Friday, September 4, 2015

Avoid Tragedy – Watch Kids Near Water This Weekend

Labor Day Weekend… summer’s last hurrah. For many Texans the holiday will involve dipping in the lake or pool to cool off and play. But sadly, that’s where most children drown, according to a Texas government agency.  Parents, keep an eye on children around water at all times. Too quickly and easily they can slip beneath the water’s surface before anyone notices. It’s already happened 68 times so far this year.

The state says most kids drown here:

  • Swimming pools (33 child/teen drownings so far in 2015)
  • Natural water bodies like lakes, ponds, etc. (22 drownings)

Don’t let tragedy spoil a fun outing and ruin lives. Read the Texas Department of Family and Protective Services news release, and learn more about protecting kids around water at WatchKidsAroundWater.org.

Thursday, September 3, 2015

Jimmy Carter's Cancer Revelation

By Sid Roberts, MD
Lufkin Radiation Oncologist

This blog post was originally published at the Lufkin Daily News and on Dr. Roberts’ blog.

When a current or former President of the United States has a major health problem, it is international news. And when a former president has cancer, we all take in a collective gasp. Especially when that former President is 90 years old. On August 12, 2015, Jimmy Carter announced that he had cancer.

As an oncologist, I read such announcements with particular interest. I look for certain words or phrases that carry a lot of meaning. According to the New York Times coverage that day, Mr. Carter has a diagnosis of “a spreading cancer that was detected by recent liver surgery.” Already, my antennae went up. No cancer in a 90 year old is good news, but a few are potentially more benign acting – not likely to be fatal – than others. For example, prostate cancer in the elderly may not even need to be treated. But just about any cancer in the liver is extremely serious, no matter what one’s age. The New York Times goes on to say that “a small mass” was removed, as if “small” is any more comforting.

But the next statement attributed to the former president’s office blew me away: “(T)he prognosis is excellent for a full recovery.” Full recovery, in my mind, means cure. What sort of propaganda is this, I wondered.

The Times noted that Mr. Carter has a strong family history of pancreatic cancer; his father and three siblings all died of pancreatic cancer, and his mother had it as well. If he had pancreatic cancer that spread to his liver, prognosis is likely months, with a chance for “full recovery” being zero. Most other metastatic cancers also have a poor prognosis, although time frames can vary. How could I reconcile what I presume medically to be a near zero chance of “full recovery” to a press release predicting an excellent prognosis?

What bothered me in the early discussion was not so much that the news media refused to speculate; that is understandable. But Mr. Carter’s team did a disservice to those who have cancer – and to those of us who treat cancer – by overly reassuring and misleading the public about his condition rather than owning up to it.

Thankfully, that misdirection did not last long. It was announced on August 20, 2015 that Mr. Carter, in fact, had metastatic melanoma. Surely that was known on August 12 (the liver surgery was August 3, after all). At a videotaped news conference on August 20, Mr. Carter explained that the melanoma in his liver had been completely removed, but that four small tumors were found in his brain. He started radiation treatment that afternoon and famously taught his Sunday School class three days later.

To Mr. Carter’s credit, he admitted on August 20 that his cancer is “likely to show up other places” in the future. And being the man of faith that he is, he is quoted as saying that his life was in God’s hands and that he was perfectly at ease with whatever comes. It was reported that when he first learned that the cancer was in his brain, he believed he “had just a few weeks left.” After radiation, he will pursue several courses of a brand new drug pembrolizumab – also known as Keytruda – over a period of several months, depending on how he is doing.

Regardless of how Mr. Carter responds to treatment or how long he lives, what started as obfuscation on the part of a press machine ultimately turned into an amazingly vulnerable self-revelation by a man of deep faith. I hope and pray President Carter responds well to treatment. I also hope that as he confronts treatment and end of life decisions he will spark an honest and open discussion of the role of palliative (comfort) care and hospice care. That would be as great a humanitarian legacy as any he has yet left behind.

Wednesday, September 2, 2015

Red Tape Kills Venerable Medical Practice

Bureaucratic red tape has killed a decades-old medical practice.

After 40 years of service and more than 20 years together, the physicians at Austin Internal Medicine Associates (AIMA) will be closing their doors for good Sept. 4. The physicians cited burdensome regulations ― including electronic health record (EHR) requirements and the looming switch to a new medical billing and coding system called ICD-10 ― as factors in their decision to close.

“It’s gotten a lot harder to run a small personal practice, and that’s because of all the regulatory and EHR requirements and things like ICD-10 and new HIPAA (Health Insurance Portability and Accountability Act) regulations,” AIMA physician R. Scott Ream, MD, said. “I mean, you could just go on and on about what we have to really worry about all the time.”

The four physicians of AIMA will retire after the practice closes its doors Sept. 4. From left to right: Ace Alsup, MD; Isabel Hoverman, MD; R. Scott Ream, MD; and Frank Robinson, MD. Photo by Jim Lincoln.
He and his colleagues prefer to worry about patients, not red tape. But medicine was a different profession when the doctors at AIMA began their practice four decades ago. Physicians Ace Alsup, MD; Isabel Hoverman, MD; Frank Robinson, MD; and Dr. Ream told Texas Medicine magazine being a doctor now is less about patient care and more about navigating an avalanche of health records, government technological requirements, and administrative red tape.

Admittedly, there’s more to AIMA’s closure. All four physicians are retiring, and about a year after closing the practice’s doors, three of them will be 70 years old. However, in recent years, circumstances of the modern medical landscape made AIMA’s closure inevitable.

The practice holds a meeting each year to evaluate its current situation. Dr. Hoverman says the physicians began thinking about closing AIMA last year, “But at our meeting [this year], it really became obvious that the administrative burden had really escalated even further, to the point that it had gotten just overwhelming,” she said.

One big factor was the increasing prevalence of the widely maligned EHRs.

AIMA never adopted an EHR system, citing limited resources. This year, for the first time, foregoing an EHR hurts medical practices’ Medicare bottom line. Beginning on Jan. 1, 2015, the Centers for Medicare & Medicaid Services docked Medicare physicians’ pay 1 percent for not meeting EHR requirements. That number increases to 2 percent in 2016 and 3 percent in 2017.

Another factor contributing to the physicians’ decision to retire was the federally mandated switch to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, or ICD-10, to document all patient diagnoses. Adoption is required by Oct. 1.

The Austin physicians’ concerns over ICD-10 are not unique: Nearly half of Texas doctors over age 61 might retire early due to anticipated cash-flow problems from ICD-10, according to a Texas Medical Association survey released last month.

“Of all the hassle factors, [ICD-10] is down the list a ways, but it’s definitely why we chose [Sept. 4],” Dr. Ream said.

The decision to close was a difficult one for Dr. Ream, and he told TMA’s Texas Medicine getting to know his patients is one of the aspects he will miss the most.

“They’re much more like family and friends, and that’s going to be difficult,” he said. “On the other hand, everywhere I look tells me it’s time to retire.”

Monday, August 31, 2015

Texas Must Fix Its Mental Health Hospital System

By David Lakey
Former Commissioner, Texas Department of State Health Services
Associate Vice Chancellor, Population Health, UT System

This piece originally appeared in TribTalk, a publication of The Texas Tribune.

Texas’ mental health hospital system was designed and built a century ago and is ill suited to meet the needs of our state. Although these hospitals play an essential role in the mental health delivery system, many of them are functionally obsolete.

That’s why the Texas Legislature next session must make restructuring and replacing the state’s outdated mental health hospital structure a top priority.

The system was developed when Texas and health care were significantly different, a time when Texas was very rural and good treatment options for mental illness weren’t available. Large campuses of 60 to 90 acres, often in rural areas of the state, were built to house 3,000 patients each, and they included farms, baseball parks and cemeteries. Most patients sent to these facilities weren’t expected to recover.

Today, there’s hope for recovery. Hospitalizations for civil commitments are shorter, with the goal of returning people back to their communities, families and jobs. The large facilities now house just over 300 people each. Increasingly, those who require inpatient treatment are sicker, more difficult to treat and more likely to be admitted following a crime.

Unfortunately, our state mental health hospital system never adjusted to these changes. Buildings are old — most were built between the 1930s and 1970s. Many are abandoned, decaying and, frankly, a safety hazard. Buildings used for clinical care are in reasonable condition but poorly designed for modern care, with convoluted hallways with poor visibility from nursing stations. Higher-acuity patients require more caregivers, further crowding already limited common spaces.

And instead of single- or double-occupancy rooms, up to six patients may sleep in a single room. Imagine the challenge a patient with paranoid schizophrenia faces sleeping in a room with five strangers and only being able to retreat to an overcrowded common room. I believe these factors lead to the patient-on-patient and staff violence that’s too often seen in these facilities.

A recent Department of State Health Services study determined that five state hospitals — Rusk, Austin, San Antonio, Terrell and North Texas at Wichita Falls — were beyond repair and should be replaced. Furthermore, the buildings and facilities at the Big Spring, Kerrville and North Texas at Vernon state hospitals, as well as the Rio Grande State Center, El Paso Psychiatric Center and Waco Center for Youth, should be repaired and renovated, and the unused, decaying buildings on these campuses should be torn down, the report said.

The mental health hospital system also lacks the capacity to meet today’s needs, and the demand will only increase as Texas’ population grows. The state needs an estimated 570 additional inpatient beds today and about 600 more beds by 2024.

Replacing and repairing these hospitals will not be cheap. Replacing the large hospitals is estimated to cost about $180 million each, so replacing five hospitals, repairing the remaining hospitals and adding capacity will have a price tag close to $2 billion.

So how can Texas best address this urgent but expensive public policy issue?

Next session, the Legislature should fund the replacement of two hospitals. Solving the problem in one session is not realistic, but replacing two hospitals is. The likely candidates would be the Rusk, Terrell or San Antonio state hospitals.

Replacing and building new hospital capacity will take time, but we need additional capacity now. The state should buy currently unused inpatient capacity from hospitals across Texas. This capacity can be purchased in more urban communities, where most of the patients reside, allowing them to be cared for closer to their families and support structures. Our rural facilities are appropriate for long-term and forensic commitments, but allowing other patients to receive their care closer to their communities would facilitate recovery.

As Texas repairs and restructures its mental health inpatient system, stronger partnerships between our academic medical centers should also be fostered. And there are already good models to follow. The Harris County Psychiatric Center is managed by the University of Texas Health Science Center at Houston and provides learning and training opportunities for our next generation of mental health workers. In 2013, the UT Health Science Center at Tyler partnered with the state to convert a 30-bed ward to care for mental health patients. These partnerships work, bringing in updated technology and additional primary care tools and resources to improve overall care.

Finally, Texas must continue to improve the availability and quality of outpatient community services, which are effective and relieve the pressure on our state mental health hospitals. Without these services, more severely mentally ill patients end up in our jails, emergency rooms and hospitals.

By working together, elected officials, state agencies and higher education institutions can develop a 21st century behavioral health system for Texas that will be a model for the rest of the nation.

David Lakey, MD, is associate vice chancellor for population health at the UT System.

Friday, August 28, 2015

States Looking For More Effective Ways To Encourage Vaccinations

By Michelle Andrews
Kaiser Health News

Content provided by Kaiser Health News

When kids start school this fall, it’s a sure bet that some won’t have had their recommended vaccines because their parents have claimed exemptions from school requirements for medical, religious or philosophical reasons. Following the much publicized outbreak of measles that started in Disneyland in California in December, these exemptions have drawn increased scrutiny.

That outbreak, which eventually infected 147 people in seven states, was a wake-up call for many parents, who may not have realized how contagious or serious the disease can be, and for states as well, say public health officials.

“States are beginning to realize that they have effective measures to combat these outbreaks, and philosophical exemptions are eroding these protections and resulting in significant costs to states,” says Dr. Carrie Byington, professor of pediatrics at the University of Utah and chairwoman of the American Academy of Pediatrics Committee on Infectious Diseases.

In addition, research shows that eliminating vaccine exemptions or making them harder to get can improve vaccination rates and reduce disease outbreaks.

California and Vermont passed laws this year eliminating exemptions in 2016 for philosophical reasons; California’s law eliminates religious exemptions as well.

The federal Centers for Disease Control and Prevention provides suggested vaccination schedules for children and adults, but there’s no federal requirement that parents vaccinate their children. All states, however, have laws or policies requiring that children be up-to-date on recommended vaccines in order to attend school or day care. Unvaccinated children can generally attend only if their parents have obtained a vaccination exemption approved by the states.

Every state allows medical exemptions for children whose immune systems are compromised because of congenital problems or cancer treatment, for example. Nearly all states allow exemptions from vaccinations because of religious beliefs; excluding California and Vermont, 18 permit exemptions because of parents’ personal or philosophical convictions, according to the National Conference of State Legislatures.

Just three states–West Virginia, Mississippi and now, California–allow vaccine exemptions only for medical reasons.

In recent years, exemption rates for children have soared, but they vary. On the low end, New Mexico’s rate was less than half a percent in 2012, while the top state rate was Oregon’s at 6.5 percent, according to a study this month in the journal Health Affairs.

Local rates may be much higher, though. There are pockets in California and Colorado, for example, where the exemption rates top 30 percent, says L.J Tan, chief strategy officer at the Immunization Action Coalition, an advocacy group that works to increase immunization rates.

But since in most places the percentage of children getting the recommended vaccines tops 90 percent for most diseases, many parents have never seen someone with measles, for example, or whooping cough and may not understand their dangers.

“In the absence of disease the alleged risks of the vaccine become easier to sell,” says Tan.

Those risks are real, says Barbara Loe Fisher, co-founder and president of the National Vaccine Information Center, a group that advocates that people be able to decline mandatory vaccines based on their philosophical or personal beliefs. Fisher testified before the California State Assembly against the new law, which takes effect next July.

“Some people are more susceptible than others to injury or death from vaccines,” Fisher says. “But it’s not clear who is at higher risk.”

For the vast majority of people, however, vaccines are very safe, and studies have failed to show a link to autism, a common concern of parents who don’t vaccinate their kids.  “The risk of getting the disease is higher than the risk of getting a vaccine,” says Dr. Mark H. Sawyer, a pediatric infectious disease specialist at the University of California, San Diego.

The Health Affairs study analyzed the different elements of state rules to tease out the extent to which they affected vaccine exemptions. It found, for example, that policies that required the state health department to approve nonmedical exemptions or permitted exemptions only for specific vaccines rather than all vaccines had a significant effect on reducing vaccine exemptions. So too did laws that imposed civil or criminal punishments such as expulsion from school (for the child) or criminal negligence charges (for parents) for not complying with vaccination rules.

The threat of penalties alone may be enough to deter parents from refusing vaccinations, says study co-author W. David Bradford, a professor of public policy at the University of Georgia.

The more restrictive policies were reflected in lower rates of whooping cough. States with the most effective exemption policies had an average incidence of 7.3 pertussis cases per 100,000 people from 2002 to 2012, while states with the least effective policies had an incident rate more than twice as high at 16.06 cases, the study reported.

More broadly, the study shows that there are tools that work. “There is room for lots of states to improve their policies in ways that encourage people to get their kids vaccinated,” says Bradford. “I take that as encouraging.”

Thursday, August 27, 2015

TMA Presents “Cutting Edge: A History of Surgery”

When Texas gained its independence in 1836, surgery was a medical treatment of last resort, always painful and often fatal. Now the average American can expect to undergo at least seven surgeries in a lifetime. The evolution of surgery from the earliest civilizations to modern day advances is on display in the Texas Medical Association’s (TMA’s) History of Medicine Gallery.

Anesthetic masks used to administer ether or chloroform to patients, c. 1900s.
TMA’s “Cutting Edge: A History of Surgery” presented by the association's History of Medicine Committee, honors the centennial of the Texas Surgical Society in 2015 by exploring improvements that allowed surgery to become essential to medicine. The exhibit features stories of the primitive and precarious nature of early Texas surgery from the time of the Spanish explorers to the Alamo to advances in anesthesia and safer surgery around the turn of century. “Uneven quality of surgical care leads to formation of Texas Surgical Society in 1915,” said Texas Surgical Society Archivist Mellick Sykes, MD. Meanwhile “Texas’ surgical reputation has skyrocketed from backwater to beacon” from the early years of the Texas republic to the present, Dr. Sykes said.

Steam atomizer used to sterilize incisions or wounds, c. 1890
Artifacts on display in the exhibit display like the steam atomizer, a device used to sterilize surgical incisions or wounds, illustrate both the inventiveness and limitations of the early Texas surgeons. Also on display is the Bohler Frame, an early 20th century metal device used to keep fractured bones stable during the post-surgery healing process. Cutting Edge: A History of Surgery also recognizes the role of pioneering Texas surgeons who brought international acclaim to Texas with their innovations and skill in transplant surgery.

Bohler Frame used in surgery and treatment to keep fractured bones in alignment, c. early 20th century
“The TMA commitment to the history of medicine — the successes, failures, and struggles of our doctors and our institutions — is deep and longstanding. The TMA archives preserve this story,” Dr. Sykes said. 

Visiting Austin?
“Cutting Edge — A History of Surgery” is in the History of Medicine Gallery on the ground floor of the TMA building at 401 W. 15th St. in Austin through March 2016. It is free and open to the public 9 am-5 pm Monday through Friday. For more information or to arrange a tour, call (512) 370-1552 or (800) 880-1300, ext. 1552, or email knowledge@texmed.org.

Tuesday, August 25, 2015

Pregnant Women May Be Getting Unnecessary Ultrasounds

By Kenneth Higby, MD 
Center for Maternal-Fetal Care, an affiliate of MEDNAX, San Antonio 
Consultant, TMA Committee on Maternal and Perinatal Health

Pregnant women are getting more ultrasounds today compared with years past, as The Wall Street Journal reported recently. Last year, American women received an average of 5.2 fetal ultrasounds prior to delivery, up 92 percent from 2004. For most of these women, that’s more than double the number of recommended ultrasounds. 

Two ultrasounds are sufficient for women with low-risk pregnancies: an early one to confirm the gestational age of the fetus — and possibly another scan called a “nuchal translucency evaluation” that assesses the fetus’ risk for certain genetic disorders — and a second ultrasound in the middle trimester to evaluate fetal anatomy and determine gender.

Additional scans in a low-risk patient are unnecessary, though higher-risk pregnancy situations might require more scans.

No objective evidence indicates that obstetrical ultrasound is dangerous to the fetus, but energy is dissipated from the ultrasound beams. Nearly every modern ultrasound machine has energy parameters located on its main screen. These numbers clearly increase when other applications are used, such as pulsed Doppler or color Doppler (techniques used to detect blood flow and fetal heartbeat). When used properly, these should be considered safe procedures for patients. 

It’s important to note that several credentialing organizations for obstetrical ultrasound ensure professionals meet criteria for performing adequate fetal evaluation, in addition to providing guidelines and protocols for patient safety. In the future, medical practices may be required to have certification to perform an obstetrical ultrasound. Such credentialing is important for consistency, performance standards, and patient safety.

TMA recognizes that ultrasound is an important tool for monitoring and assessing the health of the fetus and mother. Earlier this summer, TMA amended its policy to recommend increasing patient and physician awareness on the latest information from the U.S. Food and Drug Administration about the nonmedical use of fetal ultrasound imaging.

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