Spring Open Forum April 28, 2012

The North Carolina Pediatric Society Spring Open Forum brought us to the Watauga Medical Center in Boone, NC, thanks to the hard work of our Treasurer, Dr. Scott St. Clair. Boone seems far from Wilmington, but I learned that if you only stop for gas you can make  the trip in under five semi-legal hours. 

The members of the Executive Committee enjoyed our Friday night stay at the Holiday Inn Express. I’ve figured out what makes it an “Express.” No bar. We did emerge from the Holiday Inn Express smarter. We learned that Wal-Mart has the best wine selection, while the Food Lion has  a wall of chilled artisanal craft brews that makes you step back outside just to confirm you really are in a Food Lion. 

A few words about this blog: it is not an official function or document of the North Carolina Pediatric Society, just a set of notes I took as fast as I could between refilling my coffee and checking my email. I'm easily distracted, so there could be typos, slight inaccuracies, or complete hallucinations. That said, I hope you'll find some important information that may even help you improve your practice.

One other request: please don't skip over the policy stuff. North Carolina is arguably the best state in the nation in which to practice pediatrics, largely as a result of the tireless work members of the NC Pediatric Society have put in over decades to improve local, state, and national policies so that more children have better access to care here. All of that work is now at risk, and if we don't each speak up to defend our hard-won gains we can easily find ourselves envying colleagues in Mississippi, South Carolina, or Georgia (the former Soviet Republic).

Breakfast: sausage biscuits, Danishes (Do you have to capitalize "Danishes?" Are they really from Denmark?), orange juice and coffee. NCPS President Dr. Karen Breach welcomes us all to the Watauga Medical Center, passes the microphone around so we can all introduce ourselves.

Richard Sparks

Richard Sparks, CEO of the Watauga Medical Center, welcomes us all and accepts our thanks for the free meeting space. 

Dr. Francis Rushton and Dr. Karen Breach

Dr. Francis Rushton, chair for District IV of the AAP, comes up from South Carolina to update us on national issues.

• North Carolina Pediatric Society is consistently among the most effective in the country at advocating for pediatricians and children.
• Dr. David Tayloe of NC is now the AAP representative to the American Medical Association.
• Dr. Ivor Hill is the new AAP Chair of Continuing Medical Education.
• The other four chapters in District IV are also very strong: KY, TN, SC, VA.
• Describing what the AAP does can be difficult, as there are over 200 different groups of people working together for pediatricians and children, but the AAP Agenda For Children provides a guide.
• Pillars: Access to care, Quality of care, Finance for care.
• The circle: Health Equity, medical Home, Profession of Pediatrics
• Mission: “Dedicated to the health of ALL children.”
• Children and Media will be the newest priority in the AAP
• Early Brain and Child Development is in its second year of implementation.
• Foster Care has been integrated, moves off the icon.
• Epigenetics moves to implementation status with Dr. Bob Saul of SC heading a grand on Genetics In Primary Care
• Immigrant health was not chosen as one of the three priority planks, but it remains critical and will receive special resources.
• Health Care Reform: North Carolina is moving forward, South Carolina is not.
• We don’t really know how things will shake out after the Supreme Court rules on the constitutionality of Affordable Care Act. It’s not clear how Justices Roberts and Kennedy will rule.
• Will states have to expand their Medicaid programs to care for the uninsured? Even if other aspects of the law fall, this one may still stand.
• Coverage of kids to age 26, equity between Medicaid and Medicare payment rates are very popular, very advantageous to pediatricians; we’ll have to see if they stay.
• The AAP will have a big lobbying job to do if the ACA falls, trying to preserve the best parts for kids.
• November election is largely about the Ryan budget. Thirty percent of savings will come from Medicaid, which could see 50% reductions in funds for us.
• Membership in the AAP is a recurring issue. Still about 61,000 members nationally, but a falling percentage of eligible pediatricians are AAP members now. Young physicians are especially unlikely to pay AAP dues once they graduate. Sub-specialty pediatricians are less likely to renew their memberships.
• North Carolina does better with membership than most chapters, partly due to the efforts of Dr. Dave Williams in making personal contact with non-member pediatricians.
• New Department of Global Health at the AAP. Dr. Rushton is one of the members. We have many US-trained members who work all over the world, especially in Saudi Arabia.
• We have close affiliations with pediatric societies in China, Latin America, the Persian Gulf. We remain primarily a North American organization, but we are strengthening our ties with colleagues around the globe.
• Contact Dr. Rushton at frushton@aap.net
• National Elections coming up: Jim Perrin versus Michael Klein for President. Dr. Klein is a pediatric surgeon, Dr. Perrin academic.
• District vice chair: Bob Gunther of Virginia versus Dan Stewart of Kentucky.
• Nominating Committee: Karen Breach (our current president here in NC) verus Rob Walker of South Carolina, who works with Medimmune.

Executive Director Steve Shore, who makes this all happen!

Steve Shore reviews the work of the NC Pediatric Society Foundation.

• Foundation assumed lead in Reach Out And Read in North Carolina.
• ROR pioneer Dr. Perri Klass will be our special speaker at the Annual Meeting in September.
• Completed CHIPRA grant to enroll underserved children in Medicaid in North Carolina.
• Participated for the first time this year in The Great Human Race as walkers, runners, contributors, and fundraisers. Netted $6,377 in that endeavor.
• John Rex Endowment supports children’s activities, working on training day in Wake County for foster child care.
• Eshelman Foundation in Wilmington is funding a foster care program there as well.
• Working with BENCHMARKS and Division of Social Services on strengthening Medical Home for children in foster care.
• Applying for State Tobacco Control grant from the CDC, which may help replace some of the lost funding from the Health And Wellness Trust Fund.
• Tobacco companies are now marketing smokeless products, very youth-friendly, like SNUS and tobacco on a stick.

Dr. John Rusher

John Rusher, NCPS Vice President, discusses our legislative priorities.

• Please let us know if you have a relationship with a state legislator. We would love to have your help keeping our legislators informed about pediatric issues.
• Your dues help pay for good advocacy, including the efforts of Steve Shore and two attorneys in Raleigh, John Carr and Emma Jones.
• Please sign on to Steve Shore’s email list if you haven’t already in order to stay informed on our legislative issues.
• Scope of practice: advanced practice nurse practitioners would like to practice without MD supervision, on a par with MD’s. We are working with NCMS, Family Practice, and other organizations opposing this bill.
• Pharmacists would like to create a medical home in their pharmacies, administering vaccines to children down to age 8, not just adults and older teens. We feel this would disrupt the Patient Centered Medical Home, and we have opposed this bill as it comes up.
• We support a bill to allow teens up to age 18 to remain in juvenile court rather than being sent to adult court for any felonies. The role of juvenile court is much more rehabilitative. NC and NY are the only two states left in the US where these kids are forced into adult court for nonviolent offenses. Studies suggest the success of this bill will save the state money and help kids turn their lives around.
• Medicaid remains somewhat over budget. We are working hard to prevent Medicaid reimbursement cuts to pediatricians. Currently North Carolina is among the best states in the country for pediatrician Medicaid rates, but it has been a constant battle to keep us there.
• The Affordable Care Act is very pediatric-friendly! Some of these provisions have already kicked in, such as removal of pre-existing conditions as a reason to turn down kids’ health insurance application. Keeping kids on their parents’ insurance up  to age 26 is great for us. Strengthening the Medical Home has been important. Recognizing AAP Bright Futures as the gold standard of pediatric preventive care is a tremendous win for us. Improving payment to primary care providers, ensuring equity between Medicaid and Medicare reimbursements helps us tons.
• Please come talk to one of our officers before you agree to join an Accountable Care Organization (ACO). The model is adult-based, and it’s not at all clear how it’s suitable for pediatrics. The fact that most of our care is office-based and preventative makes our care very different from adult care. Roughly 4% of our most complicated patients may benefit from ACO model care, but for 96% of our patients it will not be of benefit.
• Health Benefits Exchanges remain nebulous, difficult to pin down. We are monitoring efforts here in North Carolina to structure an exchange to make sure the baseline pediatric benefits are comparable to those of NC Medicaid and Health Choice.
• Expansion of Community Care of North Carolina’s efforts to now include subspecialists, not just primary care pediatricians.
• Huge issue in how Medicaid is going to reimburse mental health services. There will be 11 Local Management Entities that manage all mental health services. The burden for application, documentation, approval, and billing is likely to be prohibitive for many mental health providers who now see these kids. Psychiatrists are already dropping Medicaid for this reason.
• Scott St. Clair’s practice has already lost a co-located mental health provider due to these requirements.
• Per Marion Earls these LME’s may determine who your patient sees for mental health service rather than leaving that decision to you.
• Our hope is to delay implementation until some of these big issues get worked out.
• Please bring John any stories of how these changes impact your patients. Stories matter in helping legislators understand these issues.

Dr. David Tayloe, former NCPS and AAP President

Dr. David Tayloe talks about his role with Community Care of North Carolina (CCNC) in expanding their role in pediatric specialty care.

• Child Health Collaborative Care initiative to bring care coordination to specialty care.
• Hoping to get a grant to implement this program rather than cannibalize other funds.
• Uses Care Navigators and Care Coordinators to assist patients.
• Likely to save a large amount of Medicaid money. Five percent of kids spend 60% of the healthcare money.
• Efforts will include helping primary care physicians make fewer referrals. In GI this means constipation, GERD, and functional abdominal pain, problems which can often be managed by primary care docs in the office. Will be working on focal education campaigns to include simple office-based protocols.

Beth Rowe-West, RN, BSN, NC Immunization Branch

Beth Rowe-West RN, BSN, Vaccine Update

• Will no longer be able to use State vaccines for underinsured children starting at the end of this calendar year.
• We may be able to make exceptions if we can make a case that access is a problem.
• Discretionary money can only be used for uninsured adults, not kids.
• These rules will keep the state from being able to offer State flu vaccine for non-Medicaid patients.
• New CDC software: V-track for vaccine ordering. Difficult system to use, may limit your vaccine orders. North Carolina pediatricians will continue to use the NC Immunization Registry and will handle the V-track interface so we don’t have to. We owe the Immunization Branch a big thank-you bouquet for that.
• Immunization Branch is required to visit practices every other year to monitor Vaccines For Children compliance.
• There remains a large gap between doses of vaccine shipped to offices and the number of doses reported given. Staff members in offices may skip steps in activating active lots, instead adding a historical dose. What this does in the computer is mark the vaccine as “expired,” which makes it look like docs are over-ordering vaccine. This will make it hard for you to order as much vaccine as you need in the system.
• North Carolina has created a pool of free VFC TDaP vaccine you can administer at no cost to parents/grandparents of infants. If you can give caretakers of infants TDaP vaccine without charging administration fees, please do so! You can bill administration fees for these people if you want, but it may be more work than it’s worth.
• Alamance County had an outbreak of pertussis this year. PCR may give false-positives, cultures are preferred.
• 96% of providers in the state are now on the NCIR.
• Contact the Immunization Branch if you need training to help your staff understand how to use the NCIR appropriately. They can send someone out to your office if needed.

Dr. Niraj Patel

Dr. Niraj Patel Carolinas Medical Center, Charlotte

Sick Again? When To Think About Immunodeficiency

• Two types of immune problems: genetic versus secondary. Today we’re talking about primary.
• >130 identified immunodeficiencies. 250,000 affected patients in the US are diagnosed, probably 500,000 undiagnosed
• Incidence is 1:2000 live births, higher 1:500 for IgA deficiency
• Serious immunodeficiencies affect 1:100,000 live births
• Presentation often occurs in childhood. Males are at higher risk.
• Kids would have increased incidence of infection, increased severity, prolonged duration, unexpected complications of infections.
• Risks can be elevated for autoimmune diseases and cancer, especially Non-Hodgkins lymphoma.
• The diagnostic delay is on average 12.4 years!
• How many infections is too many? It’s hard to pick one number and say, “That’s normal.”
• Ten warning signs: Four of more AOM in one year, 2 or more serious sinus infections in one year, 2 or more months on antibiotics with no effect, 2 or more pneumonias in one year, failure of weight gain, recurrent deep skin or organ abscesses, Persistent thrush or skin fungal infections, need for IV abx to clear infetions, 2 or more deep-seated infections such as septicemia, family history of immune deficiency.
• Asking family history: “Are there people in your family with early or unexplained deaths, frequent childhood infections, unusual childhood infections?
• Differential diagnosis: anatomical abnormalities, foreign bodies, defect in mucous clearance, atopic conditions, secondary immunodeficiency, primary immunodeficiency.
• Other clinical conditions: collagen vascular disease, CF, DM, newborn state, malnutrition, CRF, sarcoidosis, chronic viral illnesses, malignancies
• One opportunistic infection is a red flag for evaluation.
• Two episodes of invasive infection: sepsis, meningitis, osteomyelitis, septic arthritis.
• Multiple episodes of sinusitis, pneumonia, abscesses. Really hard to define the word “multiple”.
• Look for dysmorphic facies or heart murmur, failure to thrive, persistent thrush, severe or early eczema, small tonsils, gingival disease, absence of palpable lymph nodes, telangiectasias, lymphadenopathy/organomegaly.
• Evaluate innate and adaptive immune systems. Testing for innate immune system is becoming easier to obtain.
• Basic evaluation: CBC with differential. IgG, IgA, IgM and antibodies to diphtheria, tetanus, pertussis, pneumonia (if immunized). CH50. Dr. Patel does not include IgG subclasses in his initial workup. Abnormal vaccine response must be present for this to be a real diagnosis, so look at the vaccine response first, before you order this.
• CH50 test is going to be way low, not just a little off, if it’s really positive.
• Candida skin testing evaluates cellular migration, but 30% of normal people don’t respond.
• 2/3 of cases in kids are humoral, so the quantitative immune globulins is a high-yield study!
• Consider HIV testing.
• Depending on history may check ionized calcium and PTH, CXR (DiGeorge).
• Humoral disease presents with bacterial infections such as bacterial sinopulmonary infections, especially with encapsulated organisms Chronic or recurrent gastroenteritis is another red flag.
• Cellular defects present with recurrent viral and fungal infections: shingles, herpes, thrush after 12 months of age, failure to thrive, Pneumocystis jirovecii, graft-versus-host disease (from maternal T-cells that cross the placenta).
• Wiskott-Aldrich syndrome presents with bleeding issues.
• Phagocyte defects present with infections from catalase-positive organisms like Staph aureus, abscesses, lymphadenitis, gingivitis, periodontal disease, delayed umbilical cord separation. Include CGD, leukocyte adhesion deficiency, Chediak-Higashi syndrome.
• Complement defects are rare in kids, but present with abrupt onset of sepsis with encapsulated organisms, angioedema of the face, hands, feet, or GI tract, autoimmune manifestations, recurrent disseminated Neisseria infections.
• Bruton’s X-linked agammaglobulinemia. No B-cells so no Ig’s. Presents at 6-9 months of age, when mom’s antibodies go away. No tonsils, lymph nodes. Treat with IVIg. Avoid live viral vaccines!
• Maternal Ig transfer occurs around 32-33 weeks EGA.
• IgA deficiency is the most common, but often asymptomatic. Presents with recurrent sino-pulmonary infections. They have essentially no IgA. At risk for transfusion reactions due to anti-IgA autoantibody. At risk for progression to common variable immune deficiency.
• Common variable immunodeficiency. Onset 15-35 years of age, low IgG, IgA, IgM. Get pneumonia, bronchiectasis, sinusitis, GI infections. Cellular immunity weakens. Increased risk for autoimmunity, malignancy. Treat with IVIg.
• Transient Hypogammaglobulinemia of Infancy. This is an accentuated and prolonged physiologic hypogammaglobulinema. Do nothing. These kids have B-cells, they will recover with time.
• Hyper-IgE syndrome. Autosomal dominant. Boils, abscesses, pneumatoceles. Get Staph, Candida infections. Scoliosis, retained primary teeth, eczema, course facies. You’ll see a double row of teeth on x-rays.
• DiGeorge Syndrome. Almond eyes, fish-shaped mouth, low-set ears, absent thymus on CXR. Most kids have some T-cell function, but not complete.
• Severe combined immunodeficiency (SCID) is an immunologic emergency. Absent thymus. Low absolute lymphocyte count is a red flag. Treated with bone marrow transplant. Newborn screening is coming soon to NC!
• Wiskott-Aldrich triad: eczema, thrombocytopenia, recurrent sinopulmonary disease. CBC shows small, few platelets; mean platelet volume is your red flag.
• Chronic granulomatous disease: skin, lymph node, lung infections. Weird organisms. Test with neutrophil oxidative burst test.
• Leukocyte adhesion deficiency: extremely high WBC is a red flag! Abscesses have no pus in them, just gray and necrotic.
• Complement deficiency. Recurrent encapsulated organism infections like Neisseria.

Dr. Gerri Mattson

Gerri Mattson, MD, MPH, Children & youth Branch, NC Division of Public Health

NC Public Health programs For Children and Youth

• CCNC has been a nationwide leaser in improving outcomes and lowering costs. Cumulative savings of nearly $1billion over 6 years!
• Patient-Centered Medical Home initiative. Team based, family centered, assures primary and specialty care
• Your local health department is using a medical home model.
• All local HD’s are required to provide or assure preventive health services for children.
• All local health departments provide wrap-around services such as care coordination, WIC, environmental health
• Run child health clinics, immunization clinics, dental clinics, WIC/Bresatfeeding support, prenatal/STI/Family planning clinics, communicable disease management, refugee health.
• Provide Health Check screening, care during peak times such as school or sports physicals, care for children waiting for Medicaid or new to the area, medication assistance.
• Health Departments must follow Health Check Billing Guide
• If health department sees one of your kids, you should be getting a report from them. If not, contact them or Gerri Mattson.
• Some providers have had issues with children who have had recent wellness exams being informed by Medicaid that they’re delinquent. This has to do with how the computer defines delinquency, and Dr. Earls and Dr. Mattson are working on improving the process. Currently the computer flags kids who have not had their wellness exams within a month or two of their birthdays.
• Newborn home visiting, nurse family partnership, healthy families America are services that your Health Department may offer
• Child Care Health Consultants can help with special needs kids in your practice
• In working with your local Health Department, make sure you know who is responsible for what programs, and meet with them when appropriate. Health Departments have lots of picket guides for shared state, regional, and local resources.
• Care coordinators help with data, practice support in addition to elements of care for kids in your practice.

Jeff Miller

Jeff Miller, North Carolina Health Information Exchange

Health Information and Technology Exchanges In North Carolina

• Mission: deliver information services to the community of North Carolina.
• Three legs: promote access to health information exchange, promote use of and access to electronic information, promote exchange between different organizations within the healthcare ecosystem, promote the analysis of information. (I know, that seems like four things, but I’m just the typist, y’all.)
• How do we improve transition of care, coordination of care, improve quality of care, decrease the cost of care? These technologies have to generate value for participants/consumers.
• Nonprofit company, not a part of the state government. Independent board with 24 senior health care executives from across the state, including Dr. David Tayloe. Representation includes most stakeholders, such as labs, pharmacies, hospitals, practices, etc.
• The idea is to connect different information systems in the healthcare community to present a complete, longitudinal patient care record. Imagine one place where you can see all of a patient’s records, meds, studies, visits, etc., not just the ones you’ve documented in your own system.
• The system would store encounters, labs, and medications. The rest of the patient’s information can simply be linked from the EMR’s where they are native. This is much easier than getting every piece of data and putting it all in one place.
• The system would generate a way to link all the disparate medical record numbers from various sites of care. The computer gets about 90% of these associations correct automatically, but about 10% have to be reviewed to humans to try to reconcile them.
• In the case of suspected but unconfirmed matches, they will call the providers and check to see if they’re looking at the same patient or two different people. The default choice is to split a record in question rather than combine a record where they’re uncertain about patient identity.
• The information is standardized and aggregated across different sites. For example, labs from different sources get standardized so you can compare “sodium” one place to “Na” from another place and “acetaminophen” to “tylenol”.
• Patients can opt out of the network by contacting the company. Patients can opt out globally (of everything) or just from a specific facility, such as a psychiatrist or STI clinic. When this occurs, there is still an alert in the system that demonstrates some information has been blocked. Under emergency situations or with the patient’s consent, you can unlock this record. These breakouts are tracked and audited.
• NC PATH will utilize Allscripts My Way as the viewer for their information. A window would pop up in your EMR that would demonstrate information from another institution, such as Duke Children’s. The data would be searchable. You will have the opportunity to request push data from other institutions that see your patients.
• New information alerts can come as emails, text messages, dumps into your EMR, depending on what you choose in the system. You can configure what information you want to be made aware of at a very granular level.
• NC HIE is working with NCIR to make available a working two-way interface with our EMR’s, so that our nurses no longer have to double-key immunization details in our EMR and in the NCIR program! Hope to go-live by the end of the year.
• The HIE will cost $175 per physician per year plus a one-time fee that can be from $1500 to $10,000. 
• Initial launch occurred three weeks ago, 11 to 14 practices connected so far. Initial practices are part of the NC PATH collaborative among Blue Cross/Blue Shield, Allscripts, and NC HIE. This project includes a nearly-free EMR (Allscripts My Way), implementation, and training.
• Hospitals are contracting, three groups on board so far, fourth nearly on board. Solstas labs has signed an agreement. Quest and Labcorp are coming. Now you can have one interface with the HIE rather than multiple separate lab interfaces.
• Jeff will be travelling around the state giving roadshows, contact CCNC for more information!

Dr. Martha L. Decker

Martha L. Decker, MD, FACOG, Wake Forest University School Of Medicine

Prenatal Ultrasound And Postnatal Implications

• What does it mean if you read about increased nuchal translucency, markers of aneuoploidy, polyhydramnios, ectopy, or ventriculomegaly?
• Increased nuchal transclucency, defined as >99th percentile (or 95th). That’s a measurement of the fluid at the dorsal cervical spine.
• NT increases risk for congenital heart defect, aneuploidy, non-cardiac structural abnormalities, intrauterine fetal demise. Risk increases as the number goes up.
• Increased NT risk for developmental delay is low to nonexistent.
• Some increased risk for congenital adrenal hyperplasia, achodroplasia, DiGeorge Syndrome
• Markers of Aneuploidy: echogenic foci, papillary muscle calcification and fibrosis of unknown etiology
• Echogenic foci mean nothing if your patient does not have Down Syndrome
• Pyelectasis is associated with increased risk of Down Syndrome. Should follow if the measurement is 7-10 mm after 33 weeks EGA.
• About 40% of kids with pyelectasis in one study did end up having significant collecting system disease. In kids with two normal postnatal ultrasounds no further evaluation is necessary.
• Polyhydramnios. Amniotic fluid index of 24 or maximum vertical pocket >8 cm.
• Early, severe poly is worrisome, late and severe poly not so much. May result from maternal diabetes, fetal anomaly.
• Concern is GI tract obstruction or neck and chest masses causing secondary GI tract obstruction.
• We see VACTERL anomalies, SVT, pramturity, polyuric syndrome, pulmonary stenois.
• Increases the risk for preterm labor, usually late preterm. May indicate TE fistula, congenital myotonic dystrophy, may just be macrosomic infant.
• Ectopy: premature atrial or ventricular contractions. Occurs in 1% to 3% of all pregnancies.
• Worth a structural evaluation of the heart (fetal echo)
• If ectopy persists after birth, perform ECG. PAC’s are pretty ormal, consider cardiology referral if last >2 weeks after birth.
• PVC’s more concerning, check for long QT syndrome.
• Mild ventriculomegaly: lateral ventricles measure 10 mm to 15 mm.
• Not at all clear what the clinical implications of mild ventriculomegaly is in the postnatal world. Some association with increased risk for developmental delay.
• Prenatal ultrasound often misses structural abnormalities.

I can't wait to see you all in Wilmington September 14th to 16th! This is our first annual meeting in my adopted home town, and I want it to go well, so come on down and I will personally guarantee your hospitable greeting. I mean, we can't go to the Grove Park Inn every year, can we?