Archive for January, 2016

Your Voice Matters: Speak Up at the Legislative Day at the Capitol!

Join your family physician and medical student colleagues and attend our Legislative Day at the Capitol on Thursday, February 11, 2016.  This day-long event allows GAFP members to build and nurture relationships with state legislators and their staff at the Capitol in Atlanta.  It is also the perfect opportunity to share personal stories related to important health policy issues – such as access to primary care, scope of practice and graduate medical education.

The event is open to all GAFP members who are passionate about policy issues and want to help advance the specialty of family medicine and primary care in Georgia, as well as meet and network with fellow advocates from around the state.  Registration is free (until February 1) and will include a light breakfast and lunch.  We will invite your local legislators to sit with you during lunch.

Legislative Day at the Capitol

Thursday, February 11, 2016
Floyd Veterans Building, Floyd Room, West Tower, 20th Floor
2 Martin Luther King Drive, Atlanta, GA 30334
And Georgia State Capitol

Hosted by Patient Centered Physician Coalition of Georgia

Members:
Georgia Academy of Family Physicians, Georgia OBGyn Society, Georgia Chapter of American Academy of Pediatrics, Georgia Osteopathic Medical Association, Georgia Chapter – American College of Physicians

Schedule

8:30-10:00 am Breakfast – Advocacy Training

Keynote – Department of Community Health Briefing on Medicaid and State Health Benefit Plan

10:00-10:30 am Review of Legislative Priorities

10:30 am – Noon Legislative Visits at the Capitol

12:15 – 2:00 pm Lunch with Legislators/Wrap Up

Registration – Free Until February 1st!

Name ___________________________________________________________

HOME Address __________________________________________________________

***Home Address to Be Used to Identify Your State Representative and State Senator.

City/Zip_____________________________________________________

Phone__________________________   Email____________________________

____Physician  ____Residents/Med. Student

____Res/Med Student requesting travel stipend.(up to $75 for mileage and parking)

____Clinical/Business Staff

Please register by February 1, 2016

Fax Back: 404-321-7450 or email: Fay Fulton (ffulton@gafp.org)

Legislative Day @ the Capitol
Thursday, February 11, 2016

Plan to Attend the Georgia Academy of Family Physicians Legislative Day at the Capitol! Meet your state legislators and top government officials and learn how the state government and legislature impacts your practice and Family Medicine in Georgia. Join us under the Gold Dome!

Who Should Attend: The meeting is open to all family physicians, residents and medical students, clinical and business staff. We will be joined at the meeting by our colleagues in internal medicine, OB/GYN and pediatrics.

Congratulations to the 2016 GAFP Committee Members

Thank you for volunteering!

The following is a list of those who have volunteered to serve on a GAFP Committee this year as of January 11, 2016.  If you are interested in being on a committee and have not yet signed up, please contact Alesa McArthur at amcarthur@gafp.org or 1-800-392-3841 for assistance. 

Committees are limited to 15 members, including 1 resident and 1 student per committee.  Members are chosen by the President to serve on one committee in order to offer more positions to more members.  Committees currently with some availability are: Bylaws, Finance, and the Membership Committee.

In addition, two work groups for specific projects have been created: the State Legislative Work Group, and an educational work group for the annual meeting.  These do not have size limits and members on other committees may serve on these.

Our first Committee Conclave is March 5-6, 2016 in Pine Mountain, GA at Callaway Gardens.

Bylaws Committee

Chair: Alice House MD

Donald Fordham MD

Chip Cowart MD

Leonard Reeves MD

Education & Research Committee                                                          

Chair: Susana Alfonso MD

Vice Chair: Gurinder Doad MD

Karla Booker MD

Mike Busman MD

Angelina Cain MD

Audra Ford MD

Ken Howard MD

Theresa Jacobs MD

Riba Kelsey-Harris MD

Carl McCurdy MD

Yuan-Xiang Meng MD

Adrienne Mims MD

Jada Moore-Ruffin MD

Oguchi Andrew Nwosu MD

Harry Strothers MD

Finance Committee                                                       

Chair: Jeff Stone MD

Vice-Chair: Sharon Rabinovitz MD

Folashade Omole MD

Beverley Ann Townsend MD

Resident Member: Sunaina Jhurani MD

Legislative Committee                                                 

Co-Chair: Bruce LeClair MD

Co-Chair: Rick Wherry MD

Samuel “Le” Church MD

Bernie Cohen MD

Mitch Cook DO

Donald Fordham MD

Wayne Hoffman MD

Sabry Gabriel MD

Andrea Juliao MD

Thaddeus Lynn MD

Howard McMahan MD

Gena Marie Mastrogianakis MD

Wilhelmina Prinssen MD

Resident: Evelyn Campbell-Bayaan MD

Student: Joey Krakowiak

Membership Committee                                                            

Co-Chair: James Hagler MD

Co-Chair: Tom Fausett MD

Vice Chair: Ivy Smith MD

Kelly Vlass Culbertson MD

Nicole Haynes MD

Beulette Hooks MD

Sylveria Olatidoye MD

Monica W. Parker MD

George Shannon MD

Resident: Phil Carter MD

Practice Management Committee                                                          

Chair: Steve Wilson MD

Vice Chair: Michael Satchell MD

Sharmin Banu Anam MD

Cedrice Davis MD

David Fieseler MD

Jairaj Goberdhan MD

Michael S. Jackson MD

Sean Lynch DO

Shameka Hunt McElhaney MD

Thomas W. McNamara MD

Vera A. Reaves MD

Eddie Richardson MD

Collyn Steele MD

Resident: Peggy Bourguillon MD

Student: Ashruta Patel

Public Health Committee                                                           

Chair: David Westfall MD

Vice Chair: Sherma Peter MD

Chinyere Daisy Anyakudo MD

Denise Crawley MD

Ellie Daniels MD

Lynn T. Denny MD

Jay W. Floyd MD

Ambar Kulshreshta MD

Jessica L. Malmad MD

Brian Nadolne MD

Isioma Okwumabua MD

Lisa Marie Rosa Re MD

Jose M. Villalon-Gomez MD

Resident: Erskine Hawkins MD

Student: Alayna Maria Collier Dukes

Student and Resident Committee                                                          

Chair: Julie Dahl-Smith DO

Vice Chair: Kevin Johnson MD

Cecil Bennett MD

Michelle Cooke MD

Carmen Echols MD

Emily Herndon MD

Ifeoma Nnaji MD

Shikha Shah MD

Charles Sow MD

John Vu MD

Resident: Chetan Patel MD

Resident: Amethyst W. Wilder MD

Student: Kristin Kettelhut

Student: Lara Smith

Student: Candace Markley

State Legislative Work Group assists the Legislative Committee during the legislative session: 

Sabry Gabriel MD

Thaddeus K. Lynn MD

Gena Marie Mastrogianakis MD

Brian Nadolne MD

Wilhelmina Prinssen MD

Mitzi Rubin MD

Harry Strothers MD

Residents: Peggy Bourguillon MD

Sunaina Jhurani MD

Chetan Patel MD

Amethyst W. Wilder MD

Students: Kristin Kettelhut

Joseph Krakowiak

Candace Markley

The Annual Meeting work group will assist the Education and Research Committee with the annual meeting and these GAFP members plan to give their time:

Sharmin Banu Anam MD

Kelly Vlass Culbertson MD

Monica W. Parker MD

Charles Sow MD

Thank you to all volunteers this year and remember, if you want to join a committee or work group, there is still room for YOU!

From the National Healthy Sleep Awareness Program: Diagnosis and Treatment of Restless Legs Syndrome (RLS) During Pregnancy

Jonathan P. Hintze, MD and Shalini Paruthi, MD

Case:  A 31-year-old healthy female, 28 weeks into her third pregnancy sees her doctor to discuss her sleep. She complains of difficulty falling asleep and waking up multiple times throughout the night.  She says she “just can’t get comfortable” and is tossing and turning all night because her legs “won’t sit still.”  Upon further questioning she confirms that her legs feel worse particularly at night, and feel better when she gets up and walks around.  Her pregnancy is otherwise uncomplicated and her only daily medication is a prenatal vitamin, though she has started trying over the counter benadryl at night without improvement in her sleep.  She never had this problem with her other pregnancies.  Her physical exam, including a detailed exam of her lower extremities, is unremarkable.

Restless legs syndrome (RLS) is a common sleep disorder that increases in prevalence during pregnancy. It is estimated to affect approximately 25% of all pregnancies with a peak in the third trimester 1,2,3,4.  It is the third most common reason for insomnia during pregnancy 5, and as seen in our patient, the risk of developing RLS increases with each pregnancy and may not have been present in prior pregnancies 6,7.  It is a clinical diagnosis which is made if the following criteria are met: (1) An urge to move the legs, usually associated with an unpleasant sensation in the legs, (2) this urge is worse with rest or inactivity (i.e. lying down), (3) it is relieved at least partially with movement (e.g. walking or stretching), (4) and is worse in the evenings or at night. Additionally, symptoms cannot be explained by another condition (leg cramps or venous stasis, for example) and the symptoms must cause sleep disturbance, distress, or some impairment of function, whether mental, physical, social, or others 8.  This patient clearly meets criteria for the diagnosis of RLS.  As she describes, the sleep disturbance commonly observed in RLS is at sleep onset and may impact sleep maintenance as well 2,3,9-12.

Although the pathophysiology of RLS in pregnancy is still under investigation, in the general population there is evidence that genetics, the central dopamine system, and iron all play roles 13-17.  The role of iron is of particular interest during pregnancy, as many women develop iron deficiency during pregnancy 18.  Specifically, iron is a known co-factor for the enzyme tyrosine hydroxylase, which is a rate-limiting reaction of dopamine production and has been hypothesized as a connection between low iron status and RLS 15.  Therefore, it is not surprising the same population who is at a higher risk of iron deficiency is at a higher risk of developing RLS.

Recently, the International RLS Study Group (IRLSSG) published clinical guidelines for the diagnosis and treatment of RLS during pregnancy 19.  The first step is to accurately diagnose RLS with the above criteria, and assess severity and possible comorbid depression 20.  Next, assessing iron status should be done by checking a serum ferritin, and this may also include a hemoglobin, iron, TIBC, and percent transferrin saturation as deemed appropriate.  It is notable that ferritin is an acute phase reactant and may be elevated if there is a concurrent illness or chronic inflammation, making additional iron studies more useful.  Ferritin levels below 75 mcg/L should be treated with oral iron supplementation of 65 mg elemental iron 1-2 times daily 21, and advising patients to take vitamin C together with iron can improve absorption 22.  Repeat ferritin levels should be checked after 6-12 weeks to monitor a response.  If there is a failure of response to oral iron and ferritin remains below 30 mcg/L, intravenous iron can be considered 23,24 though is rarely needed.

Patients with RLS that is refractory to iron supplementation, or patients with an initial ferritin over 75 mcg/L may be considered for dopamine therapy specifically with carbidopa/levodopa. Low-dose clonazepam in the evening may also be considered 19. As with any medication considered during pregnancy, side effects, and the benefit to potential harm ratio must be discussed openly with each patient. However, even in patients with refractory RLS, reassurance can be given that most cases of pregnancy-related RLS will improve or resolve within one month after delivery 1-3.

Non-pharmacologic treatment considerations which have been proven to improve RLS include moderate-intensity exercise, yoga, massage, and pneumatic compression devices 25-27. Anecdotally, many patients describe relief with compression stockings during the day, warm bath/shower before bedtime, or wearing socks to sleep.

Lastly, care should be taken to avoid common RLS exacerbating factors, such as sedating antihistamines like our patient has tried.

Case conclusion: The patient and her physician decide to check her hemoglobin and ferritin.  They find that her ferritin is only 8mcg/L and begin an additional iron supplement in addition to her prenatal vitamin.  Within3 weeks she has significant improvement in her leg restlessness and is now able to fall asleep more quickly and sleep through the night. 

References

1.        M. Manconi, V. Govoni, A. De Vito, N.T. Economou, E. Cesnik, I. Casetta, et al. Restless legs syndrome and pregnancy. Neurology, 63 (2004), pp. 1065–1069.

2.       A. Hubner, A. Krafft, S. Gadient, E. Werth, R. Zimmermann, C.L. Bassetti. Characteristics and determinants of restless legs syndrome in pregnancy: a prospective study. Neurology, 80 (2013), pp. 738–742.

3.       J.P. Neau, A. Porcheron, S. Mathis, A. Julian, J.C. Meurice, J. Paquereau, et al.Restless legs syndrome and pregnancy: a questionnaire study in the Poitiers District, France. Eur Neurol, 64 (2010), pp. 268–274.

4.      Ismailogullari, S., Ozturk, A., Mazicioglu, M.M., Serin, S., Gultekin, M., and Aksu, M. Restless legs syndrome and pregnancy in Kayseri, Turkey: a hospital based survey. Sleep Biol Rhythms. 2010; 8: 137–143.

5.       Kızılırmak, A., Timur, S., and Kartal, B. Insomnia in pregnancy and factors related to insomnia. Sci World J. 2012; 2012: 1–8

6.      Berger, K., Luedemann, J., Trenkwalder, C., John, U., and Kessler, C. Sex and the risk of restless legs syndrome in the general population. Arch Intern Med. 2004; 164: 196–202.

7.       Pantaleo, N.P., Hening, W.A., Allen, R.P., and Earley, C.J. Pregnancy accounts for most of the gender difference in prevalence of familial RLS. Sleep Med. 2010; 11: 310–313.

8.      American Academy of Sleep Medicine. International classification of sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2014.

9.      Vahdat, M., Sariri, E., Miri, S., Rohani, M., Kashanian, M., Sabet, A. et al. Prevalence and associated features of restless legs syndrome in a population of Iranian women during pregnancy. Int J Gynecol Obstetrics. 2013; 123: 46–49.

10.    de Castro, C.H., Martinez, F.G., Angulo, A.M., and Alejo, M.A. Restless legs syndrome in pregnancy. Aten Primaria. 2007; 39: 625–626.

11.     Chen, P.-H., Liou, K.-C., Chen, C.-P., and Cheng, S.-J. Risk factors and prevalence rate of restless legs syndrome among pregnant women in Taiwan. Sleep Med. 2012; 13: 1153–1157.

12.    Minar, M., Habanova, H., Rusnak, I., Planck, K., and Valkovic, P. Prevalence and impact of restless legs syndrome in pregnancy. Neuro Endocrinol Lett. 2013; 34: 366–371.

13.    Trenkwalder, C., Hogl, B., and Winkelmann, J. Recent advances in the diagnosis, genetics and treatment of restless legs syndrome. J Neurol. 2009; 256: 539–553.

14.    Picchietti, M.A. and Picchietti, D.L. Advances in pediatric restless legs syndrome: iron, genetics, diagnosis and treatment. Sleep Med. 2010; 11: 643–651.

15.    Allen, R. Dopamine and iron in the pathophysiology of restless legs syndrome (RLS). Sleep Med. 2004; 5: 385–391.

16.    Clemens, S., Rye, D., and Hochman, S. Restless legs syndrome: revisiting the dopamine hypothesis from the spinal cord perspective. Neurology. 2006; 67: 125–130.

17.    Dauvilliers, Y. and Winkelmann, J. Restless legs syndrome: update on pathogenesis. Curr Opin Pulm Med. 2013; 19: 594–600.

18.    DeMayer EM, Tegman A. Prevalence of anaemia in the World. World Health Organ Qlty 1998;38: 302-16.

19.    Picchietti DL, et al. Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation, Sleep Medicine Reviews (2014), http://dx.doi.org/10.1016/j.smrv.2014.10.009.

20.   J. Wesstrom, A. Skalkidou, M. Manconi, S. Fulda, I. Sundstrom-Poromaa. Pre-pregnancy restless legs syndrome (Willis-Ekbom disease) is associated with Perinatal depression. J Clin Sleep Med, 10 (2014), pp. 527–533.

21.    R.N. Aurora, D.A. Kristo, S.R. Bista, J.A. Rowley, R.S. Zak, K.R. Casey, et al. The treatment of restless legs syndrome and periodic limb movement disorder in Adults—An update for 2012: practice parameters with an evidence-based systematic review and meta-analyses. Sleep, 35 (2012), pp. 1039–1062.

22.   Cook JD and Reddy MB. Effect of ascorbic acid intake on nonheme-iron absorption from a complete diet. Am J Clin Nutr. 2001;73:93–8.

23.   D. Vadasz, V. Ries, W.H. Oertel. Intravenous iron sucrose for restless legs syndrome in pregnant women with low serum ferritin. Sleep Med, 14 (2013), pp. 1214–1216.

24.   J. Schneider, A. Krafft, A. Bloch, A. Huebner, M. Raimondi, C. Baumann, et al. Iron infusion in restless legs syndrome in pregnancy. J Neurol, 258 (2011), p. 55.

25.   M.M. Aukerman, D. Aukerman, M. Bayard, F. Tudiver, L. Thorp, B. Bailey. Exercise and restless legs syndrome: a randomized controlled trial. J Am Board Fam Med, 19 (2006), pp. 487–493.

26.   M. Russell. Massage therapy and restless legs syndrome. J Bodyw Mov Ther, 11 (2007), pp. 146–150.

27.   C.J. Lettieri, A.H. Eliasson. Pneumatic compression devices are an effective therapy for restless legs syndrome: a prospective, randomized, double-blinded, sham-controlled trial. Chest, 135 (2009), pp. 74–80.

QI Corner: Improving Identification of Depression and Alcohol Use Disorder in Primary Care

 

Alliant Quality… Working with YOU to make Health Care Better

Seniors often have multiple medical problems and take many medications. Yet, symptoms of depression can masquerade as somatic complaints. Together we can make patients safer by finding masked depression.

We are recruiting primary care practitioners to Improve Identification of Depression and Alcohol Use Disorder. Through these efforts, we aim to increase the annual screening rate for the identification of depression (G0444) and alcohol use disorders (G0442) in Medicare beneficiaries.

Recruitment and Free Technical Assistance

If you are a primary care physician, we can provide free support and technical assistance in improving screening rates. We provide the following:

  • Education on screening tools, treatment and referral processes
  • Workflow analysis to improve screening efficiency
  • Designing process and linkages to referral programs
  • Quality improvement technical assistance and consultation
  • Training in quality improvement methodologies
  • Opportunities to participate in a Learning and Action Network that integrates behavioral health work with other initiatives.
  • Education on best practices, shared successes and lessons learned

Assistance with Quality Reporting and Coding

  • PQRS 134 (NQF 0418):  Preventive Care and Screening:  Screening for Clinical Depression and Follow-up Plan
  • CPT- G0444 – Depression Screening – 15 minutes
  • CPT – G0442 – Risky Alcohol Screening – 15 minutes
  • PCMH standards 3D, 3E, 4A, 4B, 5B, 6A, 6D – Comprehensive screening, treatment and coordination of care and continuous process improvement of patients with depression can be counted for one of the three chronic clinical measures

Alliant Quality, the Quality Innovation Network – Quality Improvement Organization (QIN-QIO) for North Carolina and Georgia has been awarded this new project by the Centers for Medicare & Medicaid Services (CMS).

 

For more information, contact:

Adrienne Mims, MD MPH FAAFP, AGSF

Adrienne.Mims@alliantquality.org

Complete the participation agreement to join these efforts in Georgia!

 

This material prepared by Telligen, has been adapted by Alliant Quality, for Alliant Quality, the Medicare Quality Innovation Network – Quality Improvement Organization for Georgia and North Carolina, 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. 11SOW-GMCFQIN-G1-15-03

Public Health Spotlight: Neonatal Abstinence Syndrome (NAS) – Georgia Notifiable Condition

A letter from DPH Commissioner Brenda Fitzgerald, MD:

December 15, 2015

Dear Provider,

Please note that effective January 1, 2016, Neonatal Abstinence Syndrome (NAS) surveillance will be
added to the list of conditions that are notifiable by law to the Georgia Department of Public Health.
The list of reportable conditions can be found using this link: dph.georgia .gov/disease-reporting.

NAS is a condition that results from the abrupt discontinuation of chronic fetal exposure to substances
that were used or abused by the mother during pregnancy. Having NAS on the list of notifiable
conditions provides the opportunity to:

1. Assess the incidence of NAS in Georgia and trends over time
2. Identify opportunities for timely intervention and education
3. Better characterize risk factors for NAS in Georgia
4. Assess capacity to address maternal addiction and provide multidisciplinary care for the
child/family affected by substance abuse

Criteria for reporting NAS will include at least one of the following: a baby born to a mother with a
history of substance abuse during pregnancy, a newborn with withdrawal symptoms and/or a newborn
with a positive drug screen. Reports should be submitted within 7 days of identification. Cases can be
reported electronically through our secure web based State Electronic Notifiable Disease Surveillance
System (SendSS) at sendss.state.ga.us. As with all notifiable disease data reported to our Department,
data regarding NAS will remain confidential in accordance with Georgia law, Code Sections 31-2-12 and
31-5-5. Frequently asked questions (FAQs) related to NAS can be found at: dph.georgia.gov/NAS.

Thank you for working with us to protect the lives of Georgia’s mothers and children. Should you have
any questions please contact the Maternal and Child Section in the Georgia Department of Public Health
at 404-657-2850.

Sincerely,

Brenda Fitzgerald, M.D.