.

Health care providers should recommend the high-dose or adjuvanted flu vaccine for patients 65 and older. These 2 types of the vaccine are designed to spur a stronger immune response. The difference between adjuvanted and high-dose vaccines is that the adjuvanted vaccine is made with MF59 adjuvant, which is designed to enhance the immune response. The high-dose vaccine is designed for patients 65 and older and contains 4 times the amount of antigen as the regular flu vaccine. As such, it is associated with a stronger immune response, and patients who received the high-dose vaccine had 24% fewer influenza infections compared with those who received the standard-dose flu vaccine.

Children aged 6 months to 8 years who have never received the vaccine should receive 2 doses, the first as soon as it is available and the second about a month later.

showed that the vaccine significantly reduces a child’s risk of dying from the influenza virus. The study looked at data from 2010 to 2014 and found that the vaccine reduced the risk of flu-associated death by 51% among children with underlying high-risk medical conditions. Just 1 in 4 children who reportedly died from influenza had received the vaccine. As of March, 61 pediatric flu-related deaths had been reported in 2017.

From 1982-2016, peak influenza activity did not occur until January or later, but it can start as early as October.

Considering inconclusive evidence that delaying immunization may increase immunity in the latter half of the flu season, the ACIP recommends that patients get vaccinated early. The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

A potential safety signal associated with the flu vaccination of pregnant women has been raised. A case control study has reported that women early in pregnancy who have been vaccinated with vaccine containing the H1N1 component had a higher rate of spontaneous abortion within 28 days of vaccination. However, the ACIP has not changed its re

commendation on not vaccinating pregnant women in any trimester. There is an ongoing study involving pregnant patients and the flu vaccine that should produce results by 2018 or 2019.

According to the CDC, the flu vaccine is associated with decreased hospitalizations among patients with diabetes (79%) and chronic lung disease (52%).

Additionally, a meta-analysis suggests that the influenza vaccine is associated with a lower risk of major cardiovascular events in patients with active coronary disease.

With these statistics in mind, health care providers should be the most prominent advocates of the flu vaccine, especially concerning these special patient populations.

Another concern when considering the flu vaccine in certain patient populations is an egg allergy. The ACIP recommends that patients who have experienced urticaria after exposure to eggs should be vaccinated. Patients who have experienced severe reactions to eggs, such as angioedema or respiratory distress, or who require epinephrine, may receive any licensed and recommended flu vaccine. However, vaccine administration should be supervised by a health care provider who is trained to manage severe allergic reactions. As always, patients who have suffered an allergic reaction to the flu vaccine previously should not receive the vaccine.

One option for patients with severe egg allergies is Flublok, a vaccine that is not produced using chicken eggs. If a patient asks for the Flublok vaccine, it should be noted that the vaccine has a slightly shorter shelf life of 9 months from the production date.

Always remember the CDC’s SHARE method: Share the reasons that the influenza vaccine is right for patients, highlight positive experiences with the vaccine, address all patient questions, remind patients that influenza vaccines protect them and their loved ones, and explain the potential costs of getting the flu. It is important that patients understand the vaccine and the reasoning behind its recommendation so that they can make informed decisions about the flu and other vaccines.

Pharmacists, nurse practitioners, physician assistants, and physicians are vital to increasing influenza immunization rates. Patients trust health care providers to provide the latest evidence involving the vaccine and data surrounding special patient populations.

is a community pharmacy resident at the University of Georgia and Kroger Pharmacy.

1. CDC. Prevention and control of influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013-2014.

2. What you should know and do this flu season if you are 65 years and older. CDC website.

. Updated October 13, 2017. Accessed November 2, 2017.

3. Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season.

4. CDC study finds flu vaccine saves children’s lives [news release].  CDC. April 3, 2017.

cdc.gov/media/releases/2017/p0403-flu-vaccine.html

5. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices - United States, 2017-18 influenza season.

2017;66(2):1-20. doi: 10.15585/mmwr.rr6602a1.

6. Flu vaccination & possible safety signal. CDC website.

cdc.gov/flu/professionals/vaccination/vaccination-possible-safety-signal.html

. Updated September 13, 2017. Accessed November 2, 2017.

Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis.

8. Flu vaccine and people with egg allergies. CDC website.

cdc.gov/flu/protect/vaccine/egg-allergies.htm

. Updated September 2, 2016. Accessed November 2, 2017.

9. Flublok seasonal influenza (flu) vaccine. CDC website.

cdc.gov/flu/protect/vaccine/qa_flublok-vaccine.htm

. Updated October 3, 2017. Accessed November 2, 2017.

10. When & how to wash your hands. CDC website.

cdc.gov/handwashing/when-how-handwashing.html

. Updated March 7, 2017. Accessed November 2, 2017.

The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

Influenza Prevention: Make Sure Patients Understand the Vaccine

Abby Case, PharmD

April is Alcohol Awareness Month, and we have simplified science on everything related—effects on the body, nutrition, and how an individual can still be on a quest with sound nutrition, making sense of how alcohol and calories mix. Patients often times have questions related to alcohol, its effects on medications, diet, and their health, so what better time to dive into this topic and share what the science has to say, to better arm healthcare providers, and to help patients.

named April National Alcohol Awareness Month in 1987 as a way to decrease the stigma associated with alcoholism, and to provide education to prevent unnecessary health risks.

There are some key terms, definitions, and implications that will prove helpful for healthcare providers to know, so that they can better educate their patients on alcohol, its effects, and the implications of certain drinking patterns.

National Council on Alcoholism and Drug Dependence

Excessive drinking is associated with a significant increase in acute health and safety risks, proportional to the amount of alcohol consumed. If this behavior becomes habitual, then over time it can lead to many other health complications.

Patients often times have questions related to alcohol, its effects on medications, diet, and their health, so what better time to dive into this topic and share what the science has to say.

The Buzz On Alcohol and the Body

Adam Martin, PharmD, ACSM-CPT

Death by external causes&#151;primarily accidents and suicide—take the lives of more than 5 million people each year, and it has evolved into a major health concern on a global scale. External causes also include violence, undetermined causes, and medical procedures.

In Japan, a country boasting one of the highest life expectancies across the globe, a recent study found that external causes take the lives of women 10 years earlier than those by all other causes. The study sought to investigate the association between female reproductive factors, and the risk of external causes of death among middle-aged women in Japan.

The study followed 49,279 women for 20 years; 8477 of the women died, and the researchers collected their death certificates to confirm their causes of death. Of these deaths, 328 were by external causes: 148 by suicide, and 167 by accident. The researchers found that women designated “ever parous” (carrying at least one pregnancy to 24 weeks) had a lower risk of suicide than those designated “never parous.” They also found that parous women who had ever breastfed were much less likely to die by accident.

The study suggests that the decreased risk of suicide in “ever parous” women is consistent with previous studies. They indicate that the presence of a child may significantly deter the decision to commit suicide, especially while the child is dependent.

In addition, researchers found that the lower risk of accidents seen among postmenopausal women may be linked to the protective effect of breastfeeding on osteoporosis, and subsequent fracture occurrences. Osteoporosis can turn a simple fall into a health crisis, ultimately traced back to an accident.

The study concludes that “suicide and accidents are never the consequence of a single cause; a combination of personal, cultural, social, and biological features likely interact with fluctuations in sex hormones among women.” The researchers acknowledge that the reproductive factors they studied are not modifiable, but emphasize that a better understanding could still help to reduce avoidable deaths by self-harm and accidents.

is a 2023 PharmD Candidate at the University of Connecticut in Storrs.

Female reproductive factors and risk of external causes of death among women: The Japan Public Health Center-based Prospective Study (JPHC Study).

9, 14329 (2019) doi:10.1038/s41598-019-50890-x

Death by external causesâ€”primarily accidents and suicideâ€”take the lives of more than 5 million people each year, and it has evolved into a major health concern on a global scale. External causes also include violence, undetermined causes, and medical procedures. 
 

Breastfeeding and Parity Linked to Lower Risk of Death by Accidents and Suicide

Adara Bochanis, PharmD Candidate

Patients with type 2 diabetes (T2D) who get the flu shot may have a reduced risk for hospitalization related to cardiovascular or respiratory issues, recent research suggests.

Researchers from the Imperial College London analyzed 7 years’ worth of flu-season data on nearly 125,000 patients with T2D seen in primary care clinic. They found that individuals who received the flu shot were 30% less likely to be admitted to the hospital for stroke, 22% less likely to be admitted for heart failure, and 15% less likely to be admitted for pneumonia or influenza than their unvaccinated counterparts.

Patients who received the flu shot also had a 24% reduced risk of all-cause mortality.

To better understand the effect of the flu vaccine on a patient’s risk for hospitalization, the researchers controlled for patients’ age, weight, smoking status, and gender. Also important to the researchers was whether or not patients had been diagnosed with or were taking prescriptions for other long-term chronic conditions, such as heart disease and asthma.

that individuals at high risk of serious flu complications include young children; pregnant women; patients with chronic health conditions like asthma, diabetes, or heart and lung disease; and those 65 years and older.

“The potential impact of influenza vaccine to reduce serious illness and death highlight the importance to renew efforts to ensure that people with diabetes receive the flu vaccine every year,” lead study author Eszter Vamos, a public health researcher at Imperial College London, told

The researchers noted that one study limitation is that those who opt to get the flu shot may be healthier overall, meaning they already had a reduced risk for hospitalization or death.

Causation notwithstanding, the best protection for those with chronic conditions is preventing the flu in the first place.

Nurse practitioners and retail clinicians should remind every patient at every visit about the importance of the flu shot.

Patients with type 2 diabetes who get the flu shot may have a reduced risk for hospitalization related to cardiovascular or respiratory issues, recent research suggests.

Flu Shot May Help Diabetes Patients Avoid Hospitalization, Death

Aine Cryts

For individuals driving with groups outside their households or using ride-share services, keeping the windows rolled down and wearing masks can decrease the risk of spreading COVID-19, according to research results from the University of Surrey in the United Kingdom.

A team at the university’s Global Centre for Clean Air Research (GCARE) used sensors to monitor the concentration of pollution particles to map how those particles varied during different settings in the vehicle and to evaluate exposure doses for 3 different ventilation settings. They evaluated scenarios with the air conditioning on and using fresh air, with air conditioning on and using air recirculation, and the windows open.

The team found that maintaining a continuous intake of fresh air by keeping the windows open while also wearing a mask is the best way to guard against the transmission of COVID-19, according to a statement.

However, this scenario also increases occupants’ exposure to toxic air pollution particles.

This creates a dilemma because guarding against air pollution in turn increases the risk of COVID-19. The study results showed that the probability of transmission increased by 28.5% when windows were closed and air recirculation was switched on.

To balance both these issues, the team found that the best chance of remaining safe from both air pollution and COVID-19 was to keep the windows closed while running the air conditioning on ambient mode, in which it draws in fresh air from outside. This approach avoids external air pollution while minimizing exposure to COVID-19.

Lead author Prashant Kumar, PhD, founding director of GCARE at the University of Surrey, said in the statement research like this is essential to end the COVID-19 pandemic.

“It’s vital that the scientific community provides society with the data it needs so we can learn from the painful experience of the past 2 years,” he said. “Our research found that if your priority is to reduce the risk of contracting COVID-19, wearing a mask and keeping car windows open is the ideal approach.”

The combination of mask wearing and keeping windows open is best for reducing COVID-19 risk in cars, finds a new study. University of Surrey. News release. August 24, 2021. Accessed August 27, 2021. 

https://www.surrey.ac.uk/news/combination-mask-wearing-and-keeping-windows-open-best-reducing-covid-19-risk-cars-finds-new-study

Guarding against external air pollution while reducing the risk of infection when driving presents a challenge. 

Keeping Windows Down, Wearing Masks Reduces COVID-19 Risk in Cars

Aislinn Antrim

Racial and ethnic minorities bore a disproportionate mental health burden during the COVID-19 pandemic, according to the authors of a study published in 

During the heights of the pandemic, research established that minority groups were disproportionately impacted by COVID-19 when compared to non-Hispanic whites, including experiencing higher rates of infection, severe disease, hospitalization, and death. Following the pandemic, reports showing a 3-fold increase in the incidence of depression symptoms showed that the pandemic had a significant impact on mental health broadly, but the effects of COVID-19 on the mental health of minorities was not clear based on the data.

In the new study, investigators used data on 691,473 individuals in the United States and United Kingdom who responded to the smartphone-based COVID Symptom Study between January 23, 2021, and June 9, 2021. Recruited through social media, participants reported baseline information before logging daily information on their symptoms and COVID-19 testing results using an app called Zoe.

According to the study, after controlling for personal factors including prior mental health diagnoses and changes in leisure time activities, Black participants in the United States were 1.16 times more likely to screen positive for depression than White participants. Hispanic participants were also 1.23 times more likely to screen positive for depression and 1.23 times more likely to show signs of anxiety compared to White participants.

“The early phase of [the] COVID-19 pandemic was incredibly disruptive to everyday life,” wrote the authors in the study. “We found that racial and ethnic minorities in the US and UK were more likely to screen positive for depression and anxiety.”

Similar results were found for Black and Asian participants in the United Kingdom, as well as those within other participant subgroups, including Black health care workers, who had higher rates of depression and anxiety than White health care workers.

Based on these findings, the authors concluded that minority communities in both the United States and the United Kingdom experience a mental health burden that was disproportionate to other communities during the COVID-19 pandemic. These problems could also last well beyond any presumed conclusion of the pandemic.

“[The findings] suggest a disproportionate impact and mental health burden on persons of color, which need to be considered as we reshape health care systems to prioritize the long-term consequences of this disease,” the authors wrote in the study.

Minorities bore disproportionate mental health impact of pandemic. News release. Science Daily; August 10, 2022. Accessed August 17, 2022. 

https://www.sciencedaily.com/releases/2022/08/220810161148.htm

Research found that Black health care workers had higher odds of depression and anxiety than White health care workers.

Study: COVID-19 Pandemic Disproportionately Impacted the Mental Health of Minority Populations

Aislinn Antrim, Associate Editor

When transgender patients pursue gender-affirming facial surgery to treat gender dysphoria, insurers often classify these insurance claims as cosmetic only due to a lack of evidence supporting their medical basis. However, a study conducted by the University of California, Los Angeles (UCLA) provided the first evidence showing the medical basis for gender-affirming facial surgery. Specifically, the surgeries were found to significantly improve quality of life for transgender patients based on psychosocial assessments.

"Access to facial gender-affirming surgeries under health insurance coverage in the United States is more limited than gender-affirming surgeries of other anatomic regions due to a lack of data on mental health quality-of-life outcomes," said the study’s lead author Justine Lee, a Bernard G. Sarnat professor of craniofacial biology and an associate professor of surgery at the David Geffen School of Medicine at UCLA, in a press release. "Our findings have the potential to change health insurance policies for the better for transgender patients."

In order to assess the impact of gender-affirming facial surgery on the quality of life for transgender patients, the researchers compared the results of mental health assessments in 107 patients awaiting facial surgery versus those of 62 patients who had already completed their surgeries, the latter of which were conducted at an average of approximately 6 and a half months following their procedures. Based on the results of this comparison, the researchers found that 7 of 11 patients who had received their gender-affirming facial surgery reported higher scores in their psychosocial health, including in their experience of anxiety, anger, depression, global mental health, positive affect, social isolation, and meaning and purpose.

Based on the data, the researchers observed that gender-affirming facial surgery may be one of the most important procedures in terms of improving the quality of life of patients with gender dysphoria, which is defined as the psychological distress that results from the incongruence between one's sex assigned at birth and one's gender identity, according to the press release.

Notably, the experience of dysphoria was found to be higher among transgender patients who were assigned male at birth, with facial characteristics reported as the most significant source of that dysphoria. Lee explained that in her experience, the majority of patients seeking gender-affirming facial reconstruction are assigned male at birth and identify as either female or nonbinary.

For transgender patients who were assigned male at birth, facial feminization surgery is a procedure they may pursue to support the pursuit of gender-affirming facial characteristics. This type of surgery encompasses procedures that include feminizing the brow bone area, reducing the jaw area, augmenting the cheeks, and reshaping the nose.

Furthermore, the data showed that facial surgery alone was a standalone predictor of higher psychosocial scores among transgender patients, even when considering and adjusting for the effects of factors such as the duration of gender-affirming hormone therapy, whether the patient had undergone previous gender-affirming surgeries, pre-existing mental health diagnoses, and the quality of the patients' social relationships.

"In the future, providers may want to consider incorporating psychosocial assessments over a period of time as a standard of care in the treatment of gender dysphoria," Lee said in the press release.

After facial feminization surgery, transgender people report better psychosocial health. Los Angeles, CA: University of California – Los Angeles Health Sciences; July 6, 2022. Accessed July 12, 2022. 

https://www.sciencedaily.com/releases/2022/07/220706165355.htm

Insurance companies often classify gender-affirming facial surgery as a cosmetic procedure, but a new study provides the first evidence demonstrating the medical basis for transgender patients experiencing gender dysphoria.

Data Show Gender-Affirming Facial Surgery Was a Standalone Predictor of Higher Psychosocial Health Scores in Transgender Patients

Alana Hippensteele, Editor

Since 2000, nurse practitioners have enhanced the availability and quality of primary care for Americans, especially aging baby boomers. However, if the primary-care health care delivery system remains fundamentally unchanged through 2020, experts project a shortage of 20,400 primary care physicians. The Health Resources and Services Administration indicates that the supply of primary care nurse practitioners (NPs) will increase by 30%, from 55,400 in 2010 to 72,100 in 2020. With proper integration of NPs and physicians’ assistants into our health care system, the physician shortage will shrink to about 6000.

Full prescriptive authority lets NPs integrate properly into the health care system.

Nurses’ roles began evolving during the Vietnam War in the 1960s, when concerns about the delivery of primary health care initially arose. The role continued to progress through many different certifications before NPs, such as certified nurse-midwives, certified registered nurse anesthetists, and clinical nurse specialists, became commonplace. These elevated roles existed mainly in acute inpatient settings and specialty units.

For NPs to practice most advantageously, they must have prescriptive authority, promulgated in state scope of practice laws as 2 distinct types: authority legislated by regulations or nursing statutes, and delegable authority.

The types of prescriptive authority permitted in nursing legislation are further broken down into 2 categories: dependent authority, under which physicians must cosign the order, and independent authority, under which NPs can prescribe alone.

Results of a study, conducted in North Carolina, showed that NPs with full prescriptive authority provide cost-effective care with high-quality outcomes.

Delegable authority mandates an initial patient-physician relationship. It is further broken down into 3 categories: physician determination of patient-specific medications, prescription renewal by the nurse, and standing order/protocols.

Barriers to full prescriptive authority come from federal and state legislature, and organization’ business structures. For example, under Medicare’s Physician Fee Schedule, NP services are paid at 85% of the physicians’ rate, which financially gives primary care practices an incentive to bill under the physician’s name. Additionally, federal regulations require physician cosigners on home care service orders. At the state level, 29 states still restrict NP practice and/or prescriptive authority by requiring collaborative relationships or physician supervision. Organizationally, in the primary care setting, physicians can employ medical assistants (MAs) to help support their practices, but NPs cannot. Results from a 2014 study showed that patient cost was cut by 9% to 12% if NPs could hire MAs as supportive personnel in primary care.

In 2016, the Department of Veteran Affairs (VA) issued a rule giving full practice and prescriptive authority to NPs. Even in states requiring physician supervision, NPs at the VA can practice with full practice rights within the scope of their VA employment.

NPs employed in pediatric intensive care units (PICUs) are also front-runners. In a 2017 national survey of 112 PICU medical directors of various organizations, 49% reported that NPs have full practice authority, and 73% reported that NPs have prescriptive authority in line with state laws.

Joy Elwell, director of the doctor of nurse practice program at the University of Connecticut in Storrs,said it best: “In all 50 states and 5 districts, NPs have some level of prescriptive authority.”

These levels are restricted by the state’s individual scope of practice, as noted above. Today, 23 states and the District of Columbia allow full practice authority, independent of physicians’ collaborative/supervision agreements. The most recent state to give NP full practice authority was Oklahoma, in March 2017.

Elwell also said, “As of 2017, NPs in Florida and Georgia can prescribe [some] controlled substances.” The other 27 states require either supervisory or collaborative practice.

“In general, the Northeast [Connecticut, Maine, New York, and Vermont], Northwest [Nevada, Oregon, Utah, and Washington], and Southwest [Arizona, New Mexico, and Wyoming] have excellent scope of practice laws,” Elwell said. “They give NPs practice and prescriptive authority equal to physicians. In the Southeast, the laws are less favorable. NPs can diagnosis, treat, and prescribe, but they must do so under supervisory/ collaborative practice with physicians.”

One of the most restrictive states is Alabama, Elwell said.

Alabama’s scope of practice law states that the supervising physician in a collaborative practice must be on-site 10% of the time. Parts of Alabama are extremely rural, and the collaborating physician may need to travel long distances. If the physician fails to arrive at the clinic, the state will close the practice, and suspend the NP’s license. Many times, the area has no other primary care practice, so patient care suffers. California, Massachusetts, New Jersey, Ohio, Pennsylvania, and Texas, among others, which have restrictive scopes of practice, have bills in their state legislatures to grant full prescriptive authority (Figure).

Patients, payers, and pharmacists tend to accept NPs without pushback.

“The American Medical Association [AMA] exerts pushback on a national level,” Elwell said. “Politically, the AMA says that physicians should resist legislation that promotes NP scope of practice.”

However, most local physicians disagree because they want to help provide health care to the 300 million-plus Americans.

The American Association of Nurse Practitioners is lobbying for change at the national level and supporting state-specific efforts. Each state also has its own NP association pushing to advance practice.

NPs have made great strides toward full practice, and prescriptive authority over the past 2 decades. Advocates, such as Elwell, think that over the next 10 years, more than 30 states will change their scope of practice laws to allow NPs to have full practice authority. As our population ages, and more people have access to health care, Americans will need NPs backed by advanced education and law to provide much-needed health care.

For updates on the different states’ scope of practice, visit

scopeofpracticepolicy.org/practitioners/nurse-practitioners

Alexandra R. Cambra, PharmD, is a graduate of the University of Connecticut in Storrs and works for CVS.

Health Resources & Services Administration. Projecting the supply and demand for primary care practitioners through 2020. bhw.hrsa.gov/health-workforce-analysis/primary-care-2020. Updated October 2016. Accessed April 10, 2018.

Edmunds MW, Cawley J. Historical review of prescriptive authority: the role of nurses (NPs, CNMs, CRNAs, and CNSs) and physician assistants. Basicmedical Key. basicmedicalkey.com/historical-review-of-prescriptive-authority-the-role-of-nurses-nps-cnms-crnas-and-cnss-and-physician-assistants/. Published July 22, 2016. Accessed April 10, 2018.

Conover C, Richards R. Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina.

. 2015;63(5):585-92. doi:10.1016/j.outlook.2015.05.009.

Poghosyan L. Federal, state, and organizational barriers affecting nurse practitioner workforce and practice.

Gigli KH, Buerhaus PI, Minnick AF, Dietrich MS. Regulation of pediatric intensive care unit nurse practitioner practice: A national survey.

Journal of the American Association of Nurse Practitioners

The Health Resources and Services Administration indicates that the supply of primary care nurse practitioners (NPs) will increase by 30% in 2020. Full prescriptive authority lets NPs integrate properly into the health care system. 

Authors