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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

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Resources for Improving Patient Cardiac Health

While clinicians are well informed of the evidence based guidelines to care for patients, often the translation of those guidelines into clinical practice is challenging. Two free programs in Georgia are actively recruiting primary care practices interested in improving the cardiac health of their patients. The projects support the mission of the Department of Health and Human Services Million Hearts Campaign – blood pressure control, lipid management, tobacco cessation and low dose aspirin therapy.

Both programs provide education, onsite technical support, assistance with data collection, interpretation and monitoring. Including:

• Establishing workflows to allow efficient and consistent data capture;
• Developing routine reports that allow quarterly monitoring of measures;
• Implementing a continuous quality improvement program to improve performance.

Alliant/GMCF, the Georgia Medicare Quality Improvement Organization – This project supports practices to successfully submit PQRS and achieve the 2012 financial incentive of 0.5 percent and avoid future penalties for non-reporting. Recruitment is statewide for practices caring for Medicare FFS members.

The COSEHC AT GOAL PI-CME Program - Each physician completing the CME Process Improvement Program will receive 20.0 AMA PRA Category 1 Credit(s)™. The Georgia Department of Public Health, Heart Disease and Stroke Prevention has identified the following high-risk districts to target in recruiting practices for this program: Dublin, Waycross, Macon, LaGrange, Valdosta, and Columbus.

For more information about these resources or the program please contact Adrienne Mims, MD, with Alliant/GMCF at 678-527-3492 and email: Adrienne.mims@gmcf.org or Debra Simmons at 336-716-1130 or dwirth@wakehealth.edu

Accountable Care Final Rule: Much Progress, Casts a Wide Net

By Justin Barnes, vice president with Greenway Medical Technologies and co-chair of the national Accountable Care Community of Practice (ACCoP)

Our nation's shared goal of a sustainable healthcare system of decreased costs and increased care quality through coordinated and accountable delivery took a positive, inclusionary step with the Centers for Medicare and Medicaid Services (CMS) Shared Savings Final Rule.

Consider that this final structuring of Accountable Care Organizations (ACOs), though still built upon primary care providers and their beneficiary patients, has broadened its scope to allow provisions for specialists and nurse practitioners to become ACO members, encourages home health agencies to participate, and embraces eligible critical access hospitals, federally qualified health centers and rural health clinics.

It maintains minimum patient levels at 5,000 and a three-year commitment, but offers logistical and logical flexibility such as allowing providers to participate in more than one ACO when billing from more than one hospital setting.

While the lowering of the number of quality measures (from 65 to 33), the flexibility of 2012 start dates through early summer, and the relaxing of financial risk was all expected, arguably the biggest news of the day was the co-announcement of the Advanced Payment Model, done to bring much of the broader participation into the program.

With Advanced Payment, CMS is putting its own level of financial risk into the program by offering three tiers of startup funding options to healthcare organizations with limited or no inpatient facilities and annual revenue below $80 million, though the startup fees would be paid back out of future shared savings. And there is some fine print: only ACOs entering the program in April or July of 2012 can benefit, also provided there is no health plan ownership in the organization.

CMS is also funding the first two years of patient engagement surveys required of an ACO as a further incentive to participate and further its own financial and programmatic commitment.

The Final Rule also clearly maintains and speaks to the key component of electronic health records (EHRs) as the data sharing connectivity and clinical support core of necessary health information technology. On one hand CMS understood that the still-maturing EHR adoption rates by healthcare providers nationally being fueled by meaningful use – while very encouraging with more than 114,000 eligible providers registered and more than $870 million granted so far in year one - did set an initial high bar by requiring that 50 percent of ACO participants be meaningful users by year two.

Instead, the Final Rule placed EHR adoption as its highest scoring Quality Measure, consistently rewarding increased adoption with higher sharing rates, which "signals the importance of EHR adoption in ACOs," according to the document.

The other quality measures, aligned in four domains of Care Coordination/Patient Safety (in which the EHR measure is rightly placed), Preventive Health, At Risk Population, and Patient/Caregiver Experience, continue to crossover with those of meaningful use and the Physician Quality Reporting System (PQRS). This again promotes EHR adoption, and the Final Rule provides for Shared Saving and PQRS reporting and reward to overlap as well.

Still, there is work to do. CMS must establish national benchmarks for the majority of the quality measures and must finalize the compilation and availability of shared claims data, for example, to do so. For providers and healthcare organizations, there is much to consider. Prior to the issuance of the Final Rule, CMS announced the Pioneer Model, the Bundled Payments for Care Improvement Initiative, and the Primary Care Initiative, all offering additional routes and choices for the pursuit of incentivized care coordination. And even here too, the Final Rule allows for some dual participations as a further incentive.

And as commercial payers, employers and health plans are increasingly entering the conversation and shaping other forms of accountable care models, it is clearly time to determine your own best practice inclusion into models being discussed and planned in your region. Care coordination took a big step toward reality with the issuance of the Final Rule, and as these organizations form, providers, like patients, should not be left out.

Family Physicians Help with Illiteracy in Georgia

In an effort to increase childhood reading levels in Georgia, the Georgia Department of Public Health (DPH) is partnering to increase the number of infants and toddlers who are screened and referred to appropriate early intervention programs. In a multi sector effort, DPH is collaborating with the Georgia Campaign for Grade Level Reading (GLRC) and other partners to increase the percentage of children in Georgia reading at or above standards adopted by the National Assessment of Education Progress (NAEP).

Three focus areas comprise the campaign in Georgia:

• School Readiness
• Summer Learning and
• School Attendance

To accomplish these goals, DPH will engage public agencies, elected officials, nonprofit and community organizations, and schools. Using a community-driven approach, agencies and partners will promote and advance adult responsiveness to improve oral language, print and sound skills among targeted children. The Department of Public Health and our partners will work to ensure that key adults in a child's life are actively engaged in behaviors that can support the child's future academic success. These activities may include early identification of developmental delays, ensuring the child's immunizations are up to date, following up on doctor's visits, reading to children, etc.

Together with physicians, community workers and child care providers, Public Health will train individuals to administer the nationally recognized Ages and Stages Questionnaires (ASQ), implement developmental screening as a method to identify developmental concerns, and increase infant and toddler referrals to appropriate early intervention programs.

Public Health looks forward to working together to ensure all children in Georgia enter kindergarten healthy and are ready to learn and succeed. The Georgia Academy of Family Physicians is proud to partner with the Georgia Department of Public Health on this initiative. GAFP will be reaching out to members in specific areas of Georgia to schedule Lunch and Learns on this important topic. For additional information contact Deanna Kauten, GAFP Public Health Consultant, at 800-392-3841 or publichealth@gafp.org

New Tobacco Cessation Resources for Family Physicians

The Georgia Tobacco Use Prevention Program of the Georgia Department of Public Health (DPH) has new educational materials available at no cost to all healthcare professionals throughout Georgia. These free materials include posters and brochures for physician offices.

The new Georgia Tobacco Quit Line/Tobacco Cessation brochures are also available beginning this month. These new brochures are available in 4 versions. Healthcare professionals can order all 4 versions and free shipping is provided throughout the entire state of Georgia. In addition, free Georgia Tobacco Quit Line prescription pads are available.

The Georgia Tobacco Quit Line: 1-877-270-STOP (7867) is a free and confidential professional cessation counseling, support and referral service for tobacco users trying to quit. Established since 2001, the Georgia Tobacco Quit Line is operated by a national tobacco cessation vendor.

Regardless of insurance status, the Georgia Tobacco Quit Line services (i.e. professional telephone counseling, referral and educational support) are free to all Georgians. To obtain more information about the Georgia Tobacco Quit Line, physicians can access the "Be Smoke-Free" section of the Live Healthy Georgia website at: http://www.livehealthygeorgia.org.

EHR Incentive Program – Clinical Quality Measures Webinar Now Available

Recently, CMS held a webinar to discuss the clinical quality measures (CQMs) and how to successfully report them during Stage 1 of meaningful use for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.

A PDF of the webinar presentation is now available online. Go to the Spotlight and Upcoming Event section at https://www.cms.gov/EHRIncentivePrograms/50_Spotlight.asp#TopOfPage of the Medicare and Medicaid EHR Incentive Programs website to download this presentation.

The presentation includes information on:

• An overview of the CQMs
• How to report CQMs during attestation
• Why CQMs are included in the EHR Incentive Programs

The webinar also includes an hour-long question-and-answer session with CMS subject matter experts. CMS plans to host another CQM webinar soon. Stay tuned for updates on how you can join this informational session.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website at https://www.cms.gov/ehrincentiveprograms/ for the latest news and updates on the EHR Incentive Programs or the local Georgia Health Extension Center at www.ga-hitrec.org.

Childhood Obesity Program – Strong4Life

Children's Healthcare of Atlanta (CHOA) has launched Strong4Life, a statewide movement to raise awareness of the childhood obesity crisis in our state and to offer solutions through programs, partnerships and clinical interventions. Strong4Life includes a large-scale public awareness campaign and programs that reach kids and families in schools, early childhood centers, physicians' offices, communities and more. With nearly 40 percent of Georgia's children being overweight or obese, Georgia has the second highest childhood obesity rate in the U.S.

CHOA sees it on the front lines in their hospitals every day: children who are overweight are now suffering from diseases once seen only in adults such as heart disease, hypertension, liver and kidney disease and Type 2 diabetes. CHOA knows that many physicians face this challenge in their practices, understanding that the issue is not just with the child, but in creating long-lasting behavior change that encompasses the entire family and community. One of the greatest hurdles physicians face is denial from both parents and our society, and addressing the health of the child often demands parents and caretakers think about their own health decisions. The studies showed that children want for those around them to be frank and open with them about the issue of obesity.

In Atlanta, you likely have seen some powerful advertising on billboards and TV. Strong4Life's "Warning" campaign, similar to other public health campaigns, is designed to alert parents about the health crisis and get people talking about the issue. CHOA's experience in launching Strong4Life in Columbus and Macon this spring demonstrated that this approach sparked critical conversation within those communities and an overwhelming majority reacted positively to the campaign's message.

Visit http://www.choa.org/Child-Wellness/Strong4Life-Programs/Providers to learn more and to get engaged in the Strong4Life movement. Together, we can make Georgia a leader in childhood wellness, instead of a leader in childhood obesity.

Behavioral Aspects of Dementia

By Adrienne Mims, MD

There have been recent concerns regarding the appropriate use of antipsychotic medications for patients in nursing homes. Boxed warnings were implemented for antipsychotic drugs in 2005 and the FDA expanded this warning to conventional antipsychotics in 2008. In May 2011, the Office of the Inspector General put out a report on Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents. The report used Medicare claims data from Part B and D and the Minimum Data Set to identify Medicare claims and payments for atypical antipsychotic drugs for elderly patients (age 65 and older) residing in nursing homes from Jan 1 through June 30, 2007.

• 14 percent of residents had claims for atypical antipsychotic drugs
• 38 percent were associated with off-label use
• 88 percent were associated with a condition in the FDA boxed warning (i.e. dementia)
• 22 percent were not administered in accordance with CMS standards (see below)

More recent CMS data, from a CMS Report for 3rd quarter calendar year 2010, noted that 39.4 percent of nursing home residents who had cognitive impairments and behavior problems, but no diagnosis of psychosis or related conditions, received an antipsychotic. 15.6 percent who had no cognitive impairment or behavior problems also received antipsychotics.

Code of Federal Regulations stipulates in 42 CFR 483.25 that:

• Antipsychotic use should treat specific condition as diagnosed and documented in chart
• Antipsychotic used should be accompanied by gradual dose reductions and behavioral interventions

To address this concern, the American Geriatric Society (AGS) has produced a resource to assist clinicians who care for patients with dementia that exhibit psychotic symptoms. This resource describes the appropriate diagnostic and therapeutic management of such patients and makes recommendations for when atypical antipsychotics can be used. The resource emphasizes the importance of a thorough evaluation of neuropsychiatric symptoms as they may be due to reversible conditions. Also, the use of non-pharmacologic treatments is addressed and the consideration for time limited use of antipsychotic drugs to reduce rather than eliminate the distressing symptoms. This resource is available at: http://dementia.americangeriatrics.org/AGSGeriPsychConsult.pdf

Additionally, the AGS has created a free companion tool application from iTunes called GeriPsych Consult. This app has been developed to assist healthcare providers in managing psychotic symptoms and disorders in older adults. This tool is available at: http://itunes.apple.com/us/app/geripsych-consult/id451511117?ls=1&mt=8

The Effective Healthcare Program: Helping You Make Better Treatment Choices

Posted by Evelyn L. Lewis, MD, MA, FAAFP

The Effective Healthcare Program was created by Congress in Section 1013 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The program is administered by the Agency for Healthcare Research and Quality (AHRQ), which is part of the U.S. Department of Health and Human Services. Under that legislation, the Agency for Healthcare Research and Quality (AHRQ) is authorized to conduct and support research with a focus on comparing the outcomes and effectiveness of different treatments and clinical approaches. Priority topic areas of study include arthritis and non- traumatic joint disorders, cancer, cardiovascular disease including stroke and hypertension, dementia including Alzheimer's disease, depression and other mental health disorders, developmental delays, ADHD, autism, diabetes, disability, pregnancy and preterm birth, substance abuse, pulmonary disease, infectious diseases and HIV/AIDS, and obesity.

It allows patients and their clinicians to work better together to choose the best treatment for an illness or condition. Comparative effectiveness research also helps patients and families understand the effectiveness and risks of different treatment options while allowing for choices based on the circumstances of the individual patient.

How is Comparative Effectiveness Research Used?

Every patient is different – with different circumstances, different medical histories, and different values. Comparative Effectiveness Research (CER) doesn't tell patients and clinicians which treatment to choose. Instead, CER reviews the benefits and harms of options and serves as a useful tool for everyone participating in the decision making:

• Patients face complicated choices: Which test will help most? Which medicine is best? Is surgery the best option? By providing more information, CER helps patients work with their clinicians to make the best possible choices.
• Doctors and other healthcare providers use CER to keep up on the best available scientific evidence on a particular healthcare topic, such as treatments for a chronic condition like diabetes. CER assists providers in learning how well a particular group of medications works in specific categories of patients. It also describes the strength of evidence behind scientific findings.
• Policymakers, business leaders, and others strive to make healthcare decisions based on the best available information. CER helps decision makers plan public health programs, design health insurance coverage, and initiate wellness or advocacy programs.

Hallmarks of the Effective Healthcare Program

There are four key hallmarks of the program. First and foremost, the program is aimed at practical issues. The reports that are produced do not make treatment recommendations but instead address practical questions about the potential harms of treatment options. The condensed summary guides that are produced contain "bottom Line" findings to help patients, clinicians, and policymakers make the best possible decisions.

Secondly, the program involves the public. Research ideas are requested from all sources – physicians, clinicians, educators, the private sector, disease advocacy groups, patients and others. Once draft research questions regarding recommended topics are formulated, they are posted online for public comment. In addition, the volunteer Effective Healthcare Program Stakeholders Group provides input in important areas. They provide guidance on improving the overall quality and impact of the Program and its products.

Thirdly, the program protects against conflict of interest. Any of the researchers participating in the program must disclose any potential conflicts of interest. All published research as well as treatment data that are available, but not yet published, is reviewed by researchers. In addition, all reports are peer reviewed before publication.

Lastly, the program pushes research forward. Each of the reports identifies relevant and specific clinical issues where reliable information is lacking. Unanswered questions as well as gaps in the research are often addressed in future projects.

The Research Process

Any individual or organization can submit a suggestion for research under the Effective Healthcare Program Web site. Topic nominations are reviewed by AHRQ staff for factors such as, how widespread and serious is the disease; what are the costs and available treatments; the amount of controversy regarding the treatment and the potential for improving and impacting care. Accepted suggestions are then sent to independent research teams to refine the research questions. The teams then either conduct a research review or produce a new research report.

Who Conducts the Research for the Effective Healthcare Program?

Networks of research and clinical teams produce the Effective Healthcare Program reports and publications across North America. For example, evidence-based practice centers perform the comprehensive research reviews of existing evidence. New scientific evidence and analytic tools are generated by DEcIDE (Developing Evidence to Inform Decisions about Effectiveness). Centers for Education & Research on Therapeutics or CERTs conduct research and provide education on the best use of drugs, biologics, and medical devices. The John M. Eisenberg Clinical Decisions and Communications Science Center converts the research results into summary guides and other resources. New evidence is generated from original research by individual investigators and their research groups located at academic institutions.

To learn more about the program and how you can get involved go to the Effective Healthcare Program website at www.effectivehealthcare.ahrq.gov to view publications, listen to audio-casts, suggest topics or comment on draft key questions. You can also contact Evelyn L. Lewis, MD, MA, FAAFP, and the Patient Centered Outcomes Consultant Regional Manager by email at elewismd@hotmail.com to schedule a visit to your practice.

Prevent Blindness Georgia Trains Physician Practices
in Vision Screening

Prevent Blindness Georgia vision screened more than 33,000 four-year old children in Georgia in 2010. The screenings are offered free of charge and are funded by grants and donations. Although most of these children are required to have EED (ear/eye/dental) screenings prior to entering school, about six percent of them fail the vision screening and are referred to an eye care professional for further evaluation. In many cases, the children failed the screening at their well-child checkups, but the parents had not followed up with an eye care professional. In other cases, the previous vision screening did not detect vision problems.

Physicians are the first line of defense in preventing vision loss in children. Prevent Blindness Georgia is making it a priority to ensure that the staffs of Georgia's family physicians and pediatricians are trained in the best evidence-based method of vision screening children, using a manual jointly published by Prevent Blindness America and the American Academy of Pediatrics. This methodology uses simple, but effective tools such as the Lea Symbols Chart with child-friendly shapes and the Random Dot "E" test with 3-D stereopsis glasses to identify children at risk for such childhood vision issues as amblyopia, strabismus, or refractive errors and refer them for an eye exam.

The Kid's Health First Pediatric Alliance and The Children's Health Network have sponsored trainings conducted by Prevent Blindness Georgia to ensure that physicians are familiar with this method.  For more information visit www.pbga.org or call Prevent Blindness Georgia at 404-266-2020.

GO! Diabetes Continues to Make a Change in Diabetic Care

In 2008, the Georgia and Oklahoma Chapters (GO!) of the American Academy of Family Physicians launched a unique pilot project to educate family medicine residents (physicians in training) on best practices related to diabetes. The focus was to improve how diabetic patients are educated on appropriate insulin therapy and self management for diabetic patients.  This grant was extended in 2009 and 2010 is our best year yet!

In March 2010, an additional grant was approved to expand the residency program training to up to 60 programs in even more states and to initiate a pilot project with up to 40 private practices in Georgia and Oklahoma.

The GO! team offered five train the trainer workshops around the U.S.

A total of 127 family medicine residents, faculty and patient educators attended one of the three training sessions.  We also had 61 physicians and staff/patient educators attend a training session from thirty-six private practices.

The private practice train the trainer sessions offered additional information on METRIC, the Diabetes Master Clinician Program and practice improvement tips and tools.  We found the practice improvement activities really engaged the clinical teams and fostered a lot of commitment to the project.

The Georgia private practices participating in the pilot project are:

Acworth Family Practice	Dallas
Bridgewater Family Pracitce	Conyers
Calhoun Family Medicine	Calhoun
Clark Robinson, MD, PC	Douglasville
Clarke-Oconee Family Practice	Athens
Cochran Total Health	Cochran
Coffee Family Medicine	Douglas
Crestview Health & Rehab Center	Atlanta
Dahlonega Family Practice	Dahlonega
Dublin Medical Center	Dublin
Elite Medical Physicians	Tucker
Family Health Care Center	Statesboro
Family Health Center of Adel	Adel
Harbin Clinic-Summerville	Summerville
Horizons Diagnostics	Columbus
Irwin Family Medicine	Ocilla
Kaiser Permanente	Duluth
Kennesaw Medical Center	Kennesaw
McIntosh Trail Family Medicine	Stockbridge
McKinney Community Health Center	Folkston
N Fulton Health Center	Marietta
Nadolne Family Medicine	Roswell
Urban Family Practice	Marietta

Extending the Education with the GO! Diabetes website
The GO! Diabetes website www.godiabetes.org became active in June 2010 with all of the presentations and forms on the website along with reports from the 2008 and 2009 grants. The website has a blog, links to video of the faculty presentations, archives of the eNewsletter, and other resources.  All GAFP members are encouraged to visit the site and participate in the educational conference calls that will extend through October.

Sept. 15, 2010          3 pm Eastern
-  Effective Patient/Physician Interactions, Wade Toalson, MD

October 6, 2010        12 noon Eastern
-  Using Your Staff to Implement a Team Approach to Care Management, Saria Carter Saccocio, MD

October 27, 2010      7 pm Eastern
-  Incorporating Patient Goal Setting into Office Visit Workflow, Donna  Rice, RN, MBA, CDE

Successes to date:
 There has been a great deal of enthusiasm and genuine excitement from the change agents who attend the Train the Trainer sessions. Many experienced faculty have embraced the project wholeheartedly and are encouraging their resident change agents and programs to participate fully.  Many of the private practice physicians have shared success stories from their early interventions.

 1. Awesome, this is amazing. I think it is about time that this wonderful program has a website of its own. This program has helped me in so many ways, such that I am able to visualize the several opportunities available for me to improve on the care that I provide to my diabetic patients. Thank you and Way to go!!!

2. We had 20 people show having invited everyone on staff (14) and also got response from our assistant VPMA, our operations manager, a new office manager in the enterprise, a diabetic educator from the enterprise and a local pharmacist – so great diversity and input! We found that 3 groups in the Nominal Group Process was necessary and came up with 3 action plans in the SMART/AIM statements that may be too cumbersome for the size of our office but would be implemented based on "A good night's sleep" and some further debate.

I ended with the Buddhist saying: Before Enlightenment: Chop wood and carry water.

After Enlightenment: Chop wood and carry water.

It wasn't necessary. As soon as I arrived to work this morning, everyone was discussing the conversations as they left off last night and how they were going to "make it work".

Tools Available to Help You Take Advantage of Medicare's Preventive Services for Diabetes

Are you taking advantage of preventive services for diabetes that are available to your Medicare patients?  Epidemiological data1 show that 72 percent of people age 65 and older have diabetes or pre-diabetes.  Of those with diabetes, it is estimated that almost half in this age range are undiagnosed.  Since 2005, Medicare has offered a free diabetes screening benefit, yet Medicare data2 show a low rate of utilization of this benefit nationwide (11.5 percent), with a lower rate for the state of Georgia (9 percent).

The Centers for Medicare and Medicaid Services (CMS) has a handy tool for your office entitled "Quick Reference Information:  Medicare Preventive Services", available for downloading here.

This two-page chart covers HCPCS/CPT and ICD-9 codes for screening and preventive services for diabetes and other diseases and conditions (including cardiovascular disease, lipids, cancer, pelvic exams, flu, glaucoma, pneumonia, hepatitis and smoking cessation) and tells you who's covered, frequency allowed, and what the beneficiary pays.

This chart has been incorporated into a promotional campaign to increase awareness and use of Medicare's benefits for diabetes screening.  The Medicare Diabetes Screening Project (MDSP), a coalition of public and private sector organizations co-chaired by the American Diabetes Association, the Healthcare Leadership Council, and Novo Nordisk, is working across the state of Georgia to urge seniors to ask you about getting tested for diabetes.

The vast majority of your patients age 65 and older will be eligible for free diabetes screening (FPG or OGTT, with no co-payment/coinsurance and no deductible).  Patients eligible are those that are age 65 or older with any one of the following risk factors:  hypertension, dyslipidemia, overweight, family history of diabetes, history of gestational diabetes, or history of high blood glucose.  One test per year is covered for patients that have never been tested, or who have not been diagnosed with pre-diabetes.  Two screening tests per year are covered for patients diagnosed with pre-diabetes. The MDSP has patient information ("Could I Have Diabetes and Not Know It?") that you can download here: http://www.screenfordiabetes.org/files/media/pdf/promos/MDSP-Senior-American-Brochure.pdf.

For more information about the MDSP, visit www.screenfordiabetes.org or contact Maurice Madden, MDSP Georgia Director, at 404-483-2640. 1Cowie, PhD, Catherine C. et al, "Full Accounting of Diabetes and Pre-Diabetes in the US Population in 1988-1994 and 2005-2006," Diabetes Care, 32: 287-294, 2009.

New GAFP Educational Activity Geared Towards Addressing the Issue of Inappropriate Medications in Seniors

The Georgia Academy has launched its first CME monograph which focuses on addressing the issue of inappropriate medications in seniors.  The monograph, which was funded by Healthcare Research, Inc., was the culmination of a year-long, multi-layered project that included a live lecture during the 2009 Annual Scientific Assembly, a subsequent online CME offering, and a Care of the Vulnerable Elderly Self-Assessment Module. 

The CME monograph project brought together experts in geriatric patient care including geriatricians and pharmacists, who expounded on the different and complex challenges that older adults face compared to the younger population. It was noted that many geriatric patients have multiple health problems and require more than one medication to manage their health conditions.

The authors expertly noted the use of multiple medications in their older patients and documented complications such as different pharmacologic behaviors in the older population as well as medications that are contraindicated in geriatric patients and increased risk of drug-drug interactions. The monograph takes an in depth look at this population, and highlights the risk for adverse events with prescription medication use, the importance of having well equipped and knowledgeable caregivers, and offers tools to recognize and avoid potential problems.

The CME monograph has been reviewed and is acceptable for up to 1 Prescribed credit by the American Academy of Family Physicians and is accredited by the GAFP for a maximum of 1 AMA PRA Category 1 credit(s)™ .  Please visit http://www.gafp.org/online_cme.asp to access the CME monograph for free.

Celebrating a Century of Progress in Sickle Cell Disease

By: James R. Eckman, MD
Professor of Hematology, Oncology, and Medicine
Emory University School of Medicine

The year 2010 is the 100th anniversary of the first description of sickle cell disease in the Western medical literature and the 30th anniversary of statewide newborn screening for sickle cell disease in Georgia.  Considerable progress has been made in the understanding of this first metabolic disease and the new knowledge is being translated into improved care for individuals with sickle cell disease.   With this improvement in care has come a dramatic increase in survival allowing affected individuals to live full, productive, and satisfying lives.

Knowledge about the genetics, pathophysiology, and clinical complications of sickle cell disease increased rapidly over the next three decades, but the prognosis for individuals with sickle cell disease did not improve until organized health care programs were started in the 1970s.  Reports by Drs. Pearson and Powars showed that early detection, preventive care, and appropriate early recognition and treatment of complications reduced morbidity and improved survival.  The landmark Penicillin Prophylaxis in Sickle Cell Disease (PROPS) study showed that detection at birth and daily penicillin administration significantly reduced serious complications and death from Streptococcus pneumonia.  This and recommendations from a National Institutes of Health (NIH) Consensus Development Conference lead to rapid introduction of newborn screening programs for sickle cell disease. Now all states and territories have universal screening for these disorders at birth.

New challenges for health care and public health are emerging in the 21st Century.  First and foremost, there are a large number of individuals with sickle cell disease transitioning to adult life.  Organized programs for adults with sickle cell disease are lacking or inadequate to provide medical homes for the large numbers of adults with sickle cell disease in states like Georgia.  There are few models for transitioning these individuals with this serious chronic illness from pediatric- based health care to adult health care systems.  It is clear that adults have a more chronic disease characterized by chronic pain syndromes, renal insufficiency and failure, pulmonary disease with respiratory compromise and pulmonary hypertension, and other chronic illnesses.  The pediatric health care community has done a marvelous job of allowing individuals with sickle cell disease to survive to adulthood and now they need to become active advocates for them as they transition to adult care.

The Centers for Disease Control initiated the "Registry and Surveillance System for Hemoglobinopathies" Program (RuSH) because of the realization that healthcare for this population is probably inadequate and their medical needs are largely unknown.   RuSH will develop a surveillance system to determine the prevalence of the disease.  Georgia is among six states funded to develop and pilot statewide surveillance systems to determine the prevalence of sickle cell disease, thalassemias, and other hemoglobinopathies.  After this phase is accomplished, patient registries will be developed to track medical needs, health outcomes, and resource utilization of these individuals.  Cooperation of the broad medical community in Georgia will be needed to assist in developing both the surveillance system and registry in the coming years.

For additional information, visit the Georgia Division of Public Health website at http://health.state.ga.us/programs/nsmscd/index.asp or contact Cathi Durham at 800-392-3841 or cdurham@gafp.org      

The Long-Term Care Discharges with Controlled Substances

By: Adrienne Mims, MD MPH

Patients who are discharged from the hospital who have pain are in need of continued medication to control their symptoms. To meet this need, there has been a long-standing practice of writing discharge narcotic medications for patients going to long-term care facilities and hospice, on the discharge order sheet along with all other medications.

In recent months the Drug Enforcement Administration (DEA) has increased its focus on the use of controlled substance medications in long-term care facilities. DEA has stated clearly and in writing that this "widely used system is not in compliance with legal requirements." Source: 66 Fed Reg. 20834.  Specifically, they are doing audits to enforce long-standing rules: 21 Code of Federal Regulations 1306.04-6, 1306.11. As a result, significant fines have been levied against nursing home pharmacy vendors who do not have hard copy or valid faxed prescriptions for Schedule II-V controlled substances. The pharmacy can potentially face administrative or civil fines and penalties for violating the Controlled Substances Act.

As a result of current practices, patients discharged to long-term care facilities or hospice have reached their new location but do not have access to crucial medications. They have been caught in the middle by not having medications to control their pain that have been previously ordered and shown to be effective.

What this means to you is that there must be a WRITTEN PRESCRIPTION for each order for a Schedule II-V controlled substance that is signed by the physician and includes the following:

1. Date issued
2. Full name and address of the patient
3. Drug name, strength, dosage form, quantity prescribed and directions for use
4. The name, address and registration number for the physician
5. The authorized number of refills for Scheduled II-V

While this may be an inconvenience for physicians who discharge patients from the inpatient setting, or who call in medications for patients in long-term care, it is small compared to the importance of maintaining pain control in our patients.

For more resource tools visit http://www.gmcf.org/hospital/drug_safety_dea.shtml.

This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 9SOW-GA-DSF-10-15

CDC Health Alert – Rotarix Vaccine

CDC released a Health Alert on March 22, 2010 regarding information that recently has become available about Rotarix, a vaccine used to prevent rotavirus disease. FDA has learned that components of an extraneous virus are present in Rotarix. Available evidence indicates that there is no increased risk to patients who have received this vaccine. While the agency is learning more about the situation, FDA is recommending that clinicians and public health professionals in the United States temporarily suspend the use of Rotarix. This recommendation applies to all lots of the Rotarix vaccine. RotaTeq vaccine is available for rotavirus immunization during this period. For children who have received one dose of Rotarix, CDC is advising clinicians to complete the series with RotaTeq.

Clinicians are requested to report any suspected adverse events following Rotarix vaccination to the Vaccine Adverse Event Reporting System (VAERS) via phone (800) 822-7967 or on-line: http://vaers.hhs.gov.

FDA intends to provide updates to patients, providers, and the general public as it becomes available. Additional information is available at: www.fda.gov.

Reduction in Premiums for Family Physicians that Perform Circumcisions

The GAFP Practice Management Committee has been hard at work for family physicians in Georgia. Recently a GAFP member brought to the committee’s attention that his insurance premiums with MAG Mutual were higher because the family physician performs circumcisions. Practice Management Committee chair, Dr. Paul LeBlanc of Calhoun, led an effort to understand this policy and investigate the possibility of revision. MAG Mutual representative Tedda Voe explained that there are four categories that family physicians are divided among. Class 1A is No Surgery; Class 2A is Minor Surgery – no obstetrics/no prenatal care after the first trimester; Class 3B is Minor Surgery – obstetrics, no C-Sections; and Class 4A is Minor Surgery – obstetrics with C-Sections. Circumcision is considered minor surgery, placing it in Class 2A thereby increasing the physician’s premium.

Following the conversation with MAG Mutual, the issue was taken to the company’s Physician Board of Directors for review. The decision was made to reclassify circumcisions from Class 2A to Class 1A - No Surgery. The change is effective immediately. However, physicians will not see their rates change until their policy renewal date. For additional information, contact your MAG Mutual insurance representative.

MAG Mutual’s Chairman of the Board, Dr. Roy Vandiver states, "MAG Mutual is pleased that our Physician Board of Directors was able to review this issue and respond to the needs of the GAFP membership."

The GAFP appreciates our longstanding relationship with MAG Mutual.

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.

CDC Health Alert – Rotarix Vaccine

CDC released a Health Alert on March 22, 2010 regarding information that recently has become available about Rotarix, a vaccine used to prevent rotavirus disease. FDA has learned that components of an extraneous virus are present in Rotarix. Available evidence indicates that there is no increased risk to patients who have received this vaccine. While the agency is learning more about the situation, FDA is recommending that clinicians and public health professionals in the United States temporarily suspend the use of Rotarix. This recommendation applies to all lots of the Rotarix vaccine. RotaTeq vaccine is available for rotavirus immunization during this period. For children who have received one dose of Rotarix, CDC is advising clinicians to complete the series with RotaTeq.

Clinicians are requested to report any suspected adverse events following Rotarix vaccination to the Vaccine Adverse Event Reporting System (VAERS) via phone (800) 822-7967 or on-line: http://vaers.hhs.gov.

FDA intends to provide updates to patients, providers, and the general public as it becomes available. Additional information is available at: www.fda.gov.