Tuesday, March 14, 2017

Vaccines, Medical Homes, and Cancer Prevention

An Updated Immunization Schedule

The 2017 update of recommended immunization schedules for children and adults were published recently by the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP). These recommendations represent agreement among professional societies and ACIP. Physicians use the schedules to ensure patients receive the right vaccinations for their age and medical condition. This year’s schedules came with a few changes worth noting.

  • ACIP now recommends boys and girls between 9 and 14 years of age only receive two doses of the human papillomavirus (HPV) vaccine, instead of the previously recommended three doses, because of the better response at the younger ages; those who begin the series at 15 years of age or older will require three doses. 
  • People with egg allergies can now take any age-appropriate flu vaccine instead of relying solely on an egg-free flu vaccine. 
  • The nasal flu vaccine is no longer recommended, as it is deemed too ineffective. 
  • The hepatitis B vaccine is now recommended for adults with chronic liver diseases like hepatitis C and cirrhosis. 
  • And the meningococcal B vaccine may be given to certain high-risk groups, like individuals between 16 and 23 years old who will be attending college.

Check out the child and adult schedules, and talk with your doctor to make sure you and your family are receiving the right vaccinations at the right time.

Medical Homes Improve Vaccination Rates

Dr. Siegel
Jane Siegel, MD, a Corpus Christi pediatric infectious disease physician, knows how essential vaccines are to both public health and individual patient health. She says one of the best ways to guarantee patients stay on top of their vaccinations is through a medical home ― a physician-led health care team that looks after a patient’s comprehensive and continuous medical care.

“Visits to a medical home provide opportunities to counsel patients on a variety of wellness topics, including vaccinations,” said Dr. Siegel. “It is a time to ensure our patients live in a safe environment in their home and that patients and families are fully informed about preventive practices like vaccines. It is important to remember: Every health care encounter is an opportunity to vaccinate.”

Medical home visits also “provide opportunities for vaccine-hesitant families to develop trust in the physician and provider team and learn the facts about vaccination,” added Dr. Siegel. “This is especially important in Texas, where the number of children getting school vaccine exemptions continues to increase yearly.”

And when it comes to maintaining accurate vaccination records for schools, a medical home can’t be beat, said Dr. Siegel: “The medical home is the best in position to maintain complete records so adolescents will have their immunization records required for higher education and jobs in areas where vaccinations are required.”

Vaccines Can Prevent Cancer

It can’t be said enough: In addition to preventing infection, some vaccines can even prevent certain cancers, stressed Dr. Siegel.

Specifically, “the HPV vaccine reduces the risk of cervical, vulvar, anal, penile, and head and neck cancers,” she said.  ”And the hepatitis B virus (HBV) vaccine reduces the risk of hepatocellular (liver) cancer. If parents and patients understand a safe vaccine can prevent cancer, who would not want to accept that vaccine?”

Wednesday, March 8, 2017

Code What? Improving Hospital Communication in an Emergency

By Scott Robins, MD
Chair, Texas Hospital Association Hospital Physician Executive Council
Division Chief Medical Officer, Medical City Healthcare

Anyone who has ever been in a hospital has probably heard over the public address system the cryptic words, “Code Pink” or “Code Black” or, more commonly, “Code Blue.” These color-based alert codes are intended to notify hospital staff and physicians and sometimes the public to an emergency of some kind.

The color-based alert codes typically are unique to each hospital. This means they lack standardization across facilities. When an emergency occurs and time is of the essence, this variation can create confusion and delay or uncertainty in response. This is particularly true for physicians who work in multiple hospitals and for new employees who have come from different hospitals.
The Texas Hospital Association has a solution.

It recommends that hospitals use standardized, plain-language emergency alerts instead of the color-based codes. The alerts are intended to allow hospitals to personalize the information to their facilities and provide site-specific details.

For example, instead of announcing “Code Pink” for a missing person alert, a hospital could instead announce “Security Alert. Missing female child, age 2. Last seen first-floor lobby.” Hospitals could choose to add additional information as warranted, such as instructions on contacting hospital security.
The intent of using plain-language alerts is to:

  • Promote the safety of patients, visitors, physicians, and hospital staff;
  • Reduce errors;
  • Increase transparency of communications and safety protocols; 
  • Align with national safety recommendations; and
  • Reduce confusion for staff or physicians who work in more than one facility. 

The initiative is completely voluntary, but THA hopes that every Texas hospital adopts all of the standardized, plain-language codes as part of the industry’s work to improve and provide higher quality, safer care.

Complete information about the initiative is available on www.tha.org/plainlanguagecodes.

Friday, March 3, 2017

Hard Hats for Little Heads: A Community Affair in Odessa

By Christine Wan
Odessa family physician
Hard Hats for Little Heads Physician Advisory Panel member

Editor’s Note: March is Brain Injury Awareness Month, and physicians encourage children and adults to wear the correct helmet for every wheeled sport to prevent brain injury or death in case of an accident.

As physicians, we love helping others. We are privileged to be in a position to help individuals in a meaningful way on a daily basis, but how can we help our community in a larger way?

For me, that opportunity came through a TMA program and a local organization. A few years ago, I joined Pilot Club of Odessa, a community service organization whose core membership is mostly professional women who want to bring positive things to our community. At a regional meeting in Lubbock, the Pilot Club of Alpine shared a presentation about how its club and a local physician, Adrian Billings, MD, cohosted a TMA Hard Hats for Little Heads event to give bike helmets to kids at a bike fair.

I knew Dr. Billings (also a Hard Hats advisory panel member) from our medical school days at The University of Texas Medical Branch, and I had heard about the Hard Hats program a few years earlier. I thought about doing Hard Hats then but didn’t know how I, as one doctor, would pull this off. After hearing about this collaboration between Pilot Club of Alpine and Hard Hats for Little Heads, I suggested our Odessa Pilot club bring the program to our community with me as the TMA physician sponsor. Everyone was in enthusiastic agreement.

Seven years later, we have given out more than 3,500 helmets to our kids. We hosted events at schools and bike fairs in our city, as well as rural areas around us in Crane and Fort Stockton. Our big yearly event is the Odessa Fall Festival, put on by the City of Odessa Parks and Recreation Department. The city began Fall Festival the same year we started our Hard Hats for Little Heads project, and organizers contacted Pilot Club about volunteering. We told them we could bring volunteers AND free bike helmets to give away. Every year, children come out early to line up for the helmets at the festival.

One year we had about 20 helmets left over, and we sent those to an orphanage in Guatemala via an Odessa church’s mission trip. Bike riding is vital in Guatemala as a form of transportation and employment. So our helmets have even gone international!

Pilot Club has a puppet presentation called “Brain Minders” that pairs nicely with the helmet giveaway when we do school presentations. The TMA Hard Hats program staff were great in helping us get started, providing resources and excellent communication. I and others have presented our Hard Hats project at local, regional, and state Pilot Club meetings and at Texas Tech School of Medicine to spread the word. So my story is one that began with a thought about how I, as one busy physician, could help my city and beyond in a bigger way. The answer to my question was to reach out to my professional and community organizations for help.

Wednesday, March 1, 2017

AMA Honors Texas Senator with Distinguished Service Award

WASHINGTON, D.C. – The American Medical Association (AMA) presented Texas State Sen. Kirk Watson with the Dr. Nathan Davis Award for Outstanding Government Service. Watson was selected for the AMA’s top government service award for asserting his community vision for health care and economic prosperity, most notably for leading the successful effort at the University of Texas Austin to build a new medical school from the ground up.

“Sen. Watson laid out a groundbreaking ‘10 Goals in 10 Years’ initiative for Austin, which included a comprehensive plan to bring a state-of-the-art medical school to the University of Texas in Austin,” said AMA Board Chair Patrice A. Harris, M.D. “Just five years later, the Dell Medical School opened its doors to the first class of 50 students in 2016. Through his bold vision and hard work, Sen. Watson is not just inspiring great change in Austin, but helping shape the landscape of medicine and medical schools well into the future.”

As part of his “10 Goals in 10 Years” initiative, Sen. Watson also put forth a vision to develop laboratories and other facilities for public and private research, provide needed psychiatric care and facilities, make Austin a center for comprehensive cancer care, and build a modern teaching hospital. The hospital – the Dell Seton Medical Center at The University of Texas – will open this year.

Watson is one of 10 honorees chosen this year to receive the Dr. Nathan Davis Award for Outstanding Government Service. The award, named for the founding father of the AMA, recognizes elected and career officials in federal, state or municipal service whose outstanding contributions have promoted the art and science of medicine and the betterment of public health.

“For more than a quarter century of the Nathan Davis Awards, the AMA has sought to salute government officials who go above and beyond the call of duty to improve public health,” said Dr. Harris. “Award winners have come from every branch of government service and are a testament to the important role public officials play in creating and implementing health policy that benefits Americans.”

Sen. Watson was presented with the award last night at a ceremony in Washington, D.C. as part of the AMA’s National Advocacy Conference.

The American Medical Association is the premier national organization dedicated to empowering the nation’s physicians to continually provide safer, higher quality, and more efficient care to patients and communities. For more than 165 years the AMA has been unwavering in its commitment to using its unique position and knowledge to shape a healthier future for America. For more information, visit ama-assn.org 

Tuesday, February 28, 2017

Physicians Can Make A Difference — A Personal Perspective

By Davor Vugrin, MD
Lubbock Oncologist
President, Lubbock-Crosby-Garza County Medical Association

Dr. Vugrin's story below describes one of the best rewards of being a physician — saving and improving patients' lives, even the lives of individuals of whom he or she might be unaware. This column was first published in the Lubbock-Crosby-Garza County Medical Society newsletter.

As a growing young boy I observed and studied the world around me with fascination and intense curiosity. One day after observing all kinds of living creatures I asked my father: "Dad, what is the purpose of (our) life?' He smiled knowingly and said: "Well, it all depends on what you make out of it."

During the summer between my 1st and 2nd year of medical school, I volunteered working on the medical floors in a hospital. I was surprised to see a number of young people, some younger, some older then I and some much younger, just kids, being admitted to the hospital with the diagnosis of "cancer." Sometimes the diagnosis was lymphoma, or leukemia or other types of cancer.

At that time, there were very few effective treatments for advanced cancers, and most cancers were advanced by the time they were diagnosed. These young people were wasting away in front of my eyes and dying. "Young people are not supposed to die. They are supposed to grow old. Only old people die" I thought in disbelief. It was at that time that I decided that I would train to become a cancer specialist once I completed my medical school education. In the enthusiasm of my youth I decided to devote my life to "saving the world" from cancer and helping to find the cure for cancer. I was determined to make a difference!

Several years later and a world away, after completing my service in the US Air Force, I was accepted into the hematology fellowship training program at the University of Michigan in Ann Arbor. All I was interested in was to study the control of malignant diseases. By that time, through advances in research, we started controlling and curing acute leukemia, Hodgkin's and Non-Hodgkin's lymphoma in those young age groups that previously I had seen dying from these diseases like flies. This strengthened my belief that we could improve the world and make it a better and a safer place to live.

In the pursuit of my life mission, subsequently, I took fellowship training in medical oncology at the Memorial Sloan Kettering Cancer Center in New York. A NFL Grant in honor of Brian Piccolo funded my research fellowship. He was a football player in Chicago who developed germ cell cancer in the chest and succumbed to it for lack of effective treatments. The NFL was funding research to find a cure for this cancer. When my mentor suddenly left, I was asked to take his position and lead and direct a group conducting clinical and basic research in germ cell cancers. This type of cancer most frequently originates in testicles of young men between ages of 15 and 35 years of age and until then it had been the most common cause of cancer death in young men. Our research program attracted desperate young men with testis cancer from all over the world. Because of this program, at our institution you would think that this was one of most common cancers around judging by the number of patients that we saw. That was also the time when those of us at Sloan Kettering Cancer Center and investigators at Indiana University made a breakthrough in the treatments of these cancers. Germ cell cancer became one of the most curable cancers even in its most advanced stages. Our two groups received plenty of recognition from around the world.

However, the recognition that I personally appreciated the most was one event that occurred in early June few years back. At the annual meeting of the American Society of Clinical Oncology in Chicago, I was approached by an oncologist who asked me:

"Dr. Vugrin, do you know who I am? You treated my brother from Brazil who was diagnosed with terminal testis cancer 28 years ago and you cured him. He is alive and well living in Sao Paolo. He is married with children and very successful in his profession. I was inspired by what happened. I went to medical school and became an oncologist and I am helping others just like you did. Do you remember Doctor S. who trained under you? He is a very famous oncologist in Brazil."

It is a good feeling to know that one's efforts have directly and indirectly populated the world with cancer survivors of whom many have become important and productive members of their communities around the world. It further strengthened my own belief that we all can make a difference in someone's life. Sometimes, we don't know the good results of all of our efforts.

We physicians make differences in people's lives.

We all make differences in people's lives, again, and again and again.

Friday, February 24, 2017

Popular Charity Heart Screenings For Teens May Cause More Problems Than They Solve

By Mary Chris Jaklevic
Kaiser Health News

Content provided by Kaiser Health News

Dozens of not-for-profit organizations have formed in the past decade to promote free or low-cost heart screenings for teens. These groups often claim such tests save lives by finding abnormalities that might pose a risk of sudden cardiac death.

But the efforts are raising concerns. There’s no evidence that screening adolescents with electrocardiograms (ECG) prevents deaths. Sudden cardiac death is rare in young people, and some physicians worry screening kids with no symptoms or family history of disease could do more harm than good. The tests can set off false alarms that can lead to follow-up tests and risky interventions or force some kids to quit sports unnecessarily.

“There are harms that I don’t think a lot of people realize,” said Dr. Kristin Burns, who oversees a two-year-old registry at the National Institutes of Health of sudden deaths in people under 20. It’s one of several efforts aimed at gathering better data about cardiac abnormalities in kids.

Studies using limited data have found between one and four sudden cardiac deaths occur annually per 100,000 kids between ages 1 and 18. By comparison, 22 out of 100,000 U.S. teens are killed in accidents, including those involving motor vehicles, and nine out of 100,000 commit suicide, according to the Centers for Disease Control and Prevention.

Some screening advocates believe sudden cardiac deaths are underreported and not enough is being done to spare families from the fate of losing a child. “We have to acknowledge that every kid who drops dead, they’ve been failed by the current system,” said Darren Sudman, who founded Simon’s Fund, a screening effort in greater Philadelphia in memory of his infant son, who died of an arrhythmia.

Screening programs say they’re educating parents about the risks. “What we want to emphasize is, make sure your kid is heart-safe,” said Dr. Jonathan Drezner, a sports and family medicine specialist in Seattle at UW Medicine and medical director of the local Nick of Time Foundation.

Enthusiasm for ECGs, which measure the electrical activity in the heart to detect abnormalities, grew after a 2006 study showed they lowered death rates among athletes in Italy. But research in other countries has not yielded similar results, and the Italian researchers recently were accused of refusing to share their data so it could be evaluated independently.

Some 60,000 to 70,000 U.S. teens were screened in 2016, most by foundations created by families who lost a child to sudden cardiac death, said Darren Sudman, who runs an online directory, Screen Across America. It’s unclear whether high school athletes face higher risk than non-athletes, so screening programs usually invite everybody.

Screenings typically are held in high schools and overseen by volunteer cardiologists, with funding from individuals and businesses including hospitals. A handful of hospitals and for-profit companies also run screenings.

It may be presumptuous to claim ECGs save lives, but parents often believe they do, said Sudman. “If I find a heart condition, I promise you there are parents who are thanking me for savings their kid’s life.”

That perception is stoked by tragic stories in the media of children who died suddenly after never reporting a symptom. Meanwhile, the drawbacks of ECGs are seldom depicted. As many as 1 in 10 ECGs detects a potential abnormality, and the emotional and financial toll of such a finding can be significant — especially when they turn out to be wrong.

Following a screening ECG and echocardiogram last fall, Daniel Garza, 16, a talented sophomore basketball player in San Antonio, was told he had hypertrophic cardiomyopathy, a thickening of the heart muscle and the most common cause of sudden cardiac death in young people. He was advised to quit all exercise, at least temporarily.

“We were shocked, just shocked,” said his mother, Denise. She said her son became depressed when he couldn’t play the sport he enjoyed and excelled at. “He came home and cried himself to sleep. He said, ‘Mom, why did God give me this gift to take it away?’”

The Garzas traveled to the Mayo Clinic in Rochester, Minn., where further tests indicated his enlarged heart was a benign condition known as athletic heart, a result of intense training. His mother estimates that correcting the misdiagnosis cost more than $20,000, including medical costs, travel and lost work.

Daniel has returned to the basketball court. Still, Denise Garza said the emotional toll was rough. “It was one of the hardest things my family has ever endured.”

Several cardiologists said they often see cases like this or worse. Even after follow-up testing, it can be unclear which cases are life-threatening, so kids with low risk could be restricted from exercise or given life-altering interventions such as implantable defibrillators, surgery or anti-arrhythmic medications.

Medical groups have wrestled with the issue. The American Heart Association and the American College of Cardiology recommended in 2014 against mass ECG screening, noting that sudden cardiac death is rare in teens and false positives generate “excessive and costly second-tier testing.” ECGs also miss at least 1 in 10 cases of hypertrophic cardiomyopathy and more than 9 in 10 cases of congenital anomalies, the second-most-common cause.

But their expert panel accepted voluntary screening “in relatively small cohorts” if there’s physician involvement, quality control and a recognition of unreliable results and ancillary costs.

By contrast, there’s broad support for automated external defibrillators, which have been shown to prevent deaths at schools and other public places. Some foundations focus their efforts on disseminating the defibrillators.

One problem with ECGs is a lack of good data.

“There’s no evidence we have that ECG screening saves lives,” said Dr. Jonathan Kaltman of the NIH’s National Heart, Lung, and Blood Institute. “There’s never been a controlled clinical trial, which is the only way to answer that question.”

Efforts are underway to improve the accuracy of the screening programs. Some are adding echocardiograms, which use ultrasound to produce images of the heart, to verify potential abnormalities. Advocates say false positives have dropped as a result of better interpretation guidelines, known as the Seattle Criteria, which are expected to soon be endorsed by cardiology societies in revised form.

But the criteria are not perfect, and there’s a “giant gap” in training cardiologists to use them, said Drezner, one of the developers. He’s also a medical adviser for Parent Heart Watch, a consortium of foundations. “If I was a parent, I’d want to know about the experience of the (cardiologists) and what they’re going to do to help my kid if they have a positive screen.”

At the urging of screening advocates, the NIH partnered with the Centers for Disease Control and Prevention to rigorously track cardiac deaths as part of a Sudden Death in the Young Case Registry. So far a handful of states and counties have joined the effort, which helps local health departments collect better data. The goal is to standardize death investigations and get a firm handle on how often kids die from heart abnormalities as well as the role of factors such as genetics. Initial findings are expected to be available in about two years. The NIH is also funding three university-based research groups to answer key questions about sudden cardiac death in the young.

Some screening organizations are getting behind a nascent initiative with the Cardiac Safety Research Consortium to harness their own screening data for research. It would require standardizing their practices and tracking outcomes, which organizations aren’t now equipped to do.

“Screening is happening. We can’t avoid that,” said Dr. Salim Idriss, director of pediatric electrophysiology at Duke University and co-chair of the initiative. “We have a really good opportunity to get the data we need to make it better.”

Separately, the UT Southwestern Medical Center in Dallas recently began a four-year pilot study involving athletes and band members at eight high schools to determine the feasibility of a full-scale randomized controlled trial.

A valid finding on the overarching question of whether ECG screening saves lives could require at least 800,000 participants and a cost of $15 million, said Dr. Benjamin Levine, a cardiologist and the lead researcher.

The pilot is partly a response to legislation that would mandate ECGs for student athletes in Texas. A similar bill was also introduced in South Carolina. Both bills failed, but it’s expected there will be more attempts to mandate ECGs, leaving state legislators looking for better guidance.

“We’re not going to solve this by having more debates, but by having more data,” Levine said.

This article was produced by Kaiser Health News

Thursday, February 16, 2017

Texas Doctors’ Prescription for the 2017 Legislature

By Ray Callas, MD
Beaumont Anesthesiologist
Chair, Texas Medical Association Council on Legislation

Growing state and federal government regulations and insurance company mandates are stealing time Texas physicians should spend with our patients. This is unacceptable. Every minute my colleagues and I spend with a patient is a minute that matters. This is why we have dedicated ourselves to tirelessly advocating for legislation that allows us to spend more quality time with our patients, foster the critical patient-physician relationship, and provide care in the manner in which we were trained.
With the 85th Texas legislative session underway, the Texas Medical Association (TMA), comprised of more than 50,000 doctors and medical school students who are caring for our state’s 27 million citizens, is urging lawmakers to take specific actions to help improve patient care. We encourage you to join us in making state legislature calls and/or to write to or call your legislator to push for the quality care that all Texans deserve.

Our 2017 prescription to keep Texas healthy includes:

1. Enact a Texas-Run Health Care Solution for Our Low-Income Families, Seniors, and Texans with Disabilities
  • Protect coverage and access to health services for our most vulnerable populations.
  • Set physicians’ Medicaid payment rates at least equal to Medicare.
  • Cover Texas’ one million-plus uninsured with private insurance that includes copays, tailored benefits, and health savings accounts.
  • Modernize the Medicaid Vendor Drug Program and improve Medicaid prior authorization requirements to cut regulative red tape.

2. Stop Health Insurance Tactics That Cause Surprise Medical Bills
  • Require health plans to comply with current network adequacy requirements and provide accurate directories of their network providers.
  • Expand the current mediation process, while maintaining the $500 threshold, to all physicians and providers providing out-of-network services at certain in-network facilities, and to certain out-of-network scenarios where patients are receiving surprise bills for emergency care.
  • Allow physicians to override health plans’ use of “step therapy” to substitute prescribed drugs for chronically ill patients.

3. Invest Wisely In Mental Health, Public Health, and Public Safety Programs
  • Ensure parents’ right to know about vaccination exemption rates at their children’s schools. 
  • Improve access to quality mental health care services.
  • Increase minimum age to buy tobacco products to 21.
  • Ban texting while driving.
  • Make state higher education and state agency campuses tobacco free.

4. Use Technology — Not Mandates — To Address “Doctor Shopping” and Opioid Diversion
  • Require prescriber licensing boards to automatically register their licensees for Texas’ Prescription Drug Monitoring Program.
  • Authorize the Board of Pharmacy to “push out” electronic notifications to prescribers and pharmacies when data suggests “doctor shopping.”
  • Add wholesaler delivery data to the Drug Monitoring Program database in order to match dispensing and delivery data by geographic area.

5. Require Same Standard of Medical Care Whether In-Person or by Telemedicine 
  • Physicians providing care to Texans must be licensed in Texas.
  • Ensure that physicians have access to the patient’s relevant clinical information in order to make a diagnosis and conform to the standard of care. 
  • A medically necessary, covered service should be paid for regardless of how it is provided.

6. Support a Strong and Fair Texas Medical Board (TMB) and Stop Diverting Physician License Fee Revenue
  • Continue and improve the TMB to ensure appropriate and safe regulation for the practice of medicine.
  • Medical Board discipline procedure needs to protect patients and guarantee physicians a transparent, fair process.
  • Stop diverting physician license fee revenue to the general fund. Instead, reduce the fee and use all funds collected to improve the Medical Board and speed up Texas medical licensing, which can take more than 12 months for the entire application process.

7. Require Medical School Training and Licensure for All Who Practice Medicine
  • Diagnoses and prescriptive authority must remain the purview of medical-school-trained, licensed physicians.

8. Protect Our State’s Medical Liability Tort Reform Caps
  • Since statewide voter approval of non-economic medical liability damage caps in 2003, Texas has gained 21,000 new physicians. Protecting these caps will help our state continue to improve upon our national ranking of 41st in active patient care physicians per capita. 

9. Keep Our Texas-Trained Doctors in Texas
  • Ensure we have 1.1 Texas residency slots for every one Texas medical school graduate.

The TMA and our physician members are fighting every day to ensure that we are putting patients first and are working to protect the personal health of all Texans. We are ready to provide counsel and advice or answer any questions you may have on these issues or others. We encourage you to reach out at (800) 880-7955 or connect with us on Facebook or Twitter @TexMed to engage and learn more.

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