Clinical Care & Research

Please see the blast fax documents on RSV recommendations in Georgia and the Medicaid CMO Palivizumab policies.

RSV Blast Fax - October 2008.pdf
RSV Blast -Page 2 - Medicaid CMO Palivizumab.pdf

Tuberculosis in Georgia

Back in the early 1990s, 800 to 900 tuberculosis cases were reported every year in Georgia. In 2007, there were 474 cases, representing a 48 percent decrease in TB cases reported in our state. However, Georgia had the 9th highest TB case rate (4.9 per 100,000 population) among the 50 states in 2007. Despite the significant decline in cases reported, Georgia still has a long way to go.

Active TB is an infection in which symptoms are present and TB bacilli are actively multiplying and attacking the body. This TB patient is contagious and should be treated appropriately. Treatment of active TB is a two step process. The first step is the initial or “intensive phase” where a four-drug regimen is used for two months. These four drugs are isoniazid, rifampin, pyrazinamide, and ethambutol. These are given five to seven times a week under directly-observed therapy (DOT). The second phase, or the “continuation phase,” consists of administering isoniazid and rifampin daily for four to seven months. Latent TB is a condition where the TB bacilli are present in the body but are being acted on by the immune system. There are no symptoms in this case; however, the patient should still receive treatment to prevent TB disease from developing later in life. Isoniazid monotherapy for nine months is the treatment of choice for latent TB infection; this regimen provides an effectiveness rate of about 90 percent in compliant patients. Public Health departments monitor patients under DOT. DOT is the standard of care for TB patients in Georgia. Family physicians should coordinate care with their respective county health department to ensure treatment completion.

In Georgia, the majority of TB cases are male and black, non-Hispanic. The age group with the highest proportion of TB cases was the 25-44 years old group. At risk populations include those Georgians who are foreign-born, drug abusers, HIV-positive, homeless, prisoners, or residents of nursing homes.

All active TB cases, as well as latent TB cases in children under five years of age, are notifiiable disease in Georiga and should be reported immediately to the county health department in the county where the patient resides. This can be done by calling the health department and completing a Notifiable Disease Report Form. You can also report TB by using the State Electronic Notifiable Disease Surveillance System (SENDSS) at https://sendss.state.ga.us/sendss/login.screen.

Reference and Additional Resource: Inge, L.D. and Wilson, J.W. (2008). Update on the treatment of Tuberculosis. American Family Physician, 78 (4), 457-465.

January 19, 2009

Woman’s Right To Know-New Provisions

During the 2007 legislative session, House Bill 147 passed, which builds upon the requirements of House Bill 197, the “Woman’s Right to Know” (WRTK) Act.

HB 147 requires that in all cases in which an ultrasound is performed prior to conducting an abortion, or a pre-abortion screen, the pregnant woman must be offered the opportunity to view the ultrasound and listen to the fetal heart rate. Although they are not required to view or to listen, this opportunity must be extended, and a completed consent placed in the chart signed by the woman indicating individually whether she declined or accepted to both view the ultrasound and listen to the heart beat.

Medical providers in licensed abortion facilities who provide information to pregnant women under these laws must continue to submit the WRTK Annual Reporting form, as they did previously, by February 28, 2009. The additional reporting requirements related to ultrasound can be accessed at http://health.state.ga.us/wrtk/

If you have questions, comments or suggestions regarding the updated requirements, please feel free to contact the Office of Birth Outcomes, Perinatal/ Women’s Health Unit at (404) 657-3143 or by email at info@atlanticpkg.com

January 19, 2009

2008-09 Flu Vaccine – Major Changes You Need To Know

According to an article in the recent Georgia Epidemiology Report, the 2008 Advisory committee on Immunization Practices (ACIP) has recommended 4 major changes from last year:

1. All children ages 5-18 years should be vaccinated annually, if feasible.

2. Children ages 6 months-4 years (and older) who are at risk for complications from influenza should continue to be the primary focus of vaccination efforts.

3. Either trivalent inactivated vaccine (TIV) or live, attenuated vaccine (LAIV) can be used for those who are healthy, ages 2-49 years.
- Children 6 months-8 years should receive 2 doses, the second dose at least 4 weeks after the initial dose, if they have never been vaccinated with the LAIV or TIV.
- Children 6 months-8 years who received only 1 dose in their first year of vaccinations, should receive 2 doses the following year, with the second dose at least 4 weeks after the initial dose.
- Children with RAD should not receive LAIV.
- Children with underlying medical conditions that put them at risk for influenza complications, children 6-23 months old, and those > 49 years old should receive TIV.

4. The trivalent vaccine virus strains for 2008-2009 are:
A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens(1).

Reference:
Centers for Disease Control and Prevention. Prevention and Control of Influenza; Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2008.MMWR 2008; 57 (No. RR-7)[pp: 1-60]

January 19, 2009

GAFP Leadership Meets With Georgia’s Leading Insurance Medical Directors

By Bruce M. LeClair, MD, MPH, FAAFP - GAFP President
I recently met with most of the major players in Georgia’s insurance industry to discuss with them the following resolution passed by the GAFP Congress of Delegates:

“Be it resolved that the GAFP issue a position statement to third party health insurance vendors operating in the state of Georgia to the effect that: - labs, imaging, studies or treatments needed in urgent or critical decision-making clinical situations be made payable to the physician; - no third party administrator be allowed to impede a physician’s ability to immediately obtain diagnostic studies or treatments deemed necessary in urgent or critical situations; - a third party physicians’ hotline for each insurance company be published and supplied to approved physician providers for immediate problem resolution in the event that any issues affecting urgent decision-making or treatments arise.”

I was heartened to hear all of the medical directors in agreement that they want to increase communication between family physicians and their companies.

As a step in the right direction, they have sent the GAFP a listing of all of their direct contacts (see below). They encouraged me to take the message back to our members that they understand the hassles related to insuring patients and working with multiple plans.

Please save this list and give it to your office manager to contact the medical directors when you encounter issues of concern to you.

Georgia Insurance Medical Directors

Aetna
Jack Spicer, MD (GAFP member)
11675 Great Oaks Way • Alpharetta, Ga. 30022
Phone: (770) 346-2131 • E-mail: spicerj@aetna.com

Blue Cross Blue Shield of Georgia
Bob McCormack, MD • Mgr. - Medical Director
3350 Peachtree Rd., NE • Mail code GAG006-0008
Atlanta, Ga. 30326
Phone: (404) 842-8286 • Fax: (404) 842-8115
E-mail: bob.mccormack@bcbsga.com

CIGNA Healthcare of Georgia, Inc.
Mary Caulfield, MD • Senior Medical Executive
Two Securities Centre
3500 Piedmont Rd., NE, Suite 200 • Atlanta, Ga. 30305
Phone: (404) 443-8820 • Fax : (404) 443-8994
E-mail: mary.caulfield@cigna.com

Coventry Health Care of Georgia
Bernard Cohen, MD (GAFP member)
1100 Circle 75 Parkway, Suite 1400 • Atlanta, Ga. 30339
Phone: (678) 202-2138 • E-mail: bmcohen@cvty.com
Humana Inc.

Monte Masten, MD, MBA, MPH, FACOG
Vice president and market medical officer
Georgia, North Carolina & South Carolina Markets
900 Ashwood Parkway, Suite 500 • Atlanta, Ga. 30338
Phone: (770) 350-2186 • E-mail: mmasten@humana.com

The Southeast Permanente Medical Group
Debra G. Carlton, MD
Associate Medical Director of Clinical Affairs
Phone: (404) 364-7209 • Fax: (404) 365-4162
E-mail: Debra.Carlton@kp.org

UnitedHealthcare Group
Catherine E. Palmier, MD
Chief Medical Officer, Southeast Region
Phone: (770) 300-3631 • Fax: (866) 567-7619
Cell: (678) 481-9864
E-mail: catherine_e_palmier@uhc.com

September 4, 2008

Survey Shows That 14 Percent of U.S. Children Have Special Healthcare Needs
A new government survey reports that 10.2 million, or 14 percent, of all children in the United States have special healthcare needs (CSHCN). Survey statistics also reveal that more than a fifth of U.S. households with children have at least one child with special needs.

Children with special healthcare needs are defined by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB) as: “those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”

This broad definition emphasizes the characteristics held in common by children with a wide range of diagnoses, including autism, attention deficit hyperactivity disorder, diabetes and asthma.

The national survey also found that:
* Sixteen percent of CSHCN do not receive all the services they need, and the most commonly mentioned service is preventive dental care.
* More than 94 percent of CSHCN have a regular source of care when they are sick. For 78 percent, this is a private doctor’s office; for 13 percent it is a clinic or health center; and for almost 4 percent, it is another setting.
* Twelve percent of families required mental health care or counseling related to the child’s medical, behavioral or other health conditions.
* Twenty-four percent of families reported that a parent had to stop working or cut work hours to care for their children.
Georgia CSHCN survey results tracked the national results in most instances and found that:
* Eighteen percent of CSHCN in Georgia do not receive all the services they need, a 2-percent increase over the national findings.
* 10.4 percent of CSHCN in Georgia were without insurance at some point in the past year, compared with 8.8 percent nationally.
* More than 94 percent of CSHCN in Georgia have a regular source of care when they are sick.
* 91 percent of CSHCN in Georgia lack a personal doctor or nurse.

While many states, including Georgia, perform well in specific areas of care, no state is providing all of the recommended care to its children with special healthcare needs. There is still much work to be done in Georgia and throughout the nation to promote family-centered, community-based, coordinated care for CSHCN and to facilitate the development of community-based systems of services for children and their families.

The 2005-2006 study provides a source of both state and national data on the size and characteristics of the population of CSHCN. The telephone survey screened 364,841 children for special healthcare needs and completed 40,840 interviews with families of CSHCN, covering a minimum of 740 CSHCN under the age of 18 in each of the 50 states and the District of Columbia. Interviews were conducted with parents or guardians who know about the child’s health.

A CSHCN screener is available in both English and Spanish at no charge. To access the CSHCN screener and supporting materials, visit www.cahmi.org. CAHMI in an acronym for Child and Adolescent Health Measurement Initiative.

The National Survey of Children with Special Health Care Needs Chartbook 2005-2006 is available online at http://mchb.hrsa.gov/cshcn05/.

May 28, 2008

GAFP Spotlight On: Georgia’s Newborn Metabolic & Sickle Cell Infant Screening Program
During fiscal year 2005, the Georgia Public Health Laboratory tested more than 199,000 newborn screening specimens (blood spots) from throughout the state. Of those specimens, 82 infants were diagnosed with metabolic diseases and 132 infants were diagnosed with sickle cell anemia. Early diagnosis and treatment of these inherited metabolic disorders (by three weeks of age) and sickle cell disorders (by two months of age) can prevent irreversible mental retardation in some children, and death in others.

These statistics underscore the importance of Georgia’s Newborn Metabolic and Sickle Cell Screening Program which is now more than three decades old and illustrate the program’s primary function to reduce child deaths and disabilities associated with nine inherited metabolic diseases and sickle cell disorders. The program, along with Children 1st and the Universal Newborn Hearing Screening and Intervention program, is part of Georgia’s newborn screening system.

This comprehensive, statewide system assures that all newborns receive screenings for selected inheritable metabolic diseases and sickle cell disorders and effective January 1, 2007, Georgia law (OCGA 31-12-6 & 31-12-7) and Rules and Regulations (Chapter 290-5-24) required that every live born infant have an adequate blood test to detect the following: Phenylketonuria, Congenital Hypothyroidism, Maple Syrup Urine Disease, Galactosemia, Tyrosinemia, Homocystinuria, Congenital Adrenal Hyperplasia, Biotinidase Deficiency, Medium-Chain Acyl-CoA Dehydrogenase Deficiency, Sickle Cell Disorders (SS, SC, S-beta thalassemia), Isovaleric acidemia, Glutaric acidemia type I, 3-OH 3-CH3 glutaric aciduria (HMG), Multiple carboxylase deficiency, Methylmalonic acidemia, 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC), Propionic acidemia, Beta-ketothiolase deficiency, Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD), Long-chain L-3-OH acyl CoA dehydrogenase deficiency (LCHAD), Trifunctional protein deficiency, Carnitine uptake defect, Citrullinemia, Argininosuccinic acidemia, and Cystic Fibrosis.

The Georgia Newborn Screening Program is a five part preventive health care system designed to identify and provide early treatment for selected inherited disorders that otherwise would cause significant morbidity or death. The five components of the program are:
1. Screening: universal testing of all newborns by the Georgia Public Health Laboratory
2. Follow-up: rapid retrieval and referral of the screen-positive newborn
3. Medical Diagnosis: confirmation of a normal or abnormal screening test result by a private physician or tertiary treatment center
4. Management: rapid implementation and long-term planning of therapy
5. Evaluation: validation of testing procedures, efficiency of follow-up and intervention, and benefit to the patient, family and society. Includes consideration of adding other tests to the system as indicated by appropriate research and scientific evidence.

Education and training on what is required by the newborn screening legislation, and how to meet those requirements, is available for all healthcare providers through the Georgia Department of Human Resources Division of Public Health Family Health Branch.

All newborns in Georgia are screened as required by law. Newborns who screen positive may also qualify for the Children’s Medical Services Program (CMS), based on financial and medical eligibility requirements.

For more information contact: Sharon Quary (404) 657-6359
E-mail: scquary@dhr.state.ga.us
http://health.state.ga.us/programs/nsmscd/
State Program Manager for Metabolic/Genetic Newborn Screening
Georgia Department of Human Resources
Division of Public Health

Editor’s Note This article is the second in a two-part series on the various functions of the Georgia Public Health Laboratory.

March 20, 2008

NPI Deadline Approaching
The National Provider Identifier (NPI) has been adopted by the U.S. Department of Health and Human Services to meet the HIPAA health care provider identification mandate. It replaces all existing health care provider identifiers including numbers assigned by Medicare, Medicaid, Blue Cross, etc. on standard HIPAA transactions.
It will be the number used to identify providers nationally. In compliance with federal regulations, Georgia Medicaid is now requiring the use of a National Provider Identifier (NPI) when submitting electronic Medicaid claims. Medicaid providers who are not eligible to receive an NPI will maintain their current Medicaid Provider ID. On May 23, 2008, standard electronic transactions may ONLY contain the NPI to identify the provider.

A complete listing of provider types and requirements for obtaining an NPI can be found on the GHP Web portal at https://www.ghp.georgia.gov/wps/portal under Provider Information- National Provider Identifier Information.

March 20, 2008

A User’s Guide to Georiga’s Public Health Laboratory
Every year, Georgia newspaper headlines report multiple outbreaks of influenza as confirmed by the Georgia Public Health Laboratory (GPHL). While high-profile public health issues such as influenza capture the public’s attention, the vital screening, diagnostic and reference laboratory services provided by the GPHL throughout the year are essential components of Georgia’s overall public health infrastructure.

The Georgia Public Health Laboratory’s principal role is to provide analytical and technical support to continually evolving state and federal public health programs through:

Direct Program Support - including laboratory testing for STD, TB and HIV and for the Stroke and Heart Attack Prevention Program. Sexually transmitted diseases and HIV testing (in addition to newborn screening) produce the GPHL’s largest volume of specimens. Physicians who need HIV submittal forms or who have questions about ordering specimen collection kits can find updated forms and fact sheets on the GPHL’s Web page: http://health.state.ga.us/programs/lab/manual.asp.

Legal Requirements - including mandated newborn metabolic and sickle cell screening. Physicians throughout the state can access screening results with a touch-tone telephone 24 hours a day, seven days a week using the Voice Response System (VRS) for the Newborn Screening Program. To ensure confidentiality and security, a state medical license number or a submitter code number is required to access the system, as well as a personal identification number (PIN) assigned at the time of enrollment.

Once registered with the system, screening results for any child born in Georgia can be accessed using the Social Security number of the infant’s mother. The newly designed specimen collection form, which includes a space for the mother’s SSN, is already in circulation. To enroll in the system, go to http://health.state.ga.us/programs/lab/vrs.asp or call
(404) 327-6800.

Epidemiology - helps to monitor reportable diseases by providing notification of positive tests performed in the laboratory for influenza, rabies, Rocky Mountain spotted fever and giardiasis.

Each year, from October to mid-May, Georgia’s Division of Public Health tracks cases of influenza throughout the state with the help of volunteer sentinel physicians. While each individual case of influenza is not reportable to health authorities, influenza activity is monitored by watching the percentage of doctors’ visits for “influenza-like illness” (fever >100 F and cough and/or sore throat). In addition to weekly reporting, these volunteer providers send throat swabs from patients for laboratory testing (virologic confirmation and subtyping).

Based on testing conducted each week at the GPHL, the Georgia Division of Public Health posts information on circulating influenza strains on its Web site at http:health.state.ga.us/epi/flu/strain07.asp. The data is then entered into a database to help determine which strains will be included in next year’s influenza vaccine. All data collected by Georgia sentinel physicians are sent to the Centers for Disease Control and Prevention (CDC) for inclusion in the nationwide network.

Reference Testing - including definitive, complex or new tests on specimens or referred cultures, principally in bacteriology, mycobacteriology or virology.
Visit http://health.state.ga.us/programs/lab/index.asp to download the Laboratory Services Manual for more information on GPHL services and contact information for managers in each program unit. Because the online version of the Laboratory Services Manual is due to be updated, e-mail gdphinfo@dhr.state.ga.us or call (404) 327-7900 if you cannot find the information you need online.

Editor’s note: This article is the first in a two-part series on the Georgia Public Health Laboratory. Part two of the article will appear in our next newsletter and will examine Georgia’s newborn metabolic screening program.

February 26, 2008

Why you Should be an Influenza Sentinel Provider
What is an influenza sentinel provider?
An influenza sentinel provider conducts surveillance for influenza-like illness (ILI) in collaboration with the state health department and the Centers for Disease Control and Prevention. Data reported by sentinel providers, in combination with other influenza surveillance data, provide a national picture of influenza virus and ILI activity in the United States. Approximately 1,600 providers throughout the country were enrolled in this network during the 2005-06 influenza seasons.

What data do sentinel providers collect?
How and to whom are data reported?
Sentinel providers report the total number of patient visits each week and the number of patient visits for influenza-like illness by age group (0-4 years, 5-24 years, 25-64 years, >65 years). These data are transmitted once a week over the Internet, a touch-tone telephone or fax to a central data repository at CDC. Most providers report that it takes them less than 30 minutes a week to compile and report their data. In addition, sentinel providers can submit specimens from a subset of patients for virus isolation free of charge.

Who can be an influenza sentinel provider?
Providers of any specialty (for example, family practice, internal medicine, pediatrics, infectious diseases) in any type of practice (private practice, public health clinic, urgent care center, emergency room, university student health center) are eligible to be sentinel providers.

Why volunteer?
Influenza viruses are constantly evolving and cause substantial morbidity and mortality (approximately 36,000 deaths) almost every winter. Data from sentinel providers are critical for monitoring the impact of influenza and, in combination with other influenza surveillance data, can be used to guide prevention and control activities, vaccine strain selection and patient care. Sentinel providers receive feedback on the data submitted, summaries of regional and national influenza data and a free subscription to CDC’s Morbidity and Mortality Weekly Report and Emerging Infectious Diseases Journal. The most important consideration is that the data provided are critical for protecting the public’s health. For more information on influenza sentinel provider surveillance, please contact Talisa Gimbel at tgimbel@gafp.org or (404) 321-7445.

October 8, 2007

2007 Pfizer Teacher Development Awards for New Physicians
The AAFP is pleased to announce the 2007 Pfizer Teacher Development Awards program. Through this program, the Foundation strives to recognize outstanding, community based new physicians who combine clinical practice with part-time teaching of family medicine. Each of the fifteen (15) awardees receives a $1,500 scholarship to enroll in a skill-building opportunity to further their development as teachers of family medicine. In addition, each winner is recognized at a special event hosted by the teaching center. A $500 stipend will be provided to the residency or medical school to offset the cost of this event.

In 2006, GAFP member Lynn T. Denny, MD of Macon received one of the $1,500 awards. Dr. Denny received her degree from Mercer University School of Medicine, and at the time the scholarship was awarded, was teaching medicine part-time at Mercer. She was recognized for the achievement during a ceremony hosted by Mercer at the Macon Free Clinic.

To learn more about the eligibility requirements and to download application forms visit www.aafpfoundation.org/ptda.xml. Individuals preferring the application packet in hard copy may contact Sondra Goodman by email at sgoodman@aafp.org or by calling (800) 274-2237, ext 4457. The application deadline is May 11.

April 10, 2007

Perinatal Hepatitis B infection carries a 90-percent risk of lifelong chronic infection, with a 25-percent risk of premature mortality due to cirrhosis or liver cancer, when postexposure prophylaxis is not administered. The Georgia Perinatal Hepatitis B Prevention Program tracks infants born to HBsAg-positive women and works with public health and private providers to prevent perinatal hepatitis B infection through immunization. One step in this process is often overlooked by providers – the post-vaccination serology.

The ACIP recommends that infants born to hepatitis B-infected mothers be tested for evidence of immunity or infection after completion of the hepatitis B vaccine series. Testing should be done when the infant is between 9 and 18 months of age to avoid interference from the HBIG injection given at birth. The only two blood tests to be ordered for these high-risk infants are the hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs).
Interpretation of lab tests:
* anti-HBs positive and HBsAg negative = immunity is achieved;
* anti-HBs and HBsAg negative = no immunity; a second series of hepatitis B vaccine is needed;
* anti-HBs negative and HBsAg positive = infant has perinatal hepatitis B infection.

Perinatal hepatitis B is a notifiable disease in Georgia and is reportable to the Centers for Disease Control and Prevention (CDC). The infected child should be routinely monitored for evidence of liver disease.

For more information, please contact Karol Travis, perinatal hepatitis B coordinator, at (404) 657-0278.

Reference: CDC. (2005) A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 1: Immunization of Infants, Children, and Adolescents. MMWR 54(RR-16);1-31.

January 19, 2007

The Georgia Newborn Screening Program will expand the number of disorders on its screening panel from 13 to 29, including hearing screening. There will be a $40 fee for specimens submitted for screening. Please see the Georgia Newborn Screening Program Web site for updates: http://health.state.ga.us/programs/nsmscd/.

Current Screening

Phenylketonuria;
Congenital Hypothyroidism;
Maple Syrup Urine Disease;
Galactosemia;
Tyrosinemia;
Homocystinuria;
Congenital Adrenal Hyperplasia;
Biotinidase Deficiency;
Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCADD);
Sickle Cell Anemia (three types).

Expanded Screening

Isovaleric acidemia;
Glutaric acidemia type I;
3-OH 3-CH3 glutaric aciduria (HMG);
Multiple carboxylase deficiency;
Methylmalonic acidemias (2 types);
3-Methylcrotonyl-CoA carboxylase deficiency (3MCC);
Propionic acidemia;
Beta-ketothiolase deficiency;
Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD);
Long-chain L-3-OH acyl CoA dehydrogenase deficiency (LCHAD);
Trifunctional protein deficiency;
Carnitine uptake defect;
Citrullinemia;
Argininosuccinic acidemia;
Cystic Fibrosis.

Please call Jill Ray at (404) 657-6314 or e-mail mjray@dhr.state.ga.us for more information.

January 19, 2007