Monday, November 23, 2015

CDC Director Urges Austin Physicians to Spread the Word: HPV Vaccination Saves Lives

We need to get the word out: To potentially protect preteen children from cancer later, vaccinate them against HPV now.

That was the message Melinda Wharton, MD, MPH, acting director for the Centers for Disease Control and Prevention’s (CDC’s) National Center for Immunization and Respiratory Diseases, delivered to Travis County physicians last week in Austin. Dr. Wharton, in town for a statewide immunization conference, spoke to physicians about how they can communicate and encourage HPV vaccination for their young patients. HPV is short for human papillomavirus, which is known to cause several cancers.

“The HPV vaccine is cancer prevention,” Dr. Wharton stressed. “You would think we would not be struggling so much with getting vaccine coverage up, but the reality is coverage is not where it should be,” especially in relation to vaccination coverage for other diseases, said Dr. Wharton.

“HPV infection is common. Almost everybody will be infected at some point in their life with at least one type of HPV infection. Many millions of Americans are currently infected, and there are millions of new infections each year,” she said. (Travis County Medical Society estimates that in Travis County alone, more than 250,000 people are infected with HPV.)

“Fortunately, most infections clear … and most people never know they’ve been infected,” said Dr. Wharton. “But they don’t always clear, and sometimes — particularly when the infections are caused by some of the cancer-causing types [of HPV] — the results are cancers.”

Dr. Wharton told the crowd that the HPV virus causes 20,000 cancers in the United States each year. The most common cancer is cervical cancer in women, but HPV can cause penile cancer in men and oropharyngeal cancer (a type of throat cancer) in both men and women.

The HPV vaccine is recommended for girls and boys 11-12 years old, but can be given to teens, young women up to age 26, and young men up to age 21. The vaccine is meant to be given to patients well before they become sexually active, and — as an added benefit — the vaccine produces a more robust immune response during the preteen years, Dr. Wharton said.

“Some parents really strongly feel that their children are not at risk — that they will not be sexually active until marriage, or that they will not be exposed,” said Dr. Wharton. “But HPV is so common that almost everybody will be infected at some time.”

Dr. Wharton emphasized the need for physicians to champion the HPV vaccine to their patients as a cancer-preventing, life-saving vaccine. “As providers, we need to make that strong recommendation,” she said.

Tuesday, November 17, 2015

World Prematurity Day – Focusing on Premature Births

Nov. 17 is World Prematurity Day, created to raise awareness of premature births. Many people are unaware they are the No. 1 killer worldwide of children under the age of 5. A new effort is underway to lower the rate of premature births.

The March of Dimes estimates 15 million babies worldwide are born premature, and nearly 1 million of them die due to complications from their early delivery into the world. Babies who survive an early birth face an increased risk of life-long health challenges, such as breathing problems, cerebral palsy, or learning disabilities. In Texas, 10.3 percent of all babies born are born premature, compared with 9.6 percent nationwide.

While the percent of preterm births in the United States has been declining since 2007, the March of Dimes says the numbers are still too high. “Many communities, as well as specific racial and ethnic groups, continue to suffer from the tragic and costly consequences of double-digit rates of premature birth,” the organization’s news release said. To mark World Prematurity Day, the March of Dimes announced a plan to reduce the nation’s preterm birth rate to 5.5 percent by 2030, focusing first on states with large numbers of premature babies, including Texas. The campaign “outlines specific interventions health care providers and officials can take to prevent preterm birth.”

Learn more about World Prematurity Day and March of Dimes’ “Prematurity Campaign Roadmap.”

Wednesday, November 11, 2015

Texas Medical Schools Beef Up Nutrition Education

At a time when obesity and diabetes are on the rise, medical schools have not provided the recommended amount of nutrition training. But Texas medical schools and residency programs are getting ahead of the curve in addressing this issue, according to Texas Medicine magazine, published by the Texas Medical Association.

On average, U.S. medical schools teach 19 hours of nutrition-related education across the four-year undergraduate medical curriculum — six hours less than the National Academy of Sciences’ recommended minimum of 25 hours. And most of this training takes place in science-based courses and not in a clinical setting with patients.

“When I was in medical school, we had one two-hour course on nutrition, and essentially all it was about was what vitamins do for you, how bad salt is, and the proper ratio of protein to carbohydrates. And the food pyramid we had then doesn’t exist anymore,” said Darrin C. D’Agostino, DO, chair and associate professor of internal medicine at the University of North Texas Health Science Center (UNTHSC) Texas College of Osteopathic Medicine (TCOM) in Fort Worth. “Now, 20 years later, we have grown in our understanding of dietary and nutrition science, and medical schools have identified that nutrition is critically important in medical education. It's a thread that moves through a lot of diseases, so we are integrating the information [into the curriculum] as best we can.”

Educators agree it's not about the quantity of time schools pour into nutrition education, rather the quality of the ingredients. And Texas medical schools are finding innovative ways to integrate the topic into required and elective courses so that it translates better to patient care.

For instance, TCOM’s curriculum teaches students about interrelationships between various systems in the body and how nutrition affects each system. Medical students also interact with trainees in other health professional schools on UNTHSC’s campus, where nutrition comes up in the context of learning collaborative practice skills.

Last spring, TCOM introduced an elective culinary medicine course that links cooking to nutrition science and teaches teamwork. Students trade their white coats for aprons and learn to cook healthy dishes for chronically ill patients with poor diets.

In Lubbock, Texas Tech University Health Sciences Center’s (TTUHSC’s) Family Medicine Residency Program included a nutritionist on its faculty, and residents spend time learning what it feels like to get and record finger sticks using a glucometer – something diabetic patients must do routinely – and understanding and eating different diets their patients might get in the hospital.

In Houston, Baylor College of Medicine’s curriculum includes lectures on the importance of personal nutrition and incorporates nutrition into courses on disease and preventive health. And three years ago, Baylor medical students themselves designed an elective to enhance the school’s nutritional curriculum. The Baylor CHEF (Choosing Healthy, Eating Fresh) course targets second-year students as they transition into working with patients, teaching them to cook while learning from physician faculty and nutritionists about personal health, nutrition basics, and the impact of nutrition on maternal and cardiovascular health.

The goal of these integrated courses, Dr. D’Agostino said, is not to turn future physicians into dieticians. Instead, he said, it’s “to prepare our students as best we can to take care of patients, and nutrition, medication, and lifestyle all have to be brought in. Nutrition is going to be one of the most critical elements of value-based care going forward.”

Monday, November 9, 2015

Epic Fail: We Physicians Must Do More to Promote Cancer-Preventing HPV Vaccine

By Jason Terk, MD
Immediate Past President, Texas Pediatric Society
Keller Pediatrician

“Epic fail.”

A couple of years ago, this was the phrase that my teenage son used as I unsuccessfully attempted to beat him in a game we were playing. At the time, I thought to myself that it was a harsh but accurate assessment of my performance. And, I was certainly motivated to practice on my own so that the next time, things would be different.

That same phrase came to mind as I read through an alarming article of interest to physicians. The article, published in Cancer Epidemiology, Biomarkers & Prevention is titled “Quality of Physician Communication about Human Papillomavirus Vaccine: Findings from a National Survey.”

Bottom line: Physicians (primarily pediatricians and family physicians) do poorly in providing the human papillomavirus (HPV) vaccine to patients.

Another source, the most recent National Immunization Survey-Teen for the year 2014, reports another alarming trend. The survey shows the number of patients who start the shots — and also complete them — lags far behind what it should be. (The HPV vaccine is given as a series of shots.)

So, it came as no surprise to me that the first article clearly showed what I have suspected for some time and which has been hinted at by previous studies. The epic failure in providing what is essentially a cancer-prevention vaccine to the recommended population of 11-12-year-old boys and girls lies not at the feet of the anti-vaccine movement or hesitant parents. Rather, the failure belongs to us physicians!

The article describes findings from an online survey sent to 2,368 pediatricians and family physicians in 2014. The 776 respondents self-reported their own performance on strength of four criteria: endorsement (how strongly they recommend the vaccine); timeliness (whether they recommend it at 11-12 years of age, which is the most beneficial age); consistency (recommending it routinely instead of “risk-based,” primarily to patients the physician believes might be at higher risk for HPV); and urgency (whether the physician recommend the patient receive the vaccination that day). More than a quarter stated they did not strongly endorse the HPV vaccine, and a similar number reported they did not recommend it be given at 11-12 years of age. Amazingly, 59 percent said they used a risk-based approach versus a routine approach to recommending the HPV vaccine, and only half the respondents recommended giving the vaccine then and there, while the doctor discussed the HPV vaccine with the patient and parent. And these results represent a best-case scenario because respondents would be unlikely to paint an unflattering picture of their own performance.

Clearly, we have a major problem with physicians struggling with their own discomfort in talking about the HPV vaccine and who erroneously believe parents do not value it. Physicians who can’t communicate the importance of this cancer-preventing vaccine in turn fail to recommend it, which is so important to protect our patients. We are at risk of being the generation of pediatricians and family physicians who collectively failed to protect our patients from a preventable cause of cancer. Only we physicians can fix what it wrong with us: Only we can reverse this epic failure!

Friday, November 6, 2015

Health Insurers’ Narrow Networks Putting Squeeze on Patients

Health insurance companies are sharply limiting the number of physicians and hospitals they include in their networks as a tool to limit how much they have to pay in covered benefits. Narrow networks are booming in plans sold both through employer-sponsored insurance and on the Affordable Care Act (ACA) marketplace exchanges.

These moves leave patients out in the cold, and squeezed for the costs of health care the plans aren’t covering. The popular news media and scientific literature have been filled with stories lately about narrow networks. Here’s a roundup.

ACA Plans Lack Specialists

As many as 14 percent of health plans on the ACA exchanges lack physicians in at least one key specialty. That’s what researchers from Harvard’s T. H. Chan School of Public Health reported in the Journal of the American Medical Association. (“Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act,” JAMA, Oct. 27, 2015.)

“We found this practice among multiple states and issuers,” the authors wrote. “This likely violates network adequacy requirements, raising concerns regarding patient access to specialty care. Such plans precipitate high out-of-pocket costs and may lead to adverse selection (i.e., sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies.”

Rheumatologists, endocrinologists, and psychiatrists were the specialists most often missing from the plans.

Texas Leads in “X-small” ACA Networks

Texas has more “x-small” networks (45 percent) on the ACA exchange than any other state in the network. That’s what the Leonard Davis Institute of Health Economics (LDI) at the University of Pennsylvania found. (“State Variation in Narrow Networks on the ACA Marketplaces,” published by the Robert Wood Johnson Foundation, August 2015.) Those super-shrunken networks offer access to 10 percent or fewer of the physicians in a rating area. 

This study looked at plans issued by 267 carriers across 355 networks in all 50 states. It used “t-shirt size” ratings of x-small (less than 10 percent), small (10 percent-25 percent), medium (25 percent-40 percent), large (40 percent-60 percent), and x-large (more than 60 percent). The variation was extensive. Some states, such as Delaware, Kansas, and North Dakota, have mostly large or x-large networks. Others don’t at all.

Here are the states with the most x-small or small networks:
  • Georgia – 83 percent
  • Florida – 79 percent
  • Oklahoma – 78 percent
  • California – 75 percent
  • Texas – 73 percent
  • Arizona – 73 percent
In an earlier study, the authors at the Davis Institute found that 41 percent of silver plans on the ACA exchanges were x-small or small. 

Half of ACA Hospital Networks Are Narrow

Patients’ choice of hospitals on the ACA exchange plans is similarly limited. That’s what the McKinsey Center for U.S. Health System Reform found. (“Hospital networks: Evolution of the configurations on the 2015 exchanges,” published by McKinsey & Co., April 2015.)

“Across the country, close to half of the 2015 networks that consumers can choose from are narrowed; in the largest cities, almost two-thirds of the networks are narrowed,” the report states.

The report defines a “narrow” network as having 70 percent or fewer of local hospitals participating. An “ultra-narrow” network has 30 percent or fewer participating.

“Many consumers, however, do not appear to understand the choices available to them or the impact of those choices (especially limits on access to care),” McKinsey found. “In our consumer survey, 44 percent of those who bought an ACA plan for the first time this year reported that they did not know the network configuration associated with their plan.”

Half of ACA Plans Don’t Cover Out of Network

Another study found that 47 percent of the plans sold on the federal ACA exchange have no coverage for out-of-network care. In Texas, that number is 67 percent. (“Almost Half of Obamacare Plans on Federal Marketplace Lack Out-Of-Network Coverage,” published by HealthPocket, Oct. 7, 2015.)

That, HealthPocket explains, means “the plans will not cover the costs except in the case of a medical emergency or if a prior authorization from the plan had been formally submitted and then approved by the health plan.”

Narrow Networks Forcing Patients to the ED

Because of narrow networks, a survey of emergency department doctors found, patients are showing up sicker in the emergency department. Also, emergency physicians are finding fewer primary care doctors and specialists to whom they can refer patients for follow-up. (“Insurance Industry Drives Patients to Sacrifice Necessary Medical Care,” published by American College of Emergency Physicians [ACEP], Oct. 26, 2015.)

Specifically, the national study of emergency physicians found:
  • 73 percent of the doctors see more Medicaid patients because insurance companies don’t provide enough primary care or specialty physicians for their patients.
  • 65 percent see more patients in the emergency department, in large part because health insurance companies don’t provide enough primary care physicians to support the community.
  • 60 percent have difficulty finding specialists for their patients, because of narrow networks.
  • More than 80 percent treat patients who said they had difficulty finding specialists to care for them because health plans have narrow networks.  
“This is a scary environment for patients,” said Jay Kaplan, MD, president of ACEP. “The insurance companies are shifting costs onto patients and medical providers as they attempt to increase their bottom lines, and this threatens the foundation of our nation’s medical care system.”

Health Plans Mount Lackluster PR Campaign

Trying to escape the cascade of negative publicity, the insurance industry issued a report blaming physicians’ overcharges for medical care as the cause of “surprise bills.” (“Texas doctors, insurers taking ‘balance billing’ fight public,” Houston Chronicle, Oct. 11, 2015; “Doctors fire back at insurance industry report on what Texans are charged for ER visits,” Quorum Report, Oct. 8, 2015)

It didn’t work. The news media saw right through it and reported this comment from TMA President Tom Garcia, MD:
This so-called report is nothing more than a desperate smoke screen to divert attention from the real problem. The health insurance industry games the system to keep more of patients’ premium dollars by forcing patients to seek care out of network. Then they have the gall to criticize what some doctors’ bill for that care.
And the San Antonio Express-News published a response to the study from William W. Hinchey, MD. 

“Insurers want your local pathologist in the network only for inpatient hospital services but not for your outpatient services — even when the pathologist wants to be in your network for both,” Dr. Hinchey explained. “The insurance company ultimately decides who will be in or out of your network. Essentially the insurers are saying to the physicians: We want you some of the time but not all the time.”

The Real Truth About Balance Billing

A TMA study examines how insurance plans’ network designs and payment decisions leave many Texans with “surprise bills” for health care services.

Inadequate and limited physician networks that insurers sell today are leaving patients with unpaid bills. Unfortunately, Texas consumers are learning the limits of the coverage they bought just when most need coverage, especially in emergencies. The consumer is no longer satisfied with the not-very-well-explained, varying levels of savings that insurance networks create, especially if that means a greater financial burden in emergencies. Yet, despite network shortcomings, consumers do not want to be left without the choice of plans that offer network benefits.

Thursday, November 5, 2015

Top Five Tips to Help You Combat Dry Winter Skin

By Michelle Tarbox, MD
Assistant Professor of Dermatology,
Texas Tech University Health Sciences Center

As the temperatures drop and the heaters go on, the indoor air gets dehydrated and your skin loses moisture from the environment. Think of it this way, when the level of moisture in the air drops due to the heating process, the dry air practically sucks the water out of your skin.

To balance out the loss of moisture, you can take some steps to repair and replenish your skin. Here are the five tips to help you combat dry winter skin.

  1. Cleanse Carefully. Healthy winter skin starts with careful cleansing. The wrong cleanser can strip your skin of its natural oils and make it more vulnerable to the dry winter air. Add to that the increased need for handwashing in the winter time due to the cold and flu season … coupled with the possibility of more time in the kitchen cooking up holiday treats and meals … and you’ve literally got a difficult situation on your hands. Choose a gentle cleanser with skin-healthy ingredients such as jojoba oil or avocado oil. Avoid harsh cleansing agents such as sodium laureth (or lauryl) sulfate, and opt for more gentle cleansers such as glycerin.

  2. Moisturize More. As the name suggests, moisturizers replenish lost moisture from the skin. I like products that contain ceramides, which are the lipid (fat) that skin actually makes to moisturize itself. Fats and oils are actually very important for skin health, but as with dietary fats, choosing the right kind is key. Look for moisturizers that are “non-comedogenic” or non-pore clogging such as avocado oil, almond oil, mineral oil, primrose oil.

  3. Slather the Sunscreen. The sun still shines in the winter time. Many people forget to use sunscreen during the cold winter months; however, as cold and overcast as it may be, UV radiation is still reaching the earth. A good broad-spectrum sunscreen should be applied to all exposed skin surfaces at least 30 minutes before outdoor sun exposure.

  4. Exfoliate Expertly. Exfoliation removes dead skin cells and improves how well skin can absorb moisturizers; however, it’s important not to overdo it. A gentle touch is the key to winter skin care, and this definitely goes for exfoliation. Dry winter skin responds well to gentle exfoliation including moisturizers with mild acids such as lactic acid or salicylic acid. It is a good idea to alternate these exfoliating moisturizers with your regular moisturizer to avoid irritation.

  5. Baby Your Bath Time. It’s tempting to crank up the water temperature during your showers or baths during the cold winter months, but this can be counterproductive to your skin health. A good rule of thumb is to bathe yourself in temperatures you would use for a baby’s skin. Similar to harsh cleansers, very hot water can strip your skin of its natural oils and make it more vulnerable to dehydration. A nice short warm bath is your skin’s best bet for healthy winter skin. 

Wednesday, November 4, 2015

Flu Shots Protect More Than Just You

Did you know your flu shot protects more than just you? A new study says when younger adults get vaccinated, older people suffer fewer cases of flu and its potentially life-threatening complications. Texas Medical Association (TMA) physicians urge Texas adults to get vaccinated now to protect yourself and those around you.

“We call this herd immunity,” said Wesley W. Stafford, MD, chair of TMA’s Council on Science and Public Health. “When a large portion of a population gets vaccinated, it protects those who can’t be vaccinated against disease or those who are most vulnerable.”

Dr. Stafford, an allergist-immunologist in Corpus Christi, said health experts have known about herd immunity for years, but a recent nationwide study showed just how important that can be. The study showed that when a third of younger adults (or 31 percent) in a community get vaccinated for the flu, the rate of flu and related illnesses drops by 21 percent among people over age 65.

The study, which appeared in the Sept. 10 issue of Clinical Infectious Diseases, looked at data from 3.3 million Medicare beneficiaries between 2002 and 2010. Medicare is the government health insurance coverage for seniors and people with disabilities.

The elderly are among the worst hit with flu-related illness. According to the Centers for Disease Control and Prevention, between 50 percent and 70 percent of hospitalizations from flu-related illness, such as pneumonia (lung infection), are in people who are over age 65. Most (80-90 percent) flu-related deaths are among the elderly.

Doctors say everyone 6 months of age and older should get a flu vaccination every year to protect themselves. Dr. Stafford says now is the time to get the shot for protection throughout the entire flu season, which can last from now through May.

In addition to the elderly, flu vaccination is especially important for other at-risk populations: young children (5 years and younger), pregnant women, and people who have chronic health conditions such as asthma and heart disease. A bonus for pregnant women who get vaccinated: The vaccine protects not only the mother but also her unborn baby. The baby remains protected by the mother’s immunity until he or she is about 6 months of age.

Several flu vaccine options are available now in addition to the standard flu shot, including a high-dose shot that for people 65 years and older provides better protection against the flu, an intradermal vaccine that uses a much smaller needle injected into the skin instead of muscle, and the nasal-spray vaccine for healthy people aged 2 to 49 years who do not have asthma and are not pregnant. Physicians suggest you talk with your doctor about which vaccine is right for you.

“The flu vaccine is the best defense against getting the flu,” said Dr. Stafford. “It’s a safe and effective way to protect yourself and those around you.”

TMA has produced a flu fact sheet and a flu facts infographic, both in English and Spanish.

To learn where flu shots are available and other flu information, visit the Texas Department of State Health Services website, or visit www.flu.gov.

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