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.

Thursday, April 27, 2017

10 Things to Know During National STD Awareness Month

By Junda Woo, MD, MPH
San Antonio obstetrician gynecologist 
Medical Director, San Antonio Metropolitan Health District
  1. Syphilis is back. Rates of this ancient scourge jumped 19 percent from 2014 to 2015, more than any other reportable STD, according to the Centers for Disease Control and Prevention (CDC). Most cases are among men who have sex with men. Men who have sex with men should get tested annually for syphilis, chlamydia, gonorrhea, and HIV.

  2. Rates of chlamydia rose too — 1.5 million people were diagnosed with this infection in 2015. Since most women with chlamydia show no symptoms, the CDC says all sexually active women should be tested every year until age 25. Yet fewer than half of insured, eligible women under 25 were tested for chlamydia in 2015, according to data collected from U.S. health plans.

  3. In 2009, Texas made it legal for doctors treating STD patients to provide an extra antibiotic prescription for the patient’s partner. This practice is called Expedited Partner Therapy. While it is better if every partner sees a doctor, that doesn’t always happen. When doctors provide partner prescriptions, re-infections of chlamydia drop 20 percent, and re-infections of gonorrhea drop 50 percent.

  4. Anyone who is treated for chlamydia, gonorrhea, or trichomoniasis — all easily curable STDs — should be retested in three months to catch re-infections, according to the CDC.

  5. About 1 in 6 sexually active people have herpes, but only one-tenth of infected people know they are infected. The CDC does not recommend routine blood tests for herpes, in part because the tests are not that accurate, and false positive tests cause emotional distress.

  6. Everyone between the ages of 13 and 64 should be tested for HIV at least once in their lives.

  7. There is now a daily pill that prevents HIV. If you are HIV-negative but your partner is HIV-positive, or you are man who has sex with men and you have multiple partners, ask your doctor about pre-exposure prophylaxis (PrEP). 
… And for physicians:
  1. Patients say they want their doctors to ask about sexual health. Doctors may feel uncomfortable asking intimate questions. The CDC offers this guide: https://www.cdc.gov/std/treatment/sexualhistory.pdf.

  2. Many people in the LGBT community are reluctant to “come out” to doctors because of previous negative experiences. For free continuing medical education (CME) on LGBT health and tips on creating an LGBT-friendly office, go to LGBThealtheducation.org.

  3. Doctors can brush up their knowledge about syphilis (“The Great Imitator”) and get free CME with the National STD Training Curriculum: https://www.std.uw.edu/.

Monday, April 10, 2017

With Throat Cancer Increasing, Doctors Urge Vaccination to Prevent It

Doctors are diagnosing more throat cancers caused by the human papillomavirus (HPV). HPV also causes other cancers, such as cervical, but throat cancer is quickly becoming the most common. The good news: the HPV vaccination, if people receive it early enough, can prevent most of these cancers, which are found in the tonsils and base of the tongue.

Four percent of U.S. adults aged 18 to 69 have a type of HPV that puts them at high risk for throat, or oropharyngeal, cancers, according to a new report from the Centers for Disease Control and Prevention. Nearly 16,000 oropharyngeal cancers are diagnosed in the U.S. each year, according to the CDC.

The cancer’s prevalence has pushed it into the spotlight this month, which has been designated Oral, Head and Neck Cancer Awareness Month. During April, Texas physicians urge parents to vaccinate their children against HPV to prevent cancer later in life.

“The vaccine is nearly 100 percent effective if it’s given before someone is exposed to HPV,” said Texas Medical Association member Erich Sturgis, MD, a head and neck surgeon at the MD Anderson Cancer Center in Houston. “Taking this preventive action during adolescence can mean better health down the road.”

Physicians and other health experts recommend the HPV vaccination for preteen boys and girls, aged 11 and 12 years, but youths can receive it as early as age 9. A second dose of HPV vaccine should be given six to 12 months after the first dose.

HPV is the most common infection in the nation spread through intimate skin-to-skin or sexual contact. Almost all — eight in 10 — sexually active people will have the virus sometime in their lives.

HPV infections can cause healthy cells to become abnormal. Typically, the body can clear the infection. But when it can’t, the infection can cause cells to become cancerous years later.

Dr. Sturgis says the HPV vaccination is important for both boys and girls, but stresses its importance for boys. Doctors can diagnose cervical cancer early through screening (the Pap test), he said, but currently no screening is available for throat cancers, so they usually are advanced when diagnosed. And while HPV-related throat cancers are expected to surpass cervical cancer by 2020, Dr. Sturgis said experts say that may occur sooner.

Men are three to five times as likely to get throat cancer as women, with most cases occurring in white, middle-aged males. Smoking and alcohol use previously caused most oropharyngeal cancers, but HPV now accounts for at least 70 percent of these cancers.

“Unfortunately, the generation of people getting HPV-related throat cancers didn’t have the benefit of vaccination,” said Dr. Sturgis. “Now we have the opportunity to protect the next generation from a very devastating disease.”

Older teens and young adults who weren’t vaccinated in adolescence also can benefit from HPV vaccination. Both males and females can get the shots until age 26. For those over age 15, however, the CDC recommends three shots for full protection. People should ask their physician about how many doses are needed and when.

TMA has published an infographic and fact sheet about the importance of HPV vaccination, both in English and Spanish.

Tuesday, March 28, 2017

New Vaccine Recommendation Cuts Number Of HPV Shots Children Need

By Michelle Andrews
Kaiser Health News

Content provided by Kaiser Health News

You’d think that a vaccine that protects people against more than a half-dozen types of cancer would have people lining up to get it. But the human papillomavirus (HPV) vaccine, which can prevent roughly 90 percent of all cervical cancers as well as other cancers and sexually transmitted infections caused by the virus, has faced an uphill climb since its introduction more than a decade ago.

Now, with a new dosing schedule that requires fewer shots and a more effective vaccine, clinicians and public health advocates hope they may move the needle on preventing these virus-related cancers.

In December, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommended reducing the number of shots in the HPV vaccine from three to two for girls and boys between the ages of 9 and 14. The recommendation was based on clinical trial data that showed two doses was just as effective as a three-dose regimen for this age group.

The study was conducted using Gardasil 9, a version of the vaccine approved by the Food and Drug Administration in late 2014. It protects against nine types of HPV: seven that are responsible for 90 percent of cervical cancers and two that account for 90 percent of genital warts.

In addition, the new version of Gardasil improved protection against HPV-related cancers in the vagina, vulva, penis, anus, rectum and oropharynx — the tongue and tonsil area at the back of the throat.

An earlier version protected against four types of HPV.

From the start, clinicians have run into some parental and political roadblocks because the vaccine, which is recommended for preteens, protects against genital human papillomavirus — a virus transmitted through sexual contact. Many physicians are also reluctant about discussing the need for the vaccine, and for many parents, the vaccine’s cancer-prevention benefits were overshadowed by concerns about discussing sexual matters with such young kids. Yet for maximum protection, the immunizations should be given before girls and boys become sexually active.

The focus should not have been on sexually transmitted infections, some say. “You only get one chance to make a first impression,” said Dr. H. Cody Meissner, a professor of pediatrics at Tufts University School of Medicine and a member of the American Academy of Pediatrics’ committee on infectious diseases. “This vaccine should have been introduced as a vaccine that will prevent cancer, not sexually transmitted infections.”

The HPV virus is incredibly common. At any given time, nearly 80 million Americans are infected, and most people can expect to contract HPV at some point in their lives. Most never know they’ve been infected and have no symptoms. Some develop genital warts, but the infection generally goes away on its own and many people never have health problems.

However, others may develop problems years later. There are approximately 39,000 HPV-related cancers every year, nearly two-thirds of them in women. In addition to cervical cancer, more than 90 percent of anal cancers and 70 percent of vaginal and vulvar cancers are thought to be caused by the HPV virus. Recent studies show that about 70 percent of cancers in the oropharynx may also be linked to HPV.

A 2015 study published in the Journal of the National Cancer Institute estimated that earlier versions of the HPV vaccine could reduce the number of HPV-related cancers by nearly 25,000 annually, and the new version of the vaccine could further reduce the number of such cancers by about 4,000.

The vaccine is estimated to prevent 5,000 cancer deaths annually, said Dr. Paul Offit, professor of pediatrics and director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.

But compliance is an ongoing problem. “They’re not getting the one vaccine that protects against diseases from which they’re most likely to suffer and die,” Offit said, noting that deaths from pertussis and meningococcal disease, for which adolescents are also vaccinated at that age, are minuscule compared with HPV-related cancers.

In 2015, 87 percent of 13-year-olds were up-to-date with the Tdap vaccine that protects against tetanus, diphtheria and pertussis, and 80 percent had received the meningococcal vaccine, according to the Centers for Disease Control and Prevention. But just 30 percent of girls and 25 percent of boys at that age had received all three doses of the HPV vaccine. In contrast to other vaccines, however, the HPV vaccine is required only in a few states for secondary school.

Public health advocates say they think the shift to a two-dose regimen could make a big difference in the number of adolescents who get all the necessary doses of the HPV vaccine. For one thing, the fewer shots the better, in general, they say.

In addition, because the second HPV shot is supposed to be given anywhere from six months to a year after the first one, “parents can fit it into a routine regimen when people go in for their 12-year-old’s regularly scheduled visit,” said Dr. Joseph Bocchini Jr., chairman of pediatrics at Louisiana State University Health in Shreveport who is president-elect at the National Foundation for Infectious Diseases.

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.

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