Thursday, July 20, 2017

Heads Up: Vaccine Required for College-Bound Students

As recent high-school graduates prepare to move into a college dorm, Texas physicians remind them to make sure their vaccinations are up to date, particularly one that is required for college admission. Texas law requires almost all new and transfer college students under age 22 to be vaccinated against meningococcal disease caused by the most common types of bacteria — or “serogroups” A,C,W, and Y — at least 10 days before classes begin.

“If your vaccinations are current according to medical recommendations, you likely received your first dose of the required vaccine at age 11 or 12 years because it is required for middle school entry, and then got a booster at age 16 to provide protection through college,” said Jane Siegel, MD, Corpus Christi, a pediatric infectious disease specialist and chair of the Texas Medical Association’s (TMA’s) Committee on Infectious Diseases.

Check your vaccination record to make sure you had the two shots, said Dr. Siegel, because colleges require entering students to show proof of vaccination within the previous five years.

“College students are at increased risk of meningococcal infection that can result in very serious disease, including meningitis, and that can spread among people who live in close quarters,” said Dr. Siegel, who is a member of TMA’s
Be Wise — ImmunizeSM Physician Advisory Panel. “This germ is spread through respiratory tract secretions, so living in close quarters like a dormitory increases the likelihood of spread of this organism and is the reason for this mandate to cover meningococcal types A, C, W, and Y.”

Meningitis strikes alarmingly quickly with fever, headache, severe muscle aches, and stiff neck. The symptoms can seem like flu but progress with vomiting, weakness, mental confusion, shock, and sometimes a purple rash. Emergency medical care is important because this illness can become deadly within hours.

Types of meningococcal disease include infections of the brain’s lining and spinal cord (meningitis) and/or the bloodstream (bacteremia or septicemia). Bacterial meningitis is a common term. The meningococcus bacteria spread through coughing, sneezing, sharing drinks or eating utensils, or kissing.

Additionally, a relatively new vaccine can safely prevent infection caused by a different serotype of the meningococcus organism, serotype B. This vaccine against serotype B is not required at this time because the infection is relatively rare. However, outbreaks of this infection have occurred on a few college campuses in the United States. For that reason, physicians and other health experts recommend families with 16- to 23-year-olds discuss the meningococcal group B vaccine with their physicians to decide whether to get this vaccine too.

Meanwhile, a shot to prevent cancer

Another vaccination to consider, said Dr. Siegel, is human papillomavirus (HPV) vaccine — a shot that can prevent cancers in men and women. “You may have gotten this vaccine at a younger age, but if not, start the three-dose series before heading to school, and complete the series at your college student health service,” she said. (Three doses are required if you get your first shot at age 15 years or older; only two doses are needed if you begin before age 15.)

Bottom line, she said, vaccines saves lives: “Immunizations are one of the 10 most important public health advancements of the 20th century. So, it is best to prevent what we can when safe and effective vaccines are available.”

Stay registered

Also, students who are 18 years of age should sign the consent form to keep their vaccination records in the Texas state registry. Having vaccine data in the registry allows adults to keep up with vaccinations throughout their lifetime.

“We know college students move around and participate in all kinds of special programs in the summer and throughout the year that require immunization records,” said Dr. Siegel. “Having the data available in the state registry is convenient and will allow you to get vaccine reports when you need them.”

TMA has published a fact sheet about the importance of meningococcal vaccination, in English and Spanish, as well as an infographic on HPV.

Wednesday, July 12, 2017

New Law Shapes the Future of Telemedicine in Texas

Texas physicians and telehealth providers are now playing by the same rules to treat patients by phone, computer, and other new technologies — the same as when physicians see patients face-to-face in a traditional doctor’s office visit. Senate Bill 1107, passed this session by the Texas Legislature and signed into law by Gov. Greg Abbott in late May, clarifies the framework to evaluate, diagnose, and treat patients remotely via telecommunication technology. Telemedicine can be a helpful tool for physicians to see some patients who cannot travel hundreds of miles — or even one mile — to the doctor’s office. Imagine “seeing” your physician via your computer or smartphone.

The bill-signing by the governor ends months of debate in the Texas legislature and caps more than a year’s worth of collaborative input by the Texas Medical Association (TMA), the Texas e-Health Alliance (TEHA), the Texas Academy of Family Physicians (TAFP), and numerous telemedicine stakeholders.

“I am happy and ecstatic for the patients of Texas,” said Ray Callas, MD, a TMA Board trustee and immediate past-chair of TMA’s Council on Legislation. “As technology advances, patients will have more access to physicians, resulting in fewer ER visits for minor ailments; and more patients, especially in rural areas, will have access to primary care at home via telemedicine technology.”

Sen. Charles Schwertner, MD (R-Georgetown), the author of SB 1107 and chair of the Senate Health and Human Services Committee, played a key role early in the session to bridge an impasse among competing telemedicine interests to define telemedicine and hold telemedicine services to a single standard of care. Rep. Four Price (R-Amarillo) sponsored the companion bill, House Bill 2697, and he also played a key role in crafting language to require health insurance plans to cover telemedicine as a service provided by the physicians they have under contract. If policyholders’ insurance covers this type of care, more physicians might be able to offer it to those patients. In fact, the law also requires health plans to post telemedicine payment policies — minus their contracted rates they will pay for this service — to their websites, to inform physicians.

The months of negotiation by TMA, TEHA, and TAFP to expand the use of technology in Texas medicine resulted in the core language of SB 1107, including:

  • The standard of care for a telemedicine visit is the same as a patient/ physician in-person visit;
  • The definition of a true patient-physician relationship to conduct telemedicine;
  • A physician must be able to access — and must use — clinically-relevant data in rendering a diagnosis in accordance with the standard of care; and
  • Health plans must cover telemedicine as a means of providing services to their insureds when a contracted physician performs the care.

“We are now seeing opportunities to access physicians and providers from anywhere at anytime for most any reason, thanks to technology. But technology by itself is not the solution to our healthcare challenges," said Austin-based telemedicine internist and psychiatrist Thomas Kim, MD, who testified for TMA in support of the bill, and helped craft its language. “At the end of the day, telemedicine care is medical care and should be held to the same standards and guidelines.”

The bottom line, doctors say, is telemedicine is a means of providing care to a patient; it is not a service in and of itself. It is a tool in the physician’s toolbox.

The new law is expected to expand the use of technology in health care. “Is this the end all, be all? No,” said Dr. Callas, “but it is the start of something that will allow patients to get the best care, and for physicians to be the captain of the ship to delegate and supervise the care of all Texans.”

Some of the law’s elements took effect when the governor signed it, while the insurance related provisions go into effect on Jan. 1, 2018.

Wednesday, June 14, 2017

HPV Vaccination Prevents Cancers in Men, Too

Men: A shot that prevents cancers — the human papillomavirus (HPV) vaccination — is for you, too, though not nearly enough males are getting it. Sadly, physicians say, vaccination rates in males are extremely low, and doctors are seeing more cancers in men caused by HPV.

Nearly half of men aged 18 to 59 years (45.2 percent) have HPV infection, according to this month’s issue of the national medical digest JAMA Oncology. Yet just one in 10 (10.7 percent) of those males eligible for the HPV shots had been vaccinated, based on data collected through the National Health and Nutrition Examination Survey (NHANES).

For years, scientists have touted the HPV vaccination’s power to reduce cervical cancer in women. Now, during Men’s Health Week, Texas physicians urge men to get vaccinated against HPV to prevent cancers. HPV causes several cancers in men and women, including oropharyngeal (cancers of the head and neck such as the throat and mouth), penile, anal, cervical and vaginal. Some cases are fatal.

“HPV vaccination could change the course of health for many men,” said David Lakey, MD, of Austin, chair of Texas Medical Association’s (TMA’s) Council on Science and Public Health. “The decision to get vaccinated during adolescence or even young adulthood could mean you don’t have to suffer from an HPV-caused cancer such as throat or genital cancer, down the road.”

More than 79 million Americans are estimated to have some strain of HPV infection. HPV is the most common sexually transmitted infection in the United States, yet there is no treatment for HPV. Half of the infections are believed to occur before people reach age 24. Usually, HPV infection goes away on its own. But when it doesn’t, the infection may cause cancer years later.

According to the JAMA article, more than 9,000 cases of HPV-related cancers are diagnosed each year in men. HPV has been found to cause 63 percent of penile cancers and 91 percent of anal cancers. Throat cancers are becoming increasingly common. Nearly 16,000 oropharyngeal cancers, found in the tonsils and base of the tongue, are diagnosed in the United States each year, according to the Centers for Disease Control and Prevention (CDC). And nearly all genital warts (90 percent) are caused by HPV infections, affecting some 160,000 men each year.

Physicians and other health experts recommend the HPV vaccination for both males and females until age 26. Ideally, adolescents receive two HPV shots for best protection — before being exposed to HPV.

But in Texas, only about one-quarter to one-third of teen males are fully vaccinated against HPV, according to the 2015 National Immunization Survey-Teen.

Older teens and young adults who weren’t vaccinated in adolescence can still benefit from HPV vaccination, said Dr. Lakey, who developed and leads TMA’s HPV Working Group. For those over age 15, however, CDC recommends three shots for full protection.

“If you’re a young male and you haven’t gotten the HPV vaccination, ask your doctor about it,” said Dr. Lakey. “It’s certainly easier and better to prevent a cancer than have to endure potentially lengthy, uncomfortable, and costly medical procedures to treat one.”

TMA’s infographic and fact sheet, both in English and Spanish, explain the importance of HPV vaccination.

Monday, June 12, 2017

Four Ways Men Can Safeguard Their Health

By Alan Howell, MD
Temple Infectious Disease Specialist
Member, TMA Be Wise — Immunize℠ Physician Advisory Panel

We’ve all heard the adage, “An ounce of prevention is worth a pound of cure.” Knowing how my household functions, and having taken care of countless men who were certain they would get better if only they “wait a little longer,” one would assume that saying was coined by a woman. Interestingly, Henry de Bracton, a 13th century English cleric and jurist (and surprisingly a man!), is the person credited with the statement.

Men’s Health Week (June 12-18) is upon us, providing those of us with a Y-chromosome a reminder to take a more active role in our personal and family health maintenance. To this end, here are several steps we can take to ensure continued good health:

  • Schedule an appointment with your primary care physician (PCP). An ongoing dialog is necessary for your PCP to provide proper education and care. If it’s been a long time since your last visit, this is the time to get reacquainted!

  • Stay on top of your vaccination needs. TMA has created a concise adult immunization infographic to provide a basis for you and your physician to determine which vaccinations you might need.

  • Kick the tobacco habit. I know, I know… you’ve heard this before. I’m not saying kicking the habit is easy. Some patients may be successful on their own. Others may need assistance. There is no right or wrong way when it comes to tobacco cessation. Your PCP, however, is an important advocate when it comes to addressing — and meeting — this goal.

  • Exercise and eat right. Obesity (Body Mass Index greater than 30) can cause a raft of additional health issues: stroke, heart disease, arthritis, and gout, to name a few.  Additionally, people who are obese spend more on medical needs each year than people of normal weight (approximately $1,400 greater). The national goal is for each state to have an obesity rate of less than 15 percent. No state has met this goal, and Texas currently DOUBLES that figure — 32.4 percent of Texans are obese. Exercise and diet are key to addressing the issue. Be a role model for your family! Healthy attitudes (as well as unhealthy attitudes) can be passed on to our children. By incorporating exercise and healthy foods into your daily routine, you can give your children a gift from which they will benefit for the rest of their life.

Bottom line: Guys, seize this reminder week to take the first step to better care for yourself. You can benefit from a healthier, happier, longer life with just a few positive tweaks. Get active. Eat healthier. Stop smoking. See your doctor for a checkup. Get your shots.

It starts today.

Tuesday, June 6, 2017

Plan a Healthy Summer Vacation

By Jason Terk, MD
Past President, Texas Pediatric Society
Keller Pediatrician
Member, TMA Be Wise Immunize Advisory Panel

The CDC's travel guide. Click to visit.
This summer, many folks will be hitting the roads, seas, and skies for travel destinations both luxurious and humble. If your travel includes international destinations, it is important to be aware of what health precautions you and your family should take. Some of these precautions will require advance planning.

When my patients ask me what they need for travel to a specific destination, I always consult the most reliable source, which is the Centers for Disease Control and Prevention (CDC) website. If you point your browser to this link, you can search for any international location and find information specific to that destination about whether you will need certain vaccines or malaria prevention medications. If you find that either are required for travel to the destination(s) you will be visiting, plan ahead to consult your doctor or visit a local travel medicine clinic.

One additional new concern is the threat of Zika transmission from the bites of mosquitoes. I cannot overemphasize this point: Pregnant women, or women who might be or are planning to become pregnant should not travel to areas with risk for Zika transmission — including the Miami area and the Rio Grande Valley. For non-pregnant couples, because Zika is also sexually transmitted, precautions must be taken during and following travel to Zika-risk areas. Non-pregnant women should abstain from sex or use a barrier contraceptive during and following travel for a period of at least eight weeks to reduce risk of transmission to their sexual partners. Because Zika persists in semen longer than in other body fluids, men should abstain from sex or use a barrier contraceptive during and following travel for a period of at least six months to reduce risk of transmission to their sexual partners. All travelers to Zika-risk areas should use an effective insect repellent that contains DEET, picaridin, IR3535, or oil of lemon eucalyptus on their bodies and a permethrin-containing insect repellent on their clothes. Bed netting may be used in rooms that are not screened or air-conditioned. Talk to your doctor and visit this link for more information.

Got a smartphone? Download the CDC’s TravWell app to help plan a safe and healthy trip. The app lets you build a trip to get destination-specific vaccine recommendations, get a checklist of what you need to do to prepare, and customize a healthy travel packing list. It also lets you store travel documents, keep a record of your medications and immunizations, and set reminders to get vaccine booster doses or take medicines while you’re traveling.

Wednesday, May 17, 2017

Women’s Health: Challenges and Advancements

By Raymond Moss Hampton, MD 
Midland Obstetrician-gynecologist; regional chair and professor, Department of Obstetrics and Gynecology, 
Texas Tech University Health Sciences Center at the Permian Basin

Women’s Health Week began this Mother’s Day, which presents a great opportunity to consider some issues facing women’s health care. Women’s health care is in the midst of some exciting, yet challenging, times. So much is changing, and so many good things are happening for women!

For example, advances in minimally invasive surgery, contraceptive options, prenatal diagnosis (diagnosing a fetus’s illness before birth), and preimplantation genetic testing (testing embryos for genetic disorders before implanting them in the mother during in-vitro fertilization) are now prevalent. Ultrasound capabilities show us pictures of the fetus we once never dreamed possible! Therapeutic options for gynecologic cancer, pelvic prolapse (when a pelvic organ drops and pushes against the vagina), urinary incontinence, or infertility issues give patients more choices with better results than ever before. Vaccines, such as the HPV vaccine, have now been shown to prevent not only cervical cancer but also vulvar cancer, anal cancer, and several head and neck cancers.

Advances in patient safety, quality improvement, and collaborative care are producing encouraging results in better patient outcomes and better care.

Of course, the challenges are significant at all levels, as well. Women in third-world countries face numerous health care disparities. In many places, there are no doctors or hospitals. Infectious diseases such as Ebola and Zika are significant threats. There are few vaccination programs, blood banks are found only in large medical centers, and free standing emergency departments are a dream. Given those obstacles, how can we help those people achieve basic levels of care?

Even here in the United States, we are not immune; women have their own set of health care challenges. The national health care debate and the repeal of the Affordable Care Act will directly affect many women’s access to care. Reproductive rights, in its many forms, is another hot topic on the national level.

In Texas, severe maternal morbidity (illness) and mortality (death) rates are unacceptably high. Access to care is threatened, and health disparities across our state are significant and affect most adversely those who are underinsured or uninsured. The unequal distribution of physicians and health care providers continues to affect health care adversely in our rural areas. Hopefully, our lawmakers will come together and pass legislation that will improve access, advance new technologies, and effectively address the unique challenges facing our state, so that we are able to give all of our patients the high-quality care they need and deserve.

We physicians face challenges too, as we attempt to care for our patients. We are all adjusting to bundled payments and electronic health records, and wondering how we will be affected by programs such as the Medicare Access and CHIP Reauthorization Act of 2015, which outlines how physicians are paid for caring for Medicare patients. Patient satisfaction scores, workforce shortages, and rising insurance premiums weigh heavily on most of us.

All of that said, Women’s Health Week offers a great opportunity to stop and ponder the next generation of women’s health care; there is so much to think about! Are we up for the challenge? I think so, because we physicians are all dedicated to the patients we serve. And we remember and are motivated by the many wonderful women in our lives, and the challenges they have faced and overcome.

Let us all work together to improve their health in every way we can. They deserve our best.

Tuesday, May 2, 2017

Nurses Are Not Physicians

By Don R. Read, MD
President, Texas Medical Association

This article was originally published on TribTalk by The Texas Tribune

Advanced practice registered nurses (APRNs) perform a vital, important function in our health care delivery system. I value them as members of my own care team and rely on them to provide excellent patient care. However, they are not physicians, any more than I am a nurse. Texas is correct to keep its team-based care approach. It ensures patients receive care from each member of the patient care team, based on his or her knowledge, training and expertise.

In 2013, physicians and nurses joined to help write a landmark state law that improved access to care and strengthened the team-based approach to providing health care to all Texans. Texas physicians still strongly support that collaborative care model, in which each team member practices to the top of his or her professional license. A collaborative model ensures patients receive safe, cost-effective and efficient care.

Yet now some nursing groups apparently reject that model. They want to practice independently as if they are physicians — without attending medical school. They claim more patients would receive care, at a lower cost, if lawmakers grant them independent practice authority.

First, there is no evidence — in Texas or elsewhere — to support the notion that granting nurse practitioners authority to diagnose and prescribe independently would improve patients’ access to care. States that have granted practice autonomy to nurse practitioners have not seen nurses rush out to rural communities to hang their shingles and start treating patients. Instead, most nurse practitioners continue to practice alongside physicians in clinics and hospitals as they always have, clustered in the same metropolitan and suburban communities.

In Texas, 52.5 percent of APRNs practice in the state’s five largest counties (Harris, Dallas, Bexar, Travis and Tarrant). Not surprisingly, 51.9 percent of primary care physicians practice in those same five counties. And while patients need primary care, only slightly more than half of America’s APRNs (52.5 percent) practice primary care. And the number of APRNs entering a primary care field has dropped by 40 percent since 2004.

Second, the evidence tells us that independent practice for these nurse practitioners actually will increase costs in our already overpriced system. Studies show nurse practitioners tend to order more expensive tests and diagnostic scans than doctors, and they are quick to refer patients to specialists — all of which drives up the cost of care. Research found that patients under APRNs’ care were hospitalized 41 percent more often than patients cared for in the same settings by physicians. And one-quarter more of the APRNs’ patients saw specialists than those under physicians’ care.

The nurses’ arguments simply do not hold water.

Meanwhile, collaborative care models such as the patient-centered medical home continue to prove their effectiveness. Nearly one-third (29 percent) fewer patients have visited emergency departments, almost 40 percent fewer patients have been hospitalized, and total medical costs are down nearly 9 percent since implementation of various patient-centered medical homes around the country.

What’s more, “primary care” often is acute, complex care, especially in rural areas. Primary care physicians (with the support of their health care teams, all working to the top of their training and abilities) care for car-accident victims, children with severe allergic reactions, people with chest pain, gunshot victims, burn victims and women about to deliver babies. Those patients and the tens of thousands of others across Texas with similar complex needs require immediate help from people who know best what to do.

The Texas Medical Association strongly opposes House Bill 1415 by Rep. Stephanie Klick, R-Fort Worth, and Senate Bill 681 by Sen. Kelly Hancock, R-North Richland Hills, which would broaden APRNs’ practice authority. Instead, TMA supports improvements to the current health care collaboration model as we work to improve access to care, especially in underserved areas.

Nurse practitioners are a vital part of Texas’ health care workforce. But as many nurses who’ve later gone to medical school readily admit, nurses simply do not know what they do not know; there are limitations built in to their training.

APRNs are not “physician substitutes.”

The typical physician completes 12,000 to 16,000 hours of clinical training in medical school and residency. The typical APRN completes 500 to 1,500 hours. That foundation, while appropriate for the nursing field, is simply is not a substitute for the comprehensive care physicians are trained to — and expected to — provide.
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