Winter Open Forum January 24, 2015

North Carolina Pediatric Society 2015 Winter Open Forum

Winston-Salem, NC

January 24, 2015

Sometimes, when I go to one of these convention hotels, I like to sit in the lobby and try to guess which meeting or wedding each guest is attending. This time, the game held no challenge.

I have to open with an apology to everyone I photographed for  this blog. I have breathed the fetid air of countless hotel meeting rooms, but this one had to be the dimmest, yellowest one yet. Add that once I took my front-row seat where every single attendee could tell when I was checking Facebook, all the speakers stood on the other side of the room, and you get the grainy, bad-Instagram-filter effect you see below. You all looked marvelous in person, I promise. Dr. Tilson, while you were radiant and gave a compelling lecture, your photo was unsalvageable. In place of Dr. Tilson’s picture, please find a basket of kittens. Next time I'll bring the Nikon. And some umbrella lights.

NC Peds President Dr. Debbie Ainsworth opens the meeting, welcomes us all. What follows is the traditional passing of the microphone so we can all introduce ourselves. Here is a rare action shot:

Autism Screening Collaborative

Elizabeth Crais, PhD, Division of Speech and Hearing Sciences

• North Carolina has won an ASD State Implementation Grant from the Maternal and Child Health Bureau
• Primary goals: to identify children with ASD by 24 months of age (current median is 46 months) and to improve families’ access to a family-centered medical home
• Have already provided training on the ADOS-2 tool for confirming autism spectrum disorder within CDSA’s. Have already had 4 regional community meetings, performed MCO trainings
• DSM-5 does away with categories of autism: it’s all Autism Spectrum Disorders, with a spectrum of differences in communication, IQ, sensory issues, repetitive behaviors
• DSM-5 looks at social communication and social interaction deficits combined, then restricted/repetitive behaviors, interests of activities.
• Early identification and intervention is critical. Some autism symptoms show up as early as 12 months, and many children show symptoms by 18 months of age. Reliable diagnosis is possible as young as 2 years. Regression is reported in 25-30% of kids, between 18-24 months.
• Two questions to ask: What is there that shouldn’t be there? What is not there but should be?
• Toddlers may show less responsiveness to people, lack of response to name, atypical eye contact (more aversion, less looking at face/eyes), limited shared enjoyment, use of another’s hand as a tool, less likely to draw others into play.
• May show unusual or repetitive play, interests in parts of objects, attachment to unusual objects, repetitive, stereotype movements, unusual sensory interests, insistence on sameness.
• Now offering CME, free webinars (in March, April, and May), review cases of children at risk. All of your practice staff can participate if you’d like.

Gerri Mattson, MD, MPH

NC Division of Public Health

Update on Immunizations

• 489,000 doses of flu vaccine shipped this year, 100,000 doses are left in our allocation to be ordered if needed.
• Look to immuniznc.gov for conferences to attend, local training workshops.
• New requirements will be effective July 1, 2015. Now before 7th grade kids will need Tdap, Menactra (2 doses, 1 at 7th grade, 1 at 12th). Before Kindergarten Varicella #2 will be required, not accepting parent history of varicella, but titers will be accepted; pneumococcal conjugate vaccine (4 doses by 15 months); Polio #4 on or after the 4th birthday.
• NC Pediatric Society now has a grant to promote HPV vaccine, and the Immunization Branch will also be working to promote HPV vaccine.
• North Carolina does not allow philosophical exemptions to vaccines. Only physicians can submit medical exemptions, which must be reviewed. Compared to other states, North Carolina has a low rate of parent vaccine refusal, with the exception of some areas in western North Carolina.
• Schools can see the NCIR vaccine registry; this is how they will confirm that vaccines have been given.

AAP Update

Dr. Jane M. Foy

AAP Board of Directors, District IV Chair

• AAP Department of Federal Affairs has 17 full-time employees, any of them lawyers, working through lobbying, coalition-building, and raising public awareness. They conduct advocacy trainings, testify in hearings, give Capitol Hill briefings, file Amicus briefs, file regulatory comments, conduct media and social media advocacy, and organize grassroots advocacy.
• Agenda for Children 2014-2015 now includes poverty and child health, epigenetics, early brain and child development, and children adolescents and the media.
• Hot topics: Access to care, federal funding for children’s priorities, care of immigrant children on the border, regulation of e-cigarettes, persistent drug shortages, and practice transformation and financing.
• Continuing resolution 2015 did include some spending for Ebola, global health, childcare development block grant, NIH and NIMH, CDC National Center for Birth Defects and Developmental Disabilities. Bad news: school nutrition requirements were weakened, CHIP not funded, Medicaid parity payments allowed to expire.
• Priorities for the 114th Congress: Extension of the Medicaid payment increase (still some hope for this to be passed), Reauthorization of the Children’s Health Insurance Program (CHIP), Federal action to provide health care for undocumented immigrant children, Child Nicotine Poisoning Prevention Act of 2014, others.
• Child and Adult Care food Program: Meal Pattern Revisions Related to the Healthy, Hunger-Free Kids Act of 2010 - there is still time to comment on this act by 4/15/2015 at http://www.regulations.gov 
• Please build relationships with your representatives at the local level. 
• Learn about the issues and help at http:/federaladvocacy.aap.org/

CHACC Guidelines

Dr. Alan Stiles

• Partnership between Community Care of NC and the academic centers to improve quality of care in NC.
• Vision is to co-manage children with chronic and complex illnesses between the hospital, the primary care provider, and the specialists to reduce inefficiencies.
• Provide evidence-based guidelines for care for chronic illnesses and high volume referrals to pediatric subspecialists to encourage the active co-management of these children.
• Also provide active care management by embedding care managers in hospital settings to facilitate warm hand-offs when patients return to the community.
• Ideally the costs of care would be reduced by 2%.
• http://www.communitycarenc.com/emerging-initiatives/child-health-accountable-care-collaborative/

Elizabeth Tilson, MD
Sickle Cell Disease: New Approaches and Guidelines (the newest part of the CHACC)

• There is a whole library of new tools available for providers, extensive. Today’s powerpoint is available at the website above. So I really don’t need to take extensive notes, do I?
• New evidence-based guidelines from the NIH run 275 pages. CHACC includes tools to implement these guidelines.
• No need to screen for pulmonary hypertension. Do remember to counsel boys/teens on priapism
• New recommendations for hydroxyurea are key. Routine use can decrease both acute and long-term complications of sickle cell disease. Promotes fetal hemoglobin production.
• All kids with sickle cell anemia should be on hydroxyurea. See guidelines for details on starting and maintaining doses.
• Reproductive counseling is critical, since hydroxyurea is a teratogen. Strongly consider long-acting birth control methods for adolescents.
• Fever management guidelines have changed.
• Okay, I can’t type this fast, but it’s all right here:

Emergency Department Vaso-occlusive Crisis Management

Fever in Adults with Sickle Cell Disease

Fever in Children with Sickle Cell Disease

Respiratory Symptoms in Patients with Sickle Cell Disease

Neurological Symptoms in Patients with Sickle Cell Disease

Anemia in Patients with Sickle Cell Disease

Pain Management in Patients with Sickle Cell Disease

Debbie Ainsworth, MD
Update on ACO in NC

• CCNC is organizing a statewide accountable care organization, Community Physicians Network of North Carolina, LLC. The idea is to have an organization ready to go for Medicaid reform.
• If you are interested in joining, contact Paul Mahoney at pmahoney at n3cn dot org

Preeti Matkins, MD, FAAP, FSAHM

Levine Children’s Hospital

Long Acting Reversible Contraception

• In North Carolina, 47-53% of high school students have ever had sexual intercourse, among the highest rates in the nation.
• NC is 14th for teen pregnancy in the US, 76 pregnancies/1000 young women ages 15-19.
• Condoms are the most common contraception method. Condoms have a high failure rate in typical use.
• NC Statute provides minor consent for prevention and treatment. Doesn’t mean that we can’t tell guardian, just that we don’t have to.
• NC is among the top states for STI’s in teens.
• New AAP policy on contraception: promote healthy sexual decision making, including abstinence and contraception. Counseling should be developmentally targeted, should distinguish between ideal and typical contraception use, should strongly consider LARC.
• 28-day hormonal contraception: missing a dose of any active pill can result in failure of the method, not just around the time of ovulation.
• WHO guide is incredibly useful, free for download here.
• LARC methods are half as likely to end in unintended pregnancy than short-acting methods.
• Depomedroxyprogesterone is every 12 weeks, progestin only, may have “crazy periods” with unpredictable bleeding at first, can be managed with OCP’s. May see 4#/year weight gain. Need to take vitamin D and calcium.
• If low bone mineral density, then switch to an estrogen-containing method. Get DEXA scan for use lasting greater than 2 years. BUT evidence suggests that any decrease in bone mineral density reverses upon stopping the medicine.
• Nexplanon is a single implant rod, lasts three years, very cost-effective. May lead to irregular bleeding (most common side effect).
• Implanon, similar.
• IUD’s: TCu Paragard, lasts 10 years, costs only $500 total. Mirena is another choice, includes levonorgestrel. IUD’s are highly effecive, lowe maintenance, provides a localized hormonal effect.
• Screen for STI’s at the time of or before insertion. May leave in place for positive test, just treat. There is no increased risk for pelvic inflammatory disease with IUD use, no evidence of increased infertility.

Julie Linton, MD, FAAP, Wake Forest Baptist Health

Immigrant Child Health in NC

• Immigrant children may be citizens or non-citizens. Non-citizens may be lawful or undocumented. The difference is critical in terms of resources available to them.
• Many families are of mixed citizenship. Some children may be US citizens, where older sibs and parents may be undocumented.
• Children in immigrant families in NC have grown from 9% to 17% of our child population between 2000 and 2012.
• Over 50,000 unaccompanied minors were detained by border control in the US in 2014, does not include the ones who were not caught. Over 2000 came to North Carolina. Few of them seek medical care.
• Fear of parental deportation can lead to tremendous anxiety in immigrant children. Social isolation due to language barriers is another big issue, as well as reluctance to participate in activities for fear of encounters with authorities.
• Well child care is a very developed-world idea. Beyond vaccinations and worm treatments, wellness care is limited to nonexistent in the developing world. Many immigrants no-show to appointments due to transportation challenges, less understanding of well child care.
• Birth outcomes are actually better for immigrant families: families are more likely to be complete and supportive. Likely these families are also self-selected for resilience.
• The AAP has been strongly outspoken in favor of providing education and health care to all immigrant children.
• Ideally, the medical home provides comprehensive, coordinated, culturally and linguistically effective care, and continuous health services.
• Should screen children for toxic stress.
• Should identify recent immigrants and apply relevant clinical guidelines.
• Screening evaluations for newly arrived immigrant children (there are CDC Guidelines, but they’re long): ideally a timely evaluation, comprehensive h&p, developmental screening, mental health screening, vaccination history, growth evaluation, hearing screen, vision screen, dental evaluation, screening for female genital mutilation.
• Labs: CBC with diff, lead, HBVsAg, HIV, TB screen (IGRA or skin test), syphilis screen (RPR with reflex), stool O&P (3 of them greater than 24 hours apart), Strongyloides IgG. Can just empirically treat with ivermectin.
• Trauma-informed care: “When something becomes speakable, it becomes tolerable.” Listen, respond with empathy, elicit other symptoms (eating, sleep, pain, anxiety), support parents.
• Look for Federally Qualified Health Centers for care, local charity care options, Battered Immigrant Project through Legal Aid of North Carolina - being a victim of a crime makes children eligible for Medicaid via a “U-visa.”
• Screening for social determinants of health. One useful screen is called IHELLP
• As a practice, consider offering co-located mental health services. Also look for a medical-legal partnership.
• Offer interpreter services for families with limited English proficiency. Please never make a child the interpreter.
• Develop protocols for newly arrived children for your clinic. If you’re in EPIC, you can build a Smart Set.
• Support school readiness, such as with Reach Out and Read.
• Develop a list of relevant community resources.
• Collaborate with your health department to coordinate care for refugees.
• Contact Julie Linton about the new NC Immigrant Health Special Interest Group (jlinton at wake dot med dot edu)

NC State Representative Donny Lambeth

The Vision: Quality, Compassionate Care - Efficiently

Introduced by Dr. Jimmy Simon

• Re-engineering, not so much as reform. Idea is to assess the problem and design a solution in order to optimize or perform better.
• Medicaid spending is driven by eligibility, benefits, fees, and utilization.
• Department of Health and Human Services is a $5.1 billion department, dominate by Medicaid. 63% of the money comes from the federal government.
• Children account for half of Medicaid enrollees, account for much less of the cost of Medicaid.
• Medicaid enrollment has increased by 18.5% since 2008. This is what drives the costs.
• Legislators are looking for a more predictable budget for Medicaid. They don’t want to see the costs vary widely from year to year.
• North Carolina is the only state where medicaid claims spending growth has declined steadily over 3 years.
• Goal is to provide a predictable, sustainable budget, care for the whole person, maximize administrative efficiency.
• Reward value, not volume.
• There is a strong voice in Raleigh to privatize Medicaid, turn it over to private, out-of-state parties. Representative Lambeth advocates for provider-led accountable care organizations based on Community Care of North Carolina. This model is succeeding in other states.
• Some argue for rapid change (18 months). Representative Lambeth prefers a 5-year timeline, building a capitated, risk-sharing model.
• Please talk to your own legislators and give them your priorities.

I have a confession to make. There was one more lecture, from 2:00 to 2:45, on a good topic, too: Autoimmune Diseases Associated with Streptococcal Infections. I was hoping to get the final word on whether PANDAS truly exist and why their babies are so stinking cute. But it's a long drive, and I had to get home in time for this:

I hope to see you all at the NC Peds Spring Open Forum April 11, 2015 at the Raleigh Renaissance North Hills. If you can’t make it, check here for the notes. I’m just hoping for better lighting.